Guidelines for inpatient diabetes management.xls

These recommendations do not take into account individual patient situations, and do not substitute for clinical judgment. Changes in diet, activity, medications (i.e.: steroids), and acuity of illness (i.e.: infection, renal insufficiency)
may quickly change treatment requirements
Inpatient Blood Glucose Targets: 80-180mg/dL (In the ICU setting: 80-150 mg/dL)
Initiate Hypoglycemia Treatment Protocol (HTP) for capillary blood glucoses <70mg/dL
Suggested timing of Capillary Blood Glucose (CBG) Monitoring:

QAC & HS (before meals and at bedtime): patients with consistent oral intake at mealtimes
BID (before breakfast and supper): stable patients receiving oral agents or one insulin injection daily
Q 6 hours: patients who are NPO or receiving continuous nutrition over 24 hours
Q 4 hours: patients who are NPO or receiving continuous nutrition with fluctuating blood glucoses requiring close monitoring
Q 3 AM: added to QID or BID regimens for patients at risk for nocturnal hypoglycemia
Initiating Subcutaneous Insulin: Usual starting dose is 0.2-0.4 units/kg/day
• 50%-70% of total daily dose is given as intermediate or long acting insulin • If NPH used as the basal insulin, give 1/2 to 2/3 of total daily dose in AM and 1/3 to 1/2 in PM• If insulin glargine (Lantus®) is used as the basal insulin, start once daily in AM or PM • 30-50% of total daily dose is given as short or rapid acting insulin as Nutritional/Prandial in 2-3 divided doses with meals Managing Subcutaneous Insulin Therapy: General Guidelines for the prescriber (all insulin MUST be ordered in number of units to be given)
Adjusting subcutaneous insulin
• If 2 or more CBG were < 80 mg/dL – use 80% of previous day's total daily dose• If 2 or more CBG were > 180 mg/dL and none were < 80 mg/dL, increase total daily dose by 10% If patient is made NPO
• NPH insulin: Give ½ usual dose plus correction insulin• Insulin glargine (Lantus®): Give 50-80% of usual dose plus correction insulin • Pre-mixed insulin: Give 1/3 of the usual dose as NPH (for example: for 30 units 70/30, give 10 units NPH)—this approximates ½ the usual NPH component of the pre-mixed insulin dose • When full doses of basal insulin are given, and patient is made NPO • For patients previously eating: begin IV of D5 at 75-100 ml/hour (if able to tolerate IV fluids) • For patients previously on enteral feedings: begin D10W at the same rate of enteral feeding, • Continue IV fluid for 12 hours following last NPH dose or 24 hours following last glargine (Lantus ®) dose Subcutaneous Insulin: Scheduled insulin
Correction Insulin
Basal insulin:
Nutritional/Prandial Insulin:
Sliding scale:
Intermediate or long acting insulin required to Short or rapid acting insulin used to prevent a rise Short or rapid acting insulin used to treat Reduce the dose if NPO
Hold if NPO
Do NOT hold if NPO
• Basal insulin is required for all patients with • Regular insulin: onset of action is 30-60 • Supplement to scheduled insulin or oral minutes (best given 30-60 minutes before • Basal insulin should be used for patients • Rapid acting analogues (insulin lispro and • Use without basal insulin is contraindicated aspart): onset of action is 15-30 minutes. In the hospital, it is best to give when meal monotherapy and still have 2 or more blood tray is in front of patient or immediately after eating (if it is unclear whether the patient will eat).
• Usually accounts for about 50-70% of total • Usually accounts for about 30-50% of total • Can be used short term (less than 24-48 daily dose of insulin, divided by 3 meals hours) as monotherapy to help determine b Pre-mixed Insulin: HumuLIN® 70/30; NovoLOG® Mix 70/30; HumaLOG® Mix 75/25; HumuLIN® 50/50
• Pre-mixed combination of intermediate acting and short or rapid acting insulin (basal and nutritional/prandial)• Pre-mixed formulations do not allow for precise dose adjustments Suggested Correction Scale based on clinical presentation
• Very Low Dose Scale: Suggested starting point for thin and elderly and those on nutritional insulin with each meal• Low Dose Scale: Usual suggested starting point for most patients, including those being initiated on TPN• Moderate Dose Scale: Suggested for insulin-resistant patients and those receiving high dose corticosteroids• High Dose Scale: Used rarely except for patients with severe insulin resistance Oral Diabetes Medications:
• May be continued during hospitalization unless contraindicated • To avoid hypoglycemia, hold sulfonylureas and nonsulfonylurea insulin secretagogues (repaglinide [Prandin ®] or nateglinide [Starlix®]) if patient is NPO or has significantly lower nutritional intake or renal function from baseline • Discontinue metformin and thiazolidinediones (pioglitazone [Avandia ®] or rosiglitazone [Actos®]) for acute exacerbations of CHF• Discontinue metformin for renal insufficiency and hold at the time of and for at least 48 hours after iodinated contrast dye; restart when serum creatinine <1.5 in men and <1.4 in women


DIRETTIVA 2008/39/CE DELLA COMMISSIONE del 6 marzo 2008 che modifica la direttiva 2002/72/CE relativa ai materiali e agli oggetti di materia plastica destinati a venire a contatto con i prodotti alimentari (Testo rilevante ai fini del SEE) loro inclusione nell’elenco comunitario è scaduto il 31 di-cembre 2006. È quindi possibile fissare la data a decor-rere dalla quale l'elenco

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