- 0Sep 17, '08 by IngyRNFor all you diabetes pro;s
I had a pt with a fasting BS 123. He was on 6u prandial humalog , along w/novolog algorithym which indicated an additonal 2u of novolog. Novolog is new to me ( I just returned to bedside after 7years) , it seems like 8units is alot for bs 123. However, my preceptor insisted this was the norm and ok to give as long as pt was eating. Could someone enlighten me??
- 0Sep 18, '08 by blondy2061h, MSN, RNNovolog is a fast acting insulin- faster than Regular with an onset of 15 minutes, a peak in an hour, and a duration around 4 hours.
It sounds like the 6 units was meant to cover the food being eaten, while the 2 units was a correction for the 123 to get it closer to an ideal fasting bg of 90.
This patient probably had some level of insulin resistance, but I would have no problem giving that dose. Doses vary so much from person to person you need to base if a dose is appropriate based on their norm, not what you've seen in other people.
- 0Sep 18, '08 by dansingrnThe Novolog dose was likely ordered to cover the amount of carbohydrate in the meal. It is not based on the current blood glucose level. In other words, the dose is calculated in proportion to the carb content. If the patient were going to consume a lot of carb, the dose would be even higher, irrespective of the current BG of 123.
The interesting thing is that the patient had an order for both Humalog and Novolog - both are rapid acting insulins. They are used in exactly the same manner, just made by different manufacturers. It is a little unusual to be taking both. Technically, Humalog has a faster onset and shorter duration than does Novolog, but only slightly. Humalog/Novolog are usually used along with a long acting insulin such as Lantus or Levemir.
- 0Sep 19, '08 by IngyRNThanks for the replies. The pt was actually just on Novolog ( apparently I was sleepy when I started the thread-sorry). The patient initially had very high BS despite being on a high dose algorithm (250 to 370's), so they added the prandial dose. After this, the BS were improved ranging 140's to low 200's. I realize Novolog is fast acting- I was afraid he would bottom out with 8 units. For my own knowledge, how do I know when it;s too much insulin and should question the order-are there any resources you can offer. I feel pretty clueless about it all.
- 0Sep 19, '08 by dansingrnYou could use the "1800 rule" as a guide to give you a reference point. Of course, this would just be for your peace of mind or a rationale if you felt you needed to verify the order with the provider who wrote the order.
1800/TDD (total daily dose) = how many points one unit of Humalog/Novolog can be expected to drop the blood glucose.
The accuracy of this rule varies by individual. It works very well in most cases, especially if the amount of long acting insulin (Lantus, Levemir) or intermediate acting insulin (NPH) taken daily is approximately 50% of the total daily insulin dose.
To figure TDD, add the long or intermediate acting dose to all the rapid or short acting doses taken through the day. This number will vary if the patient uses an insulin to carb ratio to vary the dose with each meal, but a "most common dose" estimate works just fine.
- 0Sep 19, '08 by blondy2061h, MSN, RNThe 1800 rule is a good starting point, but doses can still range so widely from person to person. I would compare the doses to what he's been getting and his previous blood sugars, and see if it seems appropriate. If the patient had 8 units yesterday and had good blood sugars, you know it's appropriate. If the patient has been having lows on 4 units, you should probably question the order.
- 0Sep 21, '08 by classicdame Guidea lot of MD's in my facility order 1:15 or 1 unit of Novolog to every 15 grams of carbohydrate. It sometimes the ratio differs, but the idea is that the dose is to cover the meal only. NPH or Long-acting like Levimir or Lantus is usually added to serve as basal dose. If the patient is getting fast acting only I assume there is an oral med or strict diet and history of compliance.
- 0Sep 22, '08 by blondy2061h, MSN, RNQuote from classicdameThat's great to hear about doctors prescribing carb ratios in hospitals. Very progressive of them. Does nutrition provide the carb count for the meal?a lot of MD's in my facility order 1:15 or 1 unit of Novolog to every 15 grams of carbohydrate. It sometimes the ratio differs, but the idea is that the dose is to cover the meal only. NPH or Long-acting like Levimir or Lantus is usually added to serve as basal dose. If the patient is getting fast acting only I assume there is an oral med or strict diet and history of compliance.