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CDM2 - Final > Van Bockern - Inpatient DM > Flashcards

Van Bockern - Inpatient DM Flashcards

1
Q

when should a1c be checked (2)

A

bg > 140 (w.o dm dx)
not done in prev 3 mo

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2
Q

bg target for most pt’s

A

140-180:
premeal < 140
random < 180

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3
Q

preferred IP insulin regimens

A

basal-bolus
basal-prandial-correction if pt is eating

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4
Q

what type of insulin is rarely used in IP setting

A

prandial

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5
Q

most important thing to avoid w. DM in hospital setting

A

hypoglycemia

underdosing is much better than overdosing

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6
Q

what should you do if a pt becomes hypoglycemic

A

change orders

always have hypoglycemia orders in place

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7
Q

4 conditions that increase risk for hypoglycemia

A

renal insufficiency
liver dz
altered nutrition
hx severe hypoglycemia

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8
Q

what do you need to do if you make a pt npo

A

change insulin orders

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9
Q

2 meds that increase risk for hypoglycemia

A

sulfonylureas
insulin

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10
Q

what med should you never prescribe to a pt w. underlying renal dz

A

sulfonylureas

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11
Q

3 rf for hypoglycemia in the hospital setting

A

changes in renal fxn
changes in meds
changes in nutrition/npo

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12
Q

3 options for hypoglycemia tx

A

oral glucose - juice
IVD50W
IM/SC glucagon

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13
Q

when would glucagon be given for hypoglycemia

A

no IV access

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14
Q

most hypoglycemic pt’s respond to __

A

oral glucose

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15
Q

basal-bolus insulin regimen includes what 2 types of insulin

A

basal - long acting
bolus - rapid acting

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16
Q

sliding scale insulin regimen includes what type of insulin

A

rapid acting only -> correction/sliding scale

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17
Q

basal-bolus insulin ex

A

lantus 10 u hs
PLUS
lispro 3 u q AC
PLUS
lispro correction scale q AC

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18
Q

insulin dosing is meant to mimic

A

non DM physiologic insulin

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19
Q

3 rapid acting insulins

A

aspart
lispro
glulisine

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20
Q

2 basal insulins

A

glargine
detemir

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21
Q

5 steps in insulin dosing

A
  1. know your pt - ex. renal dz?
  2. calculate total daily dose (tdd)
  3. dose basal insulin (50% of tdd)
  4. dose bolus insulin (50% of tdd)
  5. ongoing adjustment
22
Q

when should insulin be evaluated/adjusted

A

every day

23
Q

7 factors you must know about pt before dosing insulin

A

a1c
type 1 vs type 2
home meds
bmi
renal fxn
liver fxn
estimated insulin sensitivity

24
Q

indications for insulin-resistant/medium insulin dosing (4)

A

t2dm
bmi 24-30
steroids
home tdd 40-80 u/day

25
Q

indications for extra-resistant/high insulin dosing (3)

A

t2dm
bmi > 30
home tdd > 80

26
Q

tdd low - high

A

low: 0.3-0.5 u/kg/day
med: 0.5-1.0 u/kg/day
high: 1.0 u/kg/day

27
Q

30 y/o M, T2DM being admitted for PNA. His home meds include Metformin, Glimepiride, and Januvia. His wt is 100kg (BMI 30). His CMP is normal. A1c 9.0

how do you figure out his insulin dosing

A

calculate basal insulin
adjust w. SSI

28
Q

why do you d.c metformin in IP setting (2)

A

AKI
lactic acidosis s.e

29
Q

why do you d.c glyburide in IP setting

A

risk of hypoglycemia

30
Q

30 y/o M, T2DM being admitted for PNA. His home meds include Metformin, Glimepiride, and Januvia. His wt is 100kg (BMI 30). His CMP is normal. A1c 9.0

how do you calculate his basal insulin

A
  1. insulin “resistant”/med dose -> 0.5-1.0 u/kg/day =
    50-100 u/day
  2. use 50/50 rule to figure out starting dose:
    basal = 50% of tdd –> 25-50 u of glargine/day w. resistant SSI
  3. 50 total u/day:
    -25 u lantus
    -25 u lispro
    -divided tid
31
Q

how do you figure out resistant SSI dosing

A

~8-17 u of lispro/meal
OR
calculate: 0.1 u/kg/meal = 10 u lispro/meal

32
Q

adjust basal insulin based on __ glucose

A

fasting

33
Q

basal insulin needs to be adjusted if bg is < __ or > __

A

< 80 OR > 120

34
Q

50 y/o M, T2DM, wt 150kg
Home meds: glargine 50 units BID; lispro: “I dose it myself”
A1c 14.1%

what dose of glargine do you start with?

A

start w. 75 u daily (50% of tdd)

35
Q

50 y/o M, T2DM, wt 150kg
Home meds: glargine 50 units BID; lispro: “I dose it myself”
A1c 14.1%

calculate tdd

A
  1. “extra resistant” patient –> 1.0 u/kg/day needed = 150 u/day
  2. basal = 50% tdd (150) –> 75% u glargine/day
36
Q

target bg range for most patients on insulin and steroids

A

140-180

37
Q

when do you need to repeat a1c for pt on insulin and steroids

A

a1c results < 6.5 (non DM) w.in past 3 mo
new sx dm (polyuria, polydipsia, rapid wt loss)

38
Q

when should you check bg for patients on dex who do not have pre-DM or DM

A

qd
as long as it remains < 180

39
Q

what type of insulin is preferred in pt who is also on steroids

A

nph bid (intermediate/long acting)

40
Q

what condition do you think of when you see a hospitalized pt on steroids

A

covid pna

41
Q

why is nph insulin better for pt on steroids

A

shorter duration of action -> faster dose modification

dex makes bg spike at all times of day

42
Q

how do you manage insulin for pt on steroids who was previously on insulin

A

-increase basal insulin dose by 20% and give as nph insulin
-2/3 daily dose AM
-1/3 daily dose PM

43
Q

management of rapid acting insulin for pt on steroids who was previously on insulin

A
  • home basal insulin < 50 u: sensitive scale
  • home basal insulin 50-100 u: moderate scale
  • home basal insulin > 100 u: high resistance scale
44
Q

management of insulin for pt on steroids who was not previously on insulin

A
  • start w. totaly daily dose of nph insulin at 0.3 u/kg/day
  • 2/3 AM
  • 1/3 afternoon
  • sensitive scale lispro
45
Q

how do you adjust nph insulin for pt on steroids

A
  • increase or decrease dose by 10-20% based on bg prior to next scheduled dose

ex adjust AM dose based on PM bg

46
Q

Pt is a 63 year old male with pmh of Type II DM admitted for COVID PNA due to AHRF. Pt is started on Dex/RDV. Pt has not been taking insulin at home. He weighs 70kg. His blood sugar is 220.

What dose of NPH should he be started on?

A

70 kg x 0.3 u/kg = 21 u total
with NPH we do 2/3 AM and 1/3 PM –>
2/3 of 21 = 14u q AM
1/3 of 21 = 7u q PM

47
Q

d.c consideration for inpt on dex

A

make take several days for insulin resistance to fall back to baseline -> make sure pt is back to baseline before d/c

48
Q

up to __ of pt’s w. steroid induced hyperglycemia and no previous dx may later develop DM

A

1/3

49
Q

most important d.c instruction for inpt DM pt

A

close PCP f.u 2 weeks after d.c

50
Q

target bc in the hospital

A

140-180

51
Q

the 50/50 rule is used to dose

A

basal bolus

CDM2 - Final (9 decks)

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