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Basal Bolus – What Adjustments? Pt Weighs 80Kg

Basal Bolus – What Adjustments? Pt Weighs 80Kg

Boot Camp – Class 4 Beverly Dyck Thomassian, RN, MPH, BC‐ADM, CDE President, Diabetes Education Services

2017 www.DiabetesEd.net

Boot Camp 4 – , Patterns and More  Determine appropriate insulin dosing  Calculate insulin sensitivity and Carbs  Consider individual patient characteristics  Sick Days, Hospital and Lower Extremity Assessment, Hypoglycemia

Basal Bolus – What Adjustments? Pt weighs 80kg

Diabetes Educational Services© www.DiabetesEd.net Page 1 Basal Bolus Therapy Insulin Dosing Strategy

50/50 Rule Example  0.5‐1.0 units/kg day  Wt 50kg x 0.5 = 25 units of (.5 units/kg most common) insulin/day  Basal = 50% of total  Basal dose: 13 units Glargine Q day Glargine 13 units Q day NPH or Detemir BID NPH/Detemir 6u BID

Bolus = 50% of total  Bolus dose: 12 units usually divided into 3  4 units NovoLog, Apidra, Reg, meals Humalog each meal

Intensive Diabetes Therapy Insulin Dosing Strategy 50/50 Rule Example – You Try  0.3‐1.0 units/kg day  Wt 80 kg x 0.5 = ___ (.5 units/kg most common) units of insulin/day

 Basal = 50% of total  Basal dose: ____ units Glargine Q day Glargine ____ units QD NPH or Detemir BID NPH/Detemir ____ BID

Bolus = 50% of total  Bolus dose: ____ units usually divided into 3 ___units NovoLog, Apidra meals Humalog each meal

Basal Bolus – Using 50/50 Rule – Pt weighs 80kg

Diabetes Educational Services© www.DiabetesEd.net Page 2 Poll Question 1  Calvin takes 5 units reg before breakfast and dinner and 18 units of Lantus at HS. His am BG ranges from 143 to 172. What is best action? a. Increase dinner regular insulin to 6 units b. Decrease Lantus at HS by 2 units c. Increase Lantus dose at HS d. Evaluate him for somogyi effect

Poll Question 2  Calvin takes 5 units reg at dinner and 18 units of NPH at HS. His am BG ranges from 63 to 72. What is best action? a. Decrease dinner regular to 4 units b. Encourage him to eat bedtime snack c. Decrease NPH insulin at HS d. Have him check a 2am BG

Based on Mr R’s clinical picture – In hospital How Much Insulin Needed?

 Creatinine 1.6  76 years old  Not very hungry  BMI 21  Weighs 80kg  Glucotrol 5mg at home  A1c 7.2%

Diabetes Educational Services© www.DiabetesEd.net Page 3 Calculate Daily Insulin Needs

 Based on unique characteristics of pt, where would you start?  Body wt in Kg x ______= total daily dose  May need more or less based on clinical presentation

Less 0.3 u/kg 0.5u/kg More 1.0 u/kg

Thin, elderly,  creat Heavy, infection, steroids

Calculate Insulin Needs Basal/ insulin carb/ correct

 Body wt in Kg x 0.3  80kg x 0.3 = 24 units daily

 Basal = 12 units  Bolus = 12 units / 3 meals = 4 units each meal  What if he is nauseated?

Poll Question 3  Mr. R is scheduled to get 4 units of Novolog insulin with his lunch tray. He tells you he is nauseated and not sure if he will be able to eat. What is the best action?  A. Hold the insulin  B. Give the insulin after he eats  C. Have him drink 60 gms of juice and give insulin  D. Give half the dose

Diabetes Educational Services© www.DiabetesEd.net Page 4 Basal Bolus Section  Carb counting  Prandial coverage  Correcting for hyper and hypoglycemia

Poll Question 4  Mary takes 6 units lispro (Humalog) before dinner. Which BG result reflects that it was the right dose? a. Before breakfast BG of 97 b. 1 hr post dinner BG of 189 c. Before dinner of 102 d. 2 hour post dinner BG of 178

