help!

[ralhtar]

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insulin sliding scale not working on a pt. with a previous history of DM2 treated only with glipizide at home....now at hospital on sliding scale w/ uncontrolled blood sugars rising upto 300's
what kind of insulin would he need to be put on? he has chronic renal insuff...

i searched uptodate but didn't find anything that specifically answered this for me....if anyone finds an article or can discuss this i would appreciate it...
thanks
ralhtar

 

[Dr JPH]

Poorly controlled type 2 diabetic patient needs more than a sliding scale for in-house coverage. Sliding scales are not a way to treat a patients diabetes, but merely a way to adjust glucose after we check it...too little too late. They are good for an occassional wacky glucose level but not for standard therapy.

Your patient likely needs better PO and insulin coverage.

Renal dz is a black box warning for metformin, so unless Nephro or Endocrine suggest it I would avoid any metformin formulations.

Sulfonyureas can be your best friend short term but thats about it. TZDs are another option. You have to see what DM meds are on formulary at the hospital. Depending on how long this patient has been a diabetic, especially if they are an uncontrolled diabetic, they may be beyond many of the PO meds.

What about Lantus or Levemir? Long acting insuling with no real "peak" and "trough" as compared to other insulins?

What about NPH and Regular insulin during the day?

 

[DOtobe]

I would start him on Lantus as well as the sliding scale...he needs some basal insulin to help keep his BS under control. Usually start at 10 units qhs on someone who hasn't taken Lantus before.

(no articles to support this, just my personal experience in a year and a half of residency)

 

[Pegsie]

While he's in the hospital, where meal ingredients are known, it should be easy to put him on a carb exchange, giving a certain amount of units of preprandial insulin per gram carb in the meal that he's about to have. In addition, you can put him on a sliding scale on top of that for more coverage.

 

[ralhtar]

Hey you all,
Thank You for the responses....
So this is what my team ended up doing:
The intern started Lantis at 10 units/day (the formula she told me was 0.5-1.0 U/kg/d...and this pt is extremely obese, so even with 0.5 it would end up at 20U but she wanted to be careful given dehydration and renal dz)
The attending saw the patient and said that we can move the patient upto 20U/day. The pt's sugars still kept spiking instead of Lantis and sliding scale so we decided to move it to 30U and then the attending said 35U! so thats what we have for now....
if the sugars still stay up then we may go upto 40 tommorrow...beyond that not sure what hte next step would be....

Once again thank you for the responses🙂
ralhtar

 

[Bertelman]

Hey you all,
Thank You for the responses....
So this is what my team ended up doing:
The intern started Lantis at 10 units/day (the formula she told me was 0.5-1.0 U/kg/d...and this pt is extremely obese, so even with 0.5 it would end up at 20U but she wanted to be careful given dehydration and renal dz)
The attending saw the patient and said that we can move the patient upto 20U/day. The pt's sugars still kept spiking instead of Lantis and sliding scale so we decided to move it to 30U and then the attending said 35U! so thats what we have for now....
if the sugars still stay up then we may go upto 40 tommorrow...beyond that not sure what hte next step would be....

Once again thank you for the responses🙂
ralhtar

Please, tell me your team knew the answer to this question, and you were just using SDN for your own education. As JP said, sliding scale isn't the answer for a Pt. with known DM2 on orals. Who limited them to sliding scale to begin with? Maybe if it was diet-controlled, but on oral meds this should not have been the answer.

 

[Paws]

I have a patient currently who took glucophage at home for pretty normal blood sugars, but now in the hospital with high dose steroids as part of his treatment his blood sugars are beyond the glucometer's ability to read (= > 450).

So, we put him on 40 units of lantus qd, plus 5 units aspart before meals, and then regular for sliding scale through out the day. He is only taking the steroids for a short time, so we know he will come down again.

Insulin therapy is a beautiful thing when you can get it right, but sometimes it is hard to figure out. That's why I love hospital pharmacists ... 😍

 

[46&2]

Check the garbage. Are there candy wrappers? Any edible gifts from home in the patient's room? Is your patient 100% compliant with their diet and not eating anything in between?

Not being cynical here. Had a Type 2 DM with ESRD who had just received a kidney transplant. Blood sugars jacked above 300 (was on steroid taper). Tried messing with the sliding scale, oral meds. Talked to the nurse. Yep, likes to go the cafeteria, put cane sugar in the coffee. Cookie wrappers in the garbage. Can't beat that. After a little talking to, could get the sugars down some without extra med adjustment.