1. Pharmacy Protocol for Insulin Dosing in the Hospitalized Patient
CPS Annual Meeting
2017
Demonstrating Value through
Medication Management
‘Best Practices’
Pharmacy Protocol for Insulin Dosing in the Hospitalized Patient

2. Manny Saltiel, Pharm.D, FASHP, FCCP
Regional Vice President, Clinical
Summit Health Care
Comprehensive Pharmacy Services, White Mountains, Arizona

3. There are no conflicts of interest to declare.
Faculty Disclosures
There are no conflicts of interest to declare.

4. Learning Objectives
Differentiate between basal-bolus and sliding scale insulin dosing regimens
Explain the rationale for each component of a comprehensive pharmacy-based protocol for insulin dosing

5. Summit Healthcare, Show Low, Arizona
89 beds
12 ICU beds
Non-teaching

6. Polling question
Which of the following is an ultra-rapid acting insulin product?
Lispro
Detemir
Glargine
Insulin NPH

7. Polling question - answer
Which of the following is an ultra-rapid acting insulin product?
Lispro
Detemir
Glargine
Insulin NPH

8. Onset, Peak, and Duration of Insulins
Insulin product
Onset
Peak
Duration
Lispro (Humalog)
10-15 min
min
< 5 hr
Aspart (Novolog)
Glulisine (Apidra)
5 hr
Regular (R)
30-60 min
2-3 hr
6-8 hr
NPH (N)
2-4 hr
6-10 hr hr
Glargine (Lantus)
No peak
20-24 hr
Detemir (Levemir)
1 hr
70%/30% aspart protamine/aspart
30 min
2-12 hr
10-16 hr
Adapted from Kapustin JF. Uncomplicating Insulin Therapy. Strategies for initiation in patients with type 2 diabetes. Last updated on: October 9, Articles/Uncomplicating-Insulin-Therapy.aspx. Viewed June 26, 2017

9. Polling question
Which of the following is a reason to convert prescribing habits from sliding scale insulin (SSI) to basal-bolus insulin (BBI)?
BBI produces lower mean glucose levels
SSI produces a “roller coaster” effect
BBI is associated with fewer hypoglycemic episodes
All of the above

10. Polling question - answer
Which of the following is a reason to convert prescribing habits from sliding scale insulin (SSI) to basal-bolus insulin (BBI)?
BBI produces lower mean glucose levels
SSI produces a “roller coaster” effect
BBI is associated with fewer hypoglycemic episodes
All of the above

11. Basal-Bolus versus Sliding Scale
Retrospective study of type 2 diabetes mellitus (T2DM) 202 patients (247 admissions)
Basal-bolus insulin (BBI) associated with:
Lower fasting blood glucose 
Lower mean glucose levels throughout severe/acute hyperglycemia  
Huri HZ et al. PLoS One. 2014 Sep 2;9(9):e doi: /journal.pone

12. Basal-Bolus versus Sliding Scale
“The principal difference between the two strategies is that sliding-scale insulin does not deliver adequate glycemic control to patients and addresses hyperglycemia after it has occurred; whereas, a basal–bolus regimen is directed at preventing hyperglycemia.”
Badlani S et al. Evidence for Basal–Bolus Insulin Versus Slide Scale Insulin. Current Emergency and Hospital Medicine Reports. March 2014, Volume 2, Issue 1, pp 26–34.

13. Basal-Bolus versus Sliding Scale
Image from

14. Basal-Bolus versus Sliding Scale – Barriers to Change
Tradition/historical practice
Fear of hypoglycemia 
Unaware of problems associated with sliding scale insulin (SSI)
Unwilling to make changes to therapies initiated by another physician
Image from

15. Basal-Bolus versus Sliding Scale – Barriers to Change
Jennette Larsen BSN RN CDE hired as Diabetes educator
Based on current best-practice, sought to convert physician practice from SSI to BBI
Two years of physician and nursing education

16. Basal-Bolus versus Sliding Scale – Barriers to Change
Saying no to positive change can be a mistake
Image from

17. Pharmacist-Based Insulin Protocol
Breakthrough – Develop Pharmacist-Based Insulin Protocol (modeled after a protocol used by a colleague of hers)

18. Educational Competency Checklist
Define type 2 and type 1 diabetes mellitus (T1DM), delineate potential difference in insulin needs
Identify onset, peak, and duration of lispro, glargine, regular, 70/30 and NPH insulin
Calculate correct transition doses from mixed insulin to basal-bolus insulin

19. Educational Competency Checklist
Correctly calculate transition dose from IV to SQ insulin
Correctly calculate insulin doses for insulin-naïve patient (transition from PO diabetes mellitus medications to SQ insulin)
Assess patient and use correct calculations to determine total daily insulin dose based on patient-specific needs

20. Educational Competency Checklist
Based on patient presentation, choose appropriate correction scale
Identify correct blood glucose targets for non-critically ill and critically ill hospitalized patients
Differentiate the need for basal vs. bolus dose adjustment

21. Educational Competency Checklist
Identify potential confounding factors in HbA1c results, point of care blood glucose results
Identify concurrent factors that may affect insulin dosing, i.e., renal, liver failure, age, nutritional status, steroid use, weight, previous insulin dose, etc.

22. Per-pharmacy protocol began mid 2/17
Results
Per-pharmacy protocol began mid 2/17
N=88
N=78
N=91
N=85
N=91
N=77
N = number of patients on insulin Percentages are number of hypoglycemic episodes (<70 mg/dL) / patients on insulin per month

23. Take-Home Pearls Are you still using sliding scale insulin?
Does your hospital have a Diabetes Instructor with whom you can partner?
What is you hypoglycemic episode rate?
Can you take on a pharmacy-based insulin management program?

24. Questions / Discussion
Manny Saltiel, Pharm.D, FASHP, FCCP
Regional Vice President, Clinical
Comprehensive Pharmacy Services
Summit Health Care