Bolus Basics

 Carbohydrate/ Prandial Coverage  Match the insulin to the carbohydrates  1 unit for 15 gms ‐ Common starting point  Or can use Carb/Insulin ratio formula  Correction Bolus ‐ targets hyperglycemia  1 unit for every 30‐50 points over target  Use 1500 – 1800 rule  Adjust ratios depending on sensitivity and response

Diabetes Educational Services© www.DiabetesEd.net Page 5 Carb to Insulin Ratio > 450‐500 / Total Daily Dose 500 Rule - Humalog and Novolog • Divide 500 by total daily insulin dose. • Equals – Grams of carb covered by one unit of Humalog/Novolog insulin. • Example: Pt takes 33 total units /day. The equation is: 500 divided by 33 (total dose) = 15 • 1 unit insulin covers 15 grams carb

450 Rule for Regular Insulin • Divide 450 by total daily insulin dose. • Equals Grams of carb covered by one unit of regular insulin. • Example: Pt takes 45 units daily. The equation is: 450 divided by 45 (total dose) = 10 • 1 unit covers 10 grams of carb

Carbohydrate Ratio How does that work? Rapid/Fast Acting Insulin Serving Gms CHO Insulin  Dinner (60 gms cho) Size  Lemon Chicken 1 15 gms cho 1 unit  1 cup rice pilaf (45 gms cho)  Asparagus 2 30 gms cho 2 units  Dinner Roll (15 gms cho) 3 45 gms cho 3 units Blood Glucose 165mg/dl 4 60 gms cho 4 units

Poll Question 5  Pt on insulin pump takes 1 unit novolog for 15 gms of carb. Meal 1 cup rice, bbq steak, 1 c. skim milk, sm banana, SF ice tea. BG 118. How much insulin? a. 4.8 units b. 6.0 units c. 5.2 units d. 5.0 units

Diabetes Educational Services© www.DiabetesEd.net Page 6 Adjusting Bolus and Correction Doses Carbohydrate‐to‐Insulin Ratio

Based on three questions before meals:

1. How much carbohydrate am I going to eat? 2. What is my insulin dose for this amount of carbohydrate? 3. Should I lower the dose because I plan to be very active or have recently been active?

Correction Bolus Rapid/Fast Acting Insulin (1 unit:50 mg/dl>150)

Less than 70 Subtract 1 unit 70-150 mg/dl 0 units 151-200 mg/dl 1 unit 201-250 mg/dl 2 units 251-300 mg/dl 3 units 301-350 mg/dl 4 units 351-400 mg/dl 5 units

Poll Question 6  AR uses humalog insulin and the previous correction bolus. His blood glucose is 68 and he is going to eat 60 gms of carb (takes 1 unit for 10gms carb). How much insulin should he inject? 1. 4 units 2. 5 units 3. 6 units 4. Depends on his activity level

Diabetes Educational Services© www.DiabetesEd.net Page 7 Poll Question 7  Bob’s correction scale is 1 unit for every 30 above his target of 120. His BG is 270. How much correction insulin? 1. 4 units 2. 5 units 3. Needs to count carbs first 4. 3 units

Type 1 and a Teen  Cindy is trying to carb count and adjust her insulin, but is still having trouble. She weighs 60kg.  What is her daily dose of insulin?  What is her basal dose? 1. Pre meal target BG is 120 2. Post meal goal < 180. 3. Carb ratio: 1 unit for every 15 gms 4. Hyperglycemic correction factor is 1700 Rule one unit for every 55 above goal 1700 / TDD = insulin sensitivity 1700 / 30 = 56 (she uses Humalog and 1700 rule) 1 unit drops BG 56 points

Correction Bolus for Cindy Analog Insulin (1 unit:55 mg/dl>120) Less than 70 mg/dl Subtract 1 unit 70-119 mg/dl 0 units 120-175 mg/dl 1 unit 176-230 mg/dl 2 units 231-285 mg/dl 3 units 286-340 mg/dl 4 units 341-395 mg/dl 5 units

