Insulin for the ED

Different Flavors of Insulin

IV Regular Insulin
Fastest onset.
For managing DKA, acute poisonings requiring high-dose insulin, hyperkalemia. See below.

Fast-Onset Insulins: For quick corrections. (Managing DKA; post-meal insulins).
Aspart & Lispro SQ
Regular SQ (slower)

Intermediate Insulins, mainly the "neutral protamine Hagedorn," named after a founder.
NPHs are often mixed with a fast-acting agent. So 70/30 is usually 70% NPH and 30% regular, 75/25 is NPH and Lispro, etc., to try to get benefits of fast on and long duration.

Slow insulins taken once-twice daily for long-term control
Detemir (Levemir) and Glargine (Lantus)

Type Onset Peak Duration When to give
Regular (Humulin R, Novolin R) 30-60 mins 2-3H 8-10H 30 mins before meal
Aspart (NovoLog) 5-15 mins 30-90 mins 4-6H 15 mins before meal
Glulisine (Apidra) " " " "
Lispro (Humalog) " " " "
NPH (Humulin N, Novolin N, Novlin NPH, Isophane) 2-4H 4-10H 12-18H BID
Detemir (Levemir) 2H No peak 12-24H QD/BID
Glargine (Lantus) 2H " 24H QD


Sliding Scales

More for inpatient management than the ED.
Usually a patient with elevated blood sugar is treated for it:
1) per HHS or DKA protocols
2) by getting their home insulin doses
3) or perhaps with just IV fluids
4) or it's ignored because it's only mild hyperglycemia (i.e., under 250) and there are other issues to focus on

But sometimes none of these options work, the patient's sugar is high, and some insulin needs offered. Here is a typical sliding scale, adapted by examining multiple different sliding scales, with low-dose and, in parenthesis for more insulin-resistant patients, high-dose suggestions. Generally use SQ either regular or a rapid-acting (Lispro, Aspart):

Blood sugar in mg/dL SQ dose of regular or rapid-acting insulin
150-199 really could just ignore, or give 1 unit
200-249 2 (4)
250-299 3 (7)
300-349 4 (10)
350+ 5 (12)


Insulin in DKA

Insulin alone is not the answer — or even the first step! See the DKA discussion.

Historically in DKA, a regular insulin bolus was given followed by 0.1 U/kg/h gtt. Recent studies have skipped the bolus but used a slightly higher gtt rate of regular insulin 0.14 U/kg/h.
Roughly 10 U/hr in 70 kg patient.
Blood sugar should fall 50-70 mg/dL/h.
If not, double rate and reassess. (Sepsis? MI? Dead gut? Pancreatitis?)

Tinkering / Boarding DKA
When glc dropping fast and/or gap closing
- Halve the gtt
- Add D5 to IVF (Dropping glc a lot may be a/w cerebral edema. The goal of the insulin is not to plummet sugar to normal, but to stop fatty acid metabolism -> ketones.)
- If glc still dropping very fast, switch to D10

When glc <250 and gap closed/closing
- Change to D5 1/2NS @ 250/h
- Feed patient
- NPH or Regular Insulin 0.2 U/kg SQ
0.6 U/kg/day divided by 2-3 doses per day
- Keep gtt on 1-2 more hours, as low as 0.02-0.05 U/kg/h, then off
- When all criteria normal, DC everything and switch to sliding scale insulin

SubQ Insulin instead IV?
Two RCTs have shown giving fast-acting insulins SQ — one with Aspart (Novolog), another with Lispro (Humalog) — every 1 or 2 hours is safe and effective
But severely ill DKA should get a gtt and ICU.

Dosing regimens for SQ Aspart (Novolog) or Lispro (Humalog) in DKA
- Give bolus 0.3 U/kg SQ
- Follow with either 0.1 U/kg SQ every 1 hour, or 0.2 U/kg SQ every 2 hours
- Check fingerstick glucose either q1H if dosing q1H, or q2H if dosing q2H.
- When glc levels fall below 250 mg/dL: Reduce to 0.1 U/kg q2H until DKA resolves

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