ADJUSTING INSULIN OR ORAL AGENTS IN THE NPO PATIENT

 

TAKE HOME MESSAGES:

• stop treatments meant to prevent against effects of food (e.g. bolus insulin or insulin secretagogues) but not basal insulin

• give some form of nutrition to prevent against tissue catabolism

• NEVER STOP ALL INSULIN IN A PATIENT WITH TYPE 1 DM

 

General principles:

•  if patient will be NPO after midnight, no need to change medications given in the evening (with the exception of glargine or detemir given at hs, due to their longer duration of action)

•  ensure capillary blood glucose (e.g. Accucheks) are done at least q4h

•  give corrective doses of rapid-acting insulin while NPO (i.e. to aim to keep BG 8-12 mmol/L).  See section on sliding scales for guidance.

•  give glucose-containing IV fluids (while NPO), such as D5W or 2/3 and 1/3 to prevent against tissue catabolism

•  in the morning, give basal insulin at ½ to of their usual morning dose (less if lower BG in AM, more if higher BG in AM).  Do NOT stop all basal insulin or else you will have to deal with high BG later on.

•  consider IV insulin if patient will have a more extensive procedure (e.g. major surgery), has high insulin requirements (e.g. > 100 U/day) and/or has type 1 diabetes (see perioperative/IV insulin section for more info)

 

Example 1:

Your patient is a 35 y.o lady with T1DM who is scheduled for colonoscopy sometime tomorrow afternoon (on the waitlist).  She is on NPH 10 units sc qhs and Novorapid 8 units ac meals.  She will be NPO after midnight.  Write her insulin orders.

 

Answer:

1.  Give NPH 10 units sc at 22h00

2.  NPO after midnight

3.  Hold standing doses of Novorapid tomorrow

4.  Accuchecks q4h tomorrow [can either write a scale, or have RN call if BS > 12 mmol/L]

5.  IV 2/3 and 1/3 at 75 cc/hr starting tomorrow at 07h00 (or a rate fitting for the patient)

6.  Call MD when pt is eating

 

Housekeeping:

•  do NOT forget to resume pt’s usual insulin regimen once she is eating again: it would be a good idea to highlight this in the sign-out

 

Example 2:

Your patient is a 66 y.o male with T2DM who is scheduled for a cardioversion tomorrow afternoon.  He is on Humulin 30/70, 30 units acb and 20 units acs, as well as metformin 500 mg bid.  Write his insulin orders.

 

Answer:

1.  NPO after midnight

2.  Hold Humulin 30/70 tomorrow AM

3.  Hold metformin tomorrow

4.  Give Humulin N 12 units sc at 07h00 if BG <8.0 mmol/L or 14 units sc if BG>8.0 mmol/L (remember, 30 units of 30/70 contains 21 units of Humulin N.  of this = 14 units)

5.  Accuchecks q4h tomorrow.  Call MD if BG <4 mmol/L or > 12 mmol/L

6.  IV 2/3 and 1/3 at 75 cc/hr starting tomorrow at 07h00

7.  Call MD when pt is eating

 

Housekeeping:

•  do NOT forget to resume patient’s usual insulin regimen once he is eating again: it would be a good idea to highlight this in the sign-out (though more critical in Ex. 1 since that patient has T1DM)

 

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