Diabetes Educational Services© www.DiabetesEd.net Page 8 Adjusting Cindy’s Bolus Insulin With Ratios

BG before lunch 285, she plans to eat 45 gms of carbohydrate. 285‐120 = 165 over target, 165/55 = 3 45gms / 15 = 3 3 units bolus insulin to correct to target 3 units bolus insulin to cover carbs in meal

Total adjusted dose: 6 units humalog insulin

Adjusting Cindy’s Bolus Insulin With Ratios ‐You Try

BG before lunch 230, plans to eat 60 gms of carbohydrate. ____‐120 = ____ over target, ____/55 = ____units ______gms / ____ = ____ units ins for carbs _____ units insulin to correct for hyperglycemia _____ units insulin to cover carbs in meal Total adjusted dose: ___ units humalog insulin

How much Insulin Needed?

 Morning ‐ BG 173  Breakfast – slice cold pizza, ½ c. applesauce  Lunch BG 69  Menu‐ ham sandwich, pear, diet 7‐up, mini snickers bar.  2 hours after lunch, BG 148 ‐ ran track  Before dinner ‐ BG 98  Cheeseburger, small fries, chocolate chip cookie  At bedtime, BG 173

Diabetes Educational Services© www.DiabetesEd.net Page 9 How much Insulin Needed?  Morning ‐ BG 173  Breakfast – slice cold pizza, ½ c. applesauce  45 gms = 3 units 1 unit for hyper total = 4 units  Lunch BG 69  Menu‐ ham sandwich, pear, diet 7‐up, mini snickers  60 gms = 4 units ‐1 unit since < 70 total = 3 units  2 hours after lunch, BG 148 – ran track  Before dinner ‐ BG 98  Cheeseburger, small fries, chocolate chip cookie  75 gms = 5 units 0 units for hyper  At bedtime, BG 173 – 15 unit Lantus

Cindy, 60kg, Carb (1u/15gms) Target 120 pre meal, Hyper 1 for 55

Poll question 8  Paul has had type 1 diabetes for 40 years and injects insulin 4 times a day. Which of the following is most important to assess? a. Does he clean his needle before he reuses it? b. Is he avoiding superficial blood vessels? c. Does he bend his needle before placing in trash? d. Is he rotating sites?

Diabetes Educational Services© www.DiabetesEd.net Page 10 Insulin Teaching Keys

 Bolus insulin with meals  Toss opened insulin vial after 28 days  Basal 1‐2xs daily  Proper disposal  Abdomen preferred site  Review patients ability to withdraw and inject.  Stay 1” away from previous  Side effects include site hypoglycemia/wt gain  Don’t re‐use ultra fine  Insulin pens – syringes  Prime needle to assure accurate insulin dose given  Keep unopened insulin in  Hold needle in for 5 seconds refrigerator after injection  Look for hyper  Roll 70/30 pens

Sharps Disposal: Product and Info

 Look in the Government section white pages for a household hazardous waste listing for your city or county.  Call 1‐800‐CLEANUP (1‐800‐253‐2687)  Search for collection centers online

Monitoring, Sick Days and Hospital, Lower Extremities Objectives: 1. Identify barriers to monitoring and strategies to overcome them. 2. Discuss sick day management 3. State glucose goals during hospitalization.

Diabetes Educational Services© www.DiabetesEd.net Page 11 Poll Question 9 What is the most effective way to teach blood glucose monitoring? a. Ask pt to carefully read instructions in the box b. Send patient home with video instruction c. Demonstrate how to use meter d. Review steps and ask patient for return demonstration

How will it help me?

