[0:00]Okay, it's time for that insulin regimen that you've all been looking forward to. For a quick refresher, when patients are admitted to the hospital, you want to discontinue all of their outpatient anti-hyperglycemic. And why is that? It's because metformin can cause a risk of lactic acidosis, can also lead to an increased risk of heart failure exacerbation. Solfa ureas have a very high risk of hypoglycemia, thyazolodine dioes, or whatever you're going to call them, they have a risk of heart failure. GLP-1 agonist, risk of GI symptoms, pancreatitis, SLT2 inhibitors, risk of UTI, basically just bad news. So we want to switch people to insulin when they come into the hospital. One thing that I did want to add though is that this is something I don't really do in the hospital that much, but you can actually reconsider starting some of them if the patient is eating well and basically getting ready for discharge. One good thing to know is what is your goal blood glucose while you're inpatient? And this is 140 to 180 milligrams per deciliter per the nice sugar trial in 2009. Now that trial was done in ICU level patients and found a higher risk of hypoglycemia and adverse events for stricter glucose control. It wasn't studied in floor patients, we've kind of extrapolated this data to have a basically a goal of 140 to 180 and all our hospitalized patients. And then in epic, you should add the endocrine tab to your patient summary if you haven't already. It gives you a very clear look at the patient's glucose and the numbers of units of insulin that they've been given during their hospitalization. So if you look at this screenshot that I took here, you can see that the patient at 7:00 a.m. had a fasting glucose of 134. And then all of these daytime ones are pre-meal glucose that have been checked and they have a bedtime glucose that's checked as well. You can see at the exact same time how many units of insulin were given and then also how much of the diet that they ate. So this person was only eating 25% of their meals, uh, probably one of the reasons they were kind of running a little on the low side compared to our goal of 140 to 180. We're going to go over this in just a bit, but if their fasting AM glucose is high, that means that your bedtime basal insulin was not enough. So you need to give them more basal insulin. If their pre-meal glucoses are high, that means you need to give them more mealtime insulin. So first of all, if you're admitting a patient and they're not on insulin outpatient, how can you get them started on a basal bolus regimen right away? Um, there's this really good study called the Rabbit 2 trial, which basically showed basal bolus, it's the most physiologic, the most similar to how our body works. So the best results and the best outcomes are when we actually put patients on a basal bolus regimen, rather than just like sliding scale or any other different kind of weird regimens. So, you know, you can actually really just do a weight-based dose when they come in. If a patient is lean, on dialysis, they're frail and elderly, you can do 0.3 units per kilogram per day. So if a patient is 50 kg, for example, then you can give them a total daily insulin dose of 15 units a day. You can do 0.4 units for patients at normal weight, 0.5 for overweight patients, and 0.6 for obese patients, or high-dose steroids, or insulin-resistant patients. And these numbers typically underestimate how much the patient will need. One thing that happened to me during inter-year is that I was always worried about doing this weight-based method because sometimes you'll get a 100 kg patient and it'll tell you to give them 50 units of insulin, even though they're like not on any insulin outpatient at all. I've always felt nervous blindly giving diabetic patients high doses of insulin, but there was this study that was very reassuring that the risk of hypoglycemia is very low with these ranges. So here you can see that 0.6 units per kilogram seems to be a threshold below which the odds of hypoglycemia are relatively low. Relative to insulin doses of 0.2 units per kilogram or less, those between 0.2 to 0.4 and 0.4 to 0.6 was pretty much the same. So there was no significant increased risk of hypoglycemia in that dosing range. I also skipped over this part, but once you've calculated the total total daily insulin dose, so for example, if the patient needs 60 units daily, then you need to split it between 50% basal glargine at night and then 50% divided up three times a day with meals for your quick acting insulin.
[4:05]So for this patient with 60 units of insulin daily, they should get 30 units glargine long acting every night and 10 units of aspart short acting three times a day with meals. I did add this caveat that if the patient does come in and they have an AKI or there's any strong worry of precipitating hypoglycemia, I would definitely air on the side of caution and give sliding scale insulin for the first 24 hours. Then you can calculate how much insulin that they've used in the first 24 hours and calculate your basal bolus off of that. If the patient is on insulin as an outpatient and they're pretty reliable, then usually you just take 75 to 80% of their insulin dose and start with that while they're in the hospital. This is often because the patients are not going to be eating as much while they're in the hospital, they're also on a carb control diet, whereas at home they're probably eating a lot more carb heavy foods. So basically just reduce their insulin a little bit and see how they do with that. A couple of extra notes, remember to put everybody on sliding scale insulin in addition to their basal bolus, and then remember to add a hypoglycemia protocol so nurses can give juices, D50 or glucagon if needed for hypoglycemia. And then finally just a quick note on titrating up while patients are admitted. Sometimes you'll consistently notice that their sugars are hanging out in the 200s or 300s, so if their morning glucose is 180 to 200, then increase the basal dose by 10%. If it's 200 to 300, 20%, and if it's greater than 300, increased by 30%. For pre-meal glucoses, in the same ranges, just increase it as I've written down here. And then if all glucose measurements are elevated, then I would recalculate their total daily dose and add 10 to 20% and then just split it all evenly again. If that doesn't make sense, please leave a comment in the comments below and I will make another video to, you know, go over some examples of how to do this. And then finally, if you're making your patient NPO, discontinue their short acting insulin and change their blood glucose checks to every four hours. All right, and that's my quick approach to insulin regimens while in the hospital. Remember, discontinue everybody's outpatient medications, put them on a basal bolus insulin regimen, get them to a goal of 140 to 180 while inpatient, and then a couple other things we talked about are how to start somebody on insulin basal bolus regimen when they're not on insulin outpatient, how to convert them if they are on insulin outpatient, and then also how to adjust based on how their blood sugars are hanging out while they're admitted. All right, I hope you enjoyed that video. I hope it was useful. Please like, comment, and subscribe if it was helpful for you. And next we're going to be talking about pain regimens in the hospital because you're going to get page about pain stuff, pain control, patients in pain. Doctor, what do you want to do all the time? So let's click on that video right there and let's talk about some of the good pain medications that you can give for your patients and how to basically titrate a good pain control regimen for them. I am just rambling at this point. I don't even know what I'm saying. Okay, bye.
