1. a: Subcutaneous insulin therapy may be selected as continuation of ambulatory therapy, as new therapy, or as a transition plan from intravenous infusion of insulin, with choice of insulin and timing dependent on the pattern of carbohydrate exposure. b: Discrete meals.
a: Subcutaneous insulin therapy may be selected as continuation of ambulatory therapy, as new therapy, or as a transition plan from intravenous infusion of insulin, with choice of insulin and timing dependent on the pattern of carbohydrate exposure. b: Discrete meals. The use of a consistent carbohydrate diet can be ordered in the hospital, facilitating the implementation of basal-prandial-correction therapy with glargine and rapid-acting analog for nonpregnant patients who are eating discrete meals, with BG monitoring before meals, at bedtime, and possibly midsleep. c: Negligible or continuous carbohydrate exposure. When insulin requirements are nearly continuous, as during negligible oral intake or NPO status, or during continuous enteral feedings, intravenous infusion of 5% dextrose containing fluids at rate > 43 cc/hour, or peritoneal dialysis, and frequent doses of split mixed NPH and regular insulin provide easily reversible and almost flat-line coverage. “Hold” orders can be written for low BG or for interruption of carbohydrate exposure. BG monitoring might be at 6:00 am, noon, 6:00 pm, and midnight. d: Transitional meal plan/grazing. For patients tolerating only transitional meal plans or nutritional supplements as during chemotherapy or postoperative recovery, who may be grazing as tolerated between meals, whose exposure to carbohydrate otherwise is negligible, and who require some insulin despite poor overall oral intake, or for patients who may have gastroparesis, the pattern of insulin requirement may be well matched by use of NPH and regular insulin given in divided dosage, approximately two-thirds in the morning and one-third in the evening, with BG monitoring before meals and at bedtime. e: Daytime grazing/overnight enteral feedings. The evening doses of NPH and regular insulin constitute a larger component of therapy than the morning doses. The initial doses of regular insulin seldom exceed 33% of the TDD of insulin. BG monitoring might be before meals and at midnight. f: Corticosteroids. The design of insulin therapy depends on the timing of the corticosteroids and challenges the creativity of the caregiver.Management during pregnancy or severe hyperglycemia are not shown; please refer to the text.
Cara L. Thompson et al. Diabetes Spectr 2005;18:20-27
©2005 by American Diabetes Association