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Insulin

First Do No Harm. Insulin. John Jameson. Professor of Pharmacy Practice. Combination Products are the wave of the future. Pretty soon everyone will be taking one weekly pill for everything. I am applying for a patent on a few comboproducts :. Disclosures / ADvertising.

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Insulin

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  1. First Do No Harm Insulin John Jameson Professor of Pharmacy Practice

  2. Combination Products are the wave of the future. Pretty soon everyone will be taking one weekly pill for everything. I am applying for a patent on a few comboproducts: Disclosures / ADvertising

  3. Noestrone® (Redux was taken) Spironolactone / Tamoxifen

  4. Migraine prophylaxis without the hair loss NoMigaine® Valproate / Minoxidil

  5. Indication: Dual mechanism mood stabilization Offset® Lithium and Carbamazepine

  6. Zyloss ® Patients may still here the voices, but it will tell them not to eat. Olanzapine and Phentermine

  7. Oh wait, I think they may have beaten me to this one. Qnexa ® Topiramate and Phentermine Qsymia ®

  8. Copy of Powerpoint More Combo products Email subscription OK, BACK TO INSULIN Toomanymeds.com/pro

  9. History Sliding Scale Insulin (Insulin for Dummies) Basal Bolus Insulin Drips Clinical Pearls Stories from the Trenches Reprise A Pharmacist’s Perspective

  10. A Short History Inpatient INsulin

  11. Ye Olden Days

  12. Tight Control = Lower Mortality

  13. Benefits and Risks of Tight Glucose Control in Critically Ill Adults: A Meta-analysis JAMA. 2008;300(8):933-944. 23% vs 25 % BUT NOT DIFFERENT

  14. NICE-SUGAR <180 24.9% Died <110 27.5% Died Statistically Signficant Three Years Ago

  15. Goal Range?

  16. Diabetic Ketoacidosis Absolute Insulin Deficiency Blood Glucose Lipolysis FFA to Liver Alkali / Bicarb ACIDOSIS

  17. DKA: The potassium issue

  18. Case: 24 y.o. white female • pH = 7.13 • pCO2= 13 • pO2= 95 • HCO3= 4 • Na = 145 • K= 2.5 • Cl= 110 • HCO3= 4 • Na = 145 • K= 2.5 • Cl= 110 • HCO3= 4

  19. Na+ Na+ Na+ Pump K+ K+ K+ K+

  20. H+ Na+ H+ Na+ Na+ Pump H+ K+ K+ K+

  21. H+ Na+ H+ Na+ Na+ H+ Pump K+ H+ K+ K+ Urine

  22. H+ Na+ H+ Na+ Na+ H+ Pump K+ H+ K+ K+

  23. H+ Na+ H+ Na+ Na+ H+ Pump K+ H+ K+ K+ What’s happening to the Serum Potassium?

  24. Add Potassium to I.V. as soon as you see decent urine output Bottom Line

  25. HONK / HHS / HHNKC Relative Insulin Deficiency Lipolysis Suppressed Blood Glucose Osmotic Diuresis Mortality Rate >50 Y.O. 30% Dehydration Hyperosmolar State

  26. DKA- Acidosis / Lower Blood Sugar HONK - No Acidosis / Higher Blood Sugar DKA Vs HONK Why?

  27. .1 unit /kg load and .1 unit/kg/hour Double drip rate every hour NMT 100 gm/dl per hour Add dextrose at 200 to 300 gm/dl Intravenous Insulin

  28. normal

  29. Glucose Hyponatremia

  30. Glucose Hyponatremia

  31. Hypernatremia (after correction)

  32. Switch to ½ Normal Saline as soon as patient is stable Add Dextrose to infusion at BS = 200-300 Practical application

  33. How to stay between the ditches INsulin

  34. Sliding Scale

  35. 300 200 x x x 100

  36. Follow the Sliding scale

  37. How to stay between the ditches INsulin

  38. 70 to 100 2 units 101-150 4 151-200 6 201 250 8 251-300 10 301-350 12 351-400 14 Protocol #4

  39. Basal Bolus

  40. Basal + Prandial + Corrective Practical Guide

  41. Type 2: Eating Stop Metformin, Probably other orals Usual Daily Dose of Insulin OR 0.3 Units to 0.4 Units/kg/day 50% as Lantus 50% as Meal Novolog (aspart) Practical Guide

  42. Not Eating: ½ TOTAL daily insulin OR 0.2 to 0.3 units/kg/day No meal insulin Practical Guide

  43. SMH Low dose (Sensitive ) <40 units/day Medium Dose (Intermediate ) 40 – 80 units/day High Dose (Resistant) >80 units /day Insulin Sensitivity training

  44. Carbs Glucose units 15-29 120-149 1 30-44 150-199 2 45-59 200-249 3 60-74 250-299 5 75-89 300-349 7 90-104 >350 8* Example: Medium

  45. https://encrypted-tbn2.google.com/images?q=tbn:ANd9GcQg1kRJziUqKLr1iZAwHAtg-PtkXSX9EvUwz0RAdzBKPbh-tPINhttps://encrypted-tbn2.google.com/images?q=tbn:ANd9GcQg1kRJziUqKLr1iZAwHAtg-PtkXSX9EvUwz0RAdzBKPbh-tPIN

  46. 1700 / Daily Insulin = Blood sugar decrease/unit Novolog One Time Correction in Units of Novolog Daily Insulin (BS-150) 1700 Corrective Insulin

  47. 500/ Daily Insulin = Grams of Carb/unit Novolog Mealtime Units of Novolog Daily Insulin (Grams of Carb) 500 Carbohydrate Dosing

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