 See if your treatment plan is working  Make decisions regarding food and/or med adjustment when exercising  Find out how that pizza affected your BG  Find patterns  Manage illness

How Often Should I Check?  Be realistic!!  Type 2 on orals – Medicare covers 100 strips for 3 months  Based on individual ‐ Consider:  Types and timing of meds  Goals  Ability (physical and emotional)  Finances / Insurance

Diabetes Educational Services© www.DiabetesEd.net Page 12 ADA Guidelines  Self monitoring before: meals, snacks, bedtime  Occasional postprandial and before exercise  When patient suspects low blood glucose; after treating low blood glucose until patients are normoglycemic  Before critical tasks such as driving  Some patients will need to test more depending on activity level, frequency of eating.  Be practical, no two patients or two days are alike

Glucose Monitoring Baseline Learning  Care for meter and test strips  Perform quality control  Proper disposal of lancets  Identify BG target and when to test  Recording and interpreting data  800 number  Adequate sample  User Error most common reason for inaccurate results

Alternate Site Testing?  Yes  No  Finger fatigue  Pregnant  No risk of hypo  On intensive insulin  Stable BG Levels therapy  If BG< 90, recheck on  During finger hypoglycemia  During illness

 Not as accurate during glucose fluctuations

Diabetes Educational Services© www.DiabetesEd.net Page 13 Poll Question 10  What is the best sick day recommendation for someone with type 2 diabetes? a. Stop all diabetes b. Test BG every 1‐2 hours c. Continue to take diabetes meds d. Only drink sugar free beverages

Sick Day Patient Guidelines

 Continue to take diabetes , may need adjust dose down or up  Test glucose at least every 4 hrs  Drink plenty of  Rest  Contact physician  Plan ahead  Check urine ketones, if BG >240 & ill

Sick Day Guidelines Reasons to Call MD

 Vomiting more than once  Diarrhea > than 5x’s or for > 24 hrs  Difficulty breathing  Blood glucose > than 300mg/dl on 2 consecutive readings  Temperature > 101 F.  Positive ketones in urine.

Diabetes Educational Services© www.DiabetesEd.net Page 14 Level 2 Online Courses to Review

 Hyperglycemic Crises  Setting up a Successful Diabetes Program ‐ Diabetes Self  Chronic Complications  Lower Extremity Assess  Hospital Care and Diabetes

Life Study – Mrs. Jones Mrs. Jones is 62 years old, a little heavy and complains of feeling tired and urinating several times a night. Admitted with a foot infection. Her WBC is 12.3, glucose 237.

 What are her BG goals?  How would we manage BG in hospital?

ADA Goals and Treatments For Hospitalized Patients Non Critically Ill pts if BG 180 +  Start subq insulin  Blood glucose goals:  140 ‐ 180  Basal /bolus Insulin preferred treatment

Critically Ill pts  Start insulin therapy at BG 180  Once insulin started, BG goal 140‐180  Insulin drip preferred treatment

Diabetes Educational Services© www.DiabetesEd.net Page 15 Steps to Prevent Hypo  If fasting BG < 100, consider adjusting basal insulin  If patient has renal failure, conservative insulin dosing required  Patient has N/V or not consistent eater?  Give bolus insulin after meals  Anticipate events that put pt at risk of hypo:  NPO for surgery, decreasing steroid dose, improving infection, recovering after cardiac event  Strive to admin the least amount of insulin necessary to reach glycemic targets

Life Study – Mrs. Jones

 What kind of education would we provide?

Is Inpatient Diabetes Education Realistic?  Unique opportunity to address urgent learning needs  Brief and targeted education effective  Strategies  Empathic listening and open ended questions  “What are you most worried about when it comes to taking care of your Look for diabetes. “teaching moment” opportunities  Assist w/ needed supplies and referrals

Diabetes Educational Services© www.DiabetesEd.net Page 16 General Recommendations  Diabetes discharge planning starts on admit  Type of DM clearly identified / documented  Check A1c in hospital:  If no A1c available for past 3 months  Present with hyperglycemia and no DM history  Pts with new hyperglycemia need appropriate follow‐up testing care and testing at d/c

Topics to Cover in Hospital  Survival Skills  Diabetes, self‐monitoring, BG Goals  Hypo & Hyper – recognition, treatment and prevention  Healthy eating  Meds‐ how to take, potential side effects and action  Proper use and disposal of needles and syringes  ID of health care provider for post d/c care  Schedule for f/u visit within 1 month  Parameters of when to call for help  Sick days, N/V, if BG < 70 or > 300

