Ms. Howard is a nurse practitioner at Audie L. Murphy Veteran Affairs Hospital in San Antonio, Texas. Dr. Watts is the VHA Office of Nursing Services metabolic syndrome & diabetes advisor at Louis Stokes Cleveland VA Medical Center in Ohio.
Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
When the difference in BG readings before and 2 hours after a meal, called the Δ value, is > 50 mg/dL (2.8 mmol/L), the bolus insulin may need to be adjusted after ensuring the patient is ingesting consistent carbohydrates and performs the usual amount of activities around mealtime. For example, if the premeal reading was 130 mg/dL (7.2 mmol/L) but the 2-hour postprandial reading is > 180 mg/dL (10.0 mmol/L), the prescriber can increase the mealtime insulin by 1 unit if the mealtime insulin is < 10 units, by 2 units if < 20 units, or by 10% of the mealtime insulin dose. If the premeal BG is < 80 mg/dL (4.4 mmol/L) and the drop in BG is > Δ value of 50 mg/dL (2.8 mmol/L), the prescriber can decrease the mealtime insulin using the same calculation. Monitoring BG and titration recommendations are shown in Table 5. When adjusting the bolus insulin dose, it is best to make adjustments gradually rather than making several changes at once.
The 15/15 rule needs to be followed in cases involving hypoglycemia.21 When the BG is ≤ 70 mg/dL (3.9 mmol/L) and the patient is conscious and able to eat or drink, it is recommended they eat 15 g (30 g if BG is below 50) of carbohydrates then repeat BG check every 15 minutes until the BG is in the target range.22,23 If the patient is unconscious, providers should administer glucagon (if available), place the patient in a lateral position to avoid aspiration, and call 911. If hyperkalemia is an issue in chronic kidney disease, patients should consume apple juice rather than orange juice due to its lower potassium content. If the patient is taking α glucosidase inhibitors (AGI) like acarbose or miglitol, only pure glucose like glucose tablets needs to be given to treat hypoglycemia instead of regular soda or candy, as the AGI will slow absorption of other types of carbohydrates.24,25 After the severe hypoglycemic episode, it is imperative to assess for the cause and explore ways to prevent subsequent hypoglycemia. Providers also should advise the patient to wear medical emergency identification.
Conclusion
To avoid clinical inertia and promote better patient outcomes, bolus insulin needs to be initiated and titrated in a timely fashion (Table 6). In addition, it is recommended to refer patients to a diabetes educator and/or registered dietitian for DSME/S at the time of DM diagnosis, annually or as indicated.26 By utilizing multiprofessional approaches to DM management, control may be maximized. The fundamental aspect of DM management is to establish good rapport with the patient and initiate and titrate insulin safely.
