Insulin in the ED

Insulin in the ED:

Adjusting home insulin dosing is uncommon for ED providers however it may be encountered due to patient lack of access to primary care.

Types:  There are several different types of insulin, rapid acting (Humalog, Apidra), regular insulin, long acting (NPH, Lantus, Levemir), and insulin combinations (70/30). Regular, NPH, 70/30, and Humalog are less expensive ($40 to 60) and Apidra, Lantus, and Levemir are more expensive (approximately $200).
Action Curves:  Rapid acting insulin peaks in 15 to 30 min, regular peaks at 2 hrs, and NPH peaks at 4 to 12 hrs. Levemir has less dramatic peak and Lantus is not considered to have a peak.

Dosing:  Usual maintenance doses of insulin are 0.5 to 1 unit/kg/day in divided doses. If patients are being initiated for the first time on insulin lower doses can be used to reduce the incidence of hypoglycemia. When changing a patient from one of the newer long acting insulins (Lantus) to a combination product such as 70/30, a dose reduction of 20-30% may be considered until patient can follow up with a primary care physician to reduce hypoglycemia.

Grady Pearles:  In the EPIC system at Grady a quick phrase “DM supplies” has been created to help prescribe the supplies needed for insulin therapy. If you type DM supplies in discharge orders there will be 3 different options: Medicaid formulary, Grady formulary, and outside (private insurance). If you select the Medicaid or Grady option the correct formulary syringes, lancets, BG meter, and BG strips will be listed. If a patient has private insurance ask what supplies they use and need; there are multiple types of insulin supplies are more combinations than can be practically created for the “outside DM supplies” option.

If you are at the Grady or Midtown campuses don’t forget you can ask the pharmacist in the ED for help with insulin dosing or discharge scripts