MNT In Hospital Setting  Goal of MNT  Optimize glycemic control  Adequate calories for metabolic demands  Create meal plan guidelines for post discharge  Consistent Carb Meal plan most common  RD responsible for integrating pts clinical condition to determine a realistic plan for MNT  RD referral inpt > outpt

Diabetes Educational Services© www.DiabetesEd.net Page 17 Mrs. Jones on Insulin ‐ Now What?  Nurse administered  Nurse had an insulin and pt only ate emergency and pt a few bites of turkey already ate lunch? and drank non sugar tea?

 You just gave 3 units of Novolog and patient needs to go to OR NOW!

Poll Question 11  Nurse gave 3 units aspart (Novolog) insulin and pt needs to go to OR now! Best action?  A. Call OR and tell them to postpone surgery  B. Give the patient 4 ounces of juice  C. Push 1 amp of D50  D. Hang IV of 5‐10% Dextrose and alert

Mrs. Jones needs to go to surgery  In spite of antibiotics, her foot ulceration isn’t improving.

Diabetes Educational Services© www.DiabetesEd.net Page 18 Preparation for Surgery

 Try to schedule surgery in am, resume meds/insulin when eating and stable.  Oral medications: Hold morning dose. If on sulfonylurea, may need to hold night before  Basal Insulin:  Type 2, give 50%‐100% of usual am/pm basal dose  for type 1s give 100% of basal dose (individualize)  Bolus insulin: Use mild insulin bolus coverage for type 1 and type 2’s

Getting Mrs. Jones Ready for Discharge  Mrs. Jones is improved and ready to go home.  What glucose management strategies for home?  Her A1c = 7.9%

Medication Reconciliation  Pts meds must be crossed‐ checked to make sure no chronic meds were stopped  Ensure the safety of new prescriptions  New or changed prescriptions reviewed with pt/ family before discharge  Avoid complex insulin regimens for those with limited cognition  As pt heals, remind them that they may need less insulin / diabetes meds to control BG  Supplies for insulin administration

Diabetes Educational Services© www.DiabetesEd.net Page 19 Moving on to the Lower Half

Diabetes and Amputations

 Rate declined by 65% from 1996‐2008  From 11.2 per 1000 to 3.9 per 1000

 Diabetes = 8 fold risk of amputations  Highest rate in those over 75  50% of amputations can be avoided through self‐care skill education and early intervention  Stats from CDC 2012

No Bathroom Surgery

Diabetes Educational Services© www.DiabetesEd.net Page 20 Lower Extremities  Lift the Sheets and Look at the Feet

Foot Care Standards ADA  Provide foot care education to pts w/ diabetes  High risk pts – use multidisciplinary approach  Wound specialist, Vascular specialist, Pedorthist etc.  Refer to foot care specialists for lifelong surveillance if:  smoke, loss of protective sensation, structural abnormalities, hx of lower extremity complications  Initial screen for PAD includes:  Assess for intermittent claudication and pedal pulses.  Refer high risk pts for further vascular assess and consider exercise, meds, surgical options.

Profile of a High Risk Foot ADA  Previous amputation  Previous foot ulcer history  Peripheral neuropathy  Foot deformity  Peripheral vascular disease  Vision impairment  Diabetic neuropathy (esp if on )  Poor glycemic control  Cigarette smoking

Diabetes Educational Services© www.DiabetesEd.net Page 21 You Can Make A Difference

 Assess  Nail condition, nail care, in between the toes  Who trims your nails  Have you ever cut your self?  Shoes – type and how often  Socks  /skin care and vascular health  Ability to inspect  Loss of protective sensation

5.07 monofilament delivers 10gms linear pressure

10 Free Monofilaments www.hrsa.gov/hansensdisease/leap/

Lower Extremities  "Every time you see your doctor, take off your shoes and socks and show your feet!"  For those at high risk for foot complications  All patients with loss of protective sensation, foot deformities, or a history of foot ulcers

Diabetes Educational Services© www.DiabetesEd.net Page 22 Three Most Important Foot Care Tips  Inspect and apply to your feet every night before you go to bed.

