36.93 Physician checklist/instructions for starting Insulin

Diabetes Planned Visit Notebook

Summa Health System developed this checklist for physicians who are considering prescribing insulin to a patient. It is part of the Diabetes Planned Visit Notebook.

Physician Checklist for Starting Insulin as an Outpatient

Is the patient medically stable?

  • No ketosis or electrolyte abnormality.
  • No acute infection requiring hospitalization.

Is the patient psychologically stable?

  • Assure proper home support.

Does the patient have arrangements for patient and family education?

  • Visiting Nurse, or Summa Diabetes Center, or FPC nurse.
  • NB: Summa Diabetes Center has an INDIGENT program.

Does patient have these educational materials?

Did you calculate the patient's insulin requirements and prescribe an initial insulin regimen? (go to section below)

Does the patient have written prescriptions for:

  • Insulin.
  • Glucagon.
  • Syringes.
  • Glucose monitor, test strips and lancets.

Does the patient know to call daily and update physician or nurse regarding blood glucose levels and symptoms?

Insulin Treatment Regimens

Step One: Estimate Total Daily Dose (TDD) of insulin required

  • Type I = approximately 0.5-1 Unit/kg/day.
  • Newly diagnosed Type I 0.3 Unit/kg/day.
  • Obesity may increase TDD to > 2 Units/kg/day.

Step Two: Identify basal and mealtime needs
BASAL insulin needs = approximately 50% of TDD

  • most commonly use Novolin/Humulin N or L

MEALTIME insulin needs = approximately 50% of TDD

  • most commonly use Novolin/Humulin R or
  • Insulin Lispro (Humalog).

Step Three: choose an insulin regimen
a. Split Basal insulin into two doses

  • Bedtime N or L (with or without) AM N or L, or
  • Ultralente AC breakfast and supper.

b. Mealtime regimens based on choosing among 2,3, or 4 injection regimens

Step Four: adjust insulin regimen

  • If fasting BG > 140, increase evening Basal dose (by approximately 10%).
  • If BG < 150mg 1 to 2 hours post breakfast but > 120mg pre-lunch, increase breakfast Basal dose.
  • If BG > 150mg 1-2 hours post breakfast, but < 120mg pre-lunch, increase breakfast R dose.

Blood glucose Goals: Pre meal < 120; 1-2 hours post meal < 150; Bedtime < 140

Insulin Regimens

Practical One Injection Regimens for Type 2 DM

Nighttime Insulin
May add to oral agents
Administer at 9 PM

  1. HS NPH
      3 to 4 AM peak may cause hypoglycemia, duration of action may cause pre-supper hyperglycemia.
  2. HS Ultralente
      Peaks later, lasts longer.
  3. HS Glargine (Lantus)
      No peak lasts 24 hours.

Begin any of these 3 regimens with

  • 10 to 20 units or
  • Calculate 0.1-0.2 Units/kg.

Adjust dose every 3 days based on Fasting Glucose

  1. If FBG > 140, Increase by 4 Units.
  2. If FBG 110-140, Increase by 2 Units.
  3. May consider D/C oral agent when FBG < 110.

Morning Insulin
Glargine (same dosing and adjustment as nighttime insulin)

  • Less hypoglycemia than HS dosing.

Pre-Suppertime Insulin
May use 70/30 N/R mix, 50/50 N/R mix, 75/25 Glargine/Lispro mix
Same dosing and adjustment as Nighttime Insulin

Multi-dose Regimens to approximate physiologic insulin peaks

3 injection regimens (recommended)
a. N or Lente before breakfast and at bedtime Plus
    R before breakfast and Supper

e.g.:

MealRegimen
Breakfast25% TDD Novolin N (or Lente) plus 25% TDD Novolin R (or lispro)
LunchNo insulin
Supper25% TDD Novolin R (or lispro)
Bedtime25% TDD Novolin N (or Lente)

b. Ultralente before breakfast and supper Plus
     R or Lispro before each meal

e.g.:

MealRegimen
Breakfast30% TDD Ultralente plus 15% TDD Novolin R (or lispro)
Lunch15% TDD Novolin R (or lispro)
SupperTDD Ultralente plus 15% TDD Novolin R (or lispro)
BedtimeNo insulin
4-injection regimen
30% TDD Novolin N (or Lente) before breakfast and 25% TDD Novolin N (or Lente) at bedtime plus 15% TDD Novolin R (or Lispro) before each meal
MealRegimen
Breakfast30% TDD Novolin N (or Lente) plus 15% TDD Novolin R (or Lispro)
Lunch15% TDD Novolin R (or Lispro)
Supper15% TDD Novolin R (or Lispro)
Bedtime25% TDD Novolin N (or Lente)
Current as of January 2008
Internet Citation: 36.93 Physician checklist/instructions for starting Insulin: Diabetes Planned Visit Notebook. January 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/diabnotebk/diabnotebk3693.html