 Do NOT go barefoot, even in your house. Always wear shoes!

 Every time you see your doctor, take off your shoes and show your feet. Report any foot problems right away!

Hypoglycemia

Objectives:  Describe identification and treatment of hypoglycemia.  Discuss it’s impact on the person living with diabetes

Diabetes Educational Services© www.DiabetesEd.net Page 23 Mr. Jones ‐ What are Your Recommendations? Patient Profile Self‐Care Skills 64 yr old with type 2 for  Walks dog around 11 yrs. Hx of CVD. On block 3 x’s a week glyburide 10mg BID.  Bowls every Friday Labs:  3 beers daily  A1c 6.3%   HDL 37 mg/dl What concerns?  Triglyceride 260mg/dl  Tells you I get  Proteinuria ‐ neg shaky a lot?  B/P 152/94

Poll question 11  Which of the following put Mr. Jones at risk for hypoglycemia? a. 3 beers a day b. Elevated triglyceride levels c. Limited income to purchase food d. Hypoglycemia unawareness

Hypoglycemia – “Limiting Factor”

 Defined as glucose of 70mg/dl or below  50% of episodes occur during night  Mortality with severe hypoglycemia secondary to sulfonylureas  Especially (glyburide) Micronase®, Diabeta®  Blood glucose levels don’t describe severity, response is individual

Diabetes Educational Services© www.DiabetesEd.net Page 24 Hypoglycemia Symptoms

 Autonomic Neuroglycopenia  Anxiety Irritability  Palpitations Drowsiness  Sweating Dizziness  Tingling Blurred Vision  Trembling Difficulty with  Hypoglycemic speech Unawareness Confusion Feeling faint

Hypoglycemia: Clinical Risk Factors

 Diabetes medications  Intensive insulin therapies  Impaired kidney or function  Advanced age, poor nutrition  Near normal A1c  History of frequent hypoglycemic episodes  Neuropathy  Alcohol intake

Nocturnal Hypoglycemia

 Signs include:  Vivid dreams  Waking up with headache  Night sweats  Waking up hungry  Elevated (rebound) or low morning blood glucose

Diabetes Educational Services© www.DiabetesEd.net Page 25 Hypoglycemia Awareness  autonomic symptoms adrenergically based  after 2‐5 yrs of type 1 diabetes,  glucagon secretion impaired  epinephrine secretion becomes primary mechanism to restore BG levels  over time, epinephrine response diminished or delayed  decreases awareness of hypo and hormonal response

Treatment of Hypoglycemia  If blood glucose 70mg/dl or below: 10‐15 gms of carb to raise BG 30 ‐ 45mg/dl Retest in 15 minutes, if still low, treat again, even without symptoms Follow with usual meal or snack If BG less than 40, allow recovery time Decrease diabetes meds

Tx of Severe Hypoglycemia  If can swallow w/out risk of aspiration, try gel, honey, etc. inside cheek  If unable to swallow, D50 IV or Glucagon  Glucagon injection – teach support person  Dosing:  Adults 1mg  Children <20kg 0.5mg  Glycemic effect 20 ‐ 30mg, short lived  Must intake carb as soon as able  Need prescription, check exp. date

Diabetes Educational Services© www.DiabetesEd.net Page 26 Glucagon Emergency Kit

Store 68‐77 degrees prior to reconstitution single use only

Preventing Hypoglycemia Nocturnal Lows Other  On insulin, don’t skip  Monitor kidney presleep snacks function / wt changes  If bedtime glucose  Monitor BG trends <110, reduce meds  Don’t over medicate  If increased activity,  Balance food / activity increase cals  Plan ahead  Eval hs insulin/meds  Alcohol

Thank You

 www.diabeteseduniversity.net

Diabetes Educational Services© www.DiabetesEd.net Page 27