Narrator - Dr. Abel 00:00 Welcome to HelixTalk, an educational podcast for healthcare students and providers, covering real life clinical pearls, professional pharmacy topics and drug therapy discussions. This podcast Narrator - ? 00:11 is provided by pharmacists and faculty members at Rosalind Franklin University, College of Pharmacy. Narrator - Dr. Abel 00:17 This podcast contains general information for educational purposes only. This is not professional advice and should not be used in lieu of obtaining advice from a qualified health care provider. Narrator - ? 00:27 And now on to the show. Dr. Sean Kane 00:31 Welcome to HelixTalk, Episode 87 I'm your co host, Dr. Kane. Unknown Speaker 00:34 I'm Dr. Schuman, and Dr. Khyati Patel 00:36 I'm Dr. Patel, and in this continuing episode of everything you need to know about insulin in one shot, technically two shots. Episode 87 we're going to continue our discussion on insulin. If you remember, in the last episode, we discussed different types of insulin, how they're available, what should be kept in mind as far as the admin technique go, and what are the different storage specification in this episode, however, we're going to talk about the dosing for both type one and type two patient. What are the dosing adjustments as we need to titrate the insulin? What are some sliding scale dosing methods, criteria to keep in mind and just the overall education that should go along with initiating insulin therapy. Dr. Sean Kane 01:17 Why don't we kick it off with just talking about insulin dosing? And as I understand it, type one diabetic patients are going to be a little bit different than type two Dr. Khyati Patel 01:24 diabetic patients, correct type one diabetes patients, again, underlying pathophysiology is insulin resistant, meaning they may still have, in the initial years, some insulin production, so their needs for the total daily dose of insulin is going to be a little bit different. And the way we start therapy. And type two patient is a little different too. We Don't bombard them with, you know, 24 hour basal bolus insulin therapy. We usually start out with basal insulin Dr. Sean Kane 01:50 first, and again, the purpose of that is that they already have a pancreas that typically is making insulin, so they don't need as much as someone who is a type one, where they basically make very little, if any, insulin at all. Right? Dr. Khyati Patel 02:01 Type one patient would need to be given insulin in a physiologic manner, so something that covers them throughout the day, as well as something that covers them after meals. Speaker 1 02:11 So yeah. So a good rule of thumb is first starting would be something like point one 2.2, units per kilogram, again, making sure they're dosing it in kilograms here per day. So an example maybe would be, if we've got an 80 kilogram patient, we're talking point two units per kilo, that'd be somewhere around 16 units daily. Again, if you start at point one, that'd be eight units daily. And so, you know, fairly close to kind of a 1015, unit starting dose, which I think is another rule of thumb, and that's injected any time of the day. I think, is something we've talked about, Dr. Patel about comparing basal to other regimen. Can get away with doing it once a day, specifically, especially at those lower doses, as long as we're really consistent with how it is administered. Dr. Khyati Patel 02:49 Yeah, and I do want to remind our listeners over here that you know, if you were to do a lab experiment, one unit of insulin will lower the blood sugar by 25 to 30 milligram per deciliter. Now that's a standard number. Everybody has a different level of insulin resistance. Everybody has a different response to glucose When digested, right? So this dosing needs to be more weight specific. Rather than saying, I'm just going to start everybody on 10 units of basal insulin if they're type two and if they're obese, I'm going to go with 15. Sometimes you're under shooting it, although sometimes in some frail individuals, or those who are prone to hypoglycemia at the initial doses, we might be overshooting it too. So it's very careful. And always keep in mind that there is always room for titration. Dr. Sean Kane 03:36 And I think that you know, again, on the inpatient side, what you said, Dr. Patel, is absolutely correct, and that when we initiate like a long acting basal insulin on a critically ill patient, almost always, we're trying to shoot a little bit lower than a little bit more aggressive, because we can see that patient the next day and reevaluate and titrate, generally speaking, especially in the hospital setting, it's a very bad prognostic thing for a patient to get hypoglycemic. So again, depending on how easy it is to monitor their patient, you may choose to shoot a little bit lower and titrate up, as opposed to be more aggressive, and then have a hypoglycemic event for that patient, Dr. Khyati Patel 04:10 and you're going to evaluate, you know, how easy is that patient to get in touch with? Are you going to be able to call them in a week to see how they're doing? You know, titrate the dose accordingly, just overall education level and their literacy level as to, you know what this therapy is all about, you, you kind of have to gauge all of that, because, again, I'm going to mention that insulin is a high risk medication according to ISMP, and so I would rather do a slower approach. And as it is when we are talking about hyperglycemia versus hypoglycemia, we know we have time to treat hyperglycemia. However, when it's hypoglycemia, it's an emergency, and there could be fatality if not resolved properly. Speaker 1 04:51 All right, so we've kind of started talking about a bolus insulin and starting it gradually. So where we move as far as, let's say, we decide we need to be a little more intensive with a type. Diabetic patients. So what do we do with bolus insulin? How do we start it? Dr. Khyati Patel 05:03 So for bolus insulin, there are a couple other approaches that we can consider. Most of the times providers are not as aggressive to start boluses at all meals. We can evaluate, ask the patient, what is the largest meal of your day? We will start the bolus insulin then and then we can always ask them to check two hour postprandial sugar and then see how they're responding to that bolus insulin, and then accordingly, add to other meals as needed. So for some patients, we can start with just large the largest meal of the day, typically at four units. If you want to just like shoot the dart in the dark, you can do a weight based approach, which is about point one units per kilogram. And it's a little bit aggressive way of adding insulin that for our patient of 80 kilo, that would come up about eight units, or you can do about 10% of the basal dose. So for again, our previous example, our patient's basal dose was 16, but technically, that was the initial dose. So by the time you're adding the bolus insulin, perhaps we have titrated their dose quite a bit that we can take the 10% of that bolus dose and then add it to their largest meal of a high number regimen, right? Speaker 1 06:16 Because if we're doing 10% of 16, you know, 1.6 units, that's, you know, kind of a hard dose to tease out and get exact. Dr. Sean Kane 06:24 And I think that the dosing is really important for any healthcare provider, because as you mentioned, Dr. Patel, these are high risk medications. And if I was to fill a prescription on an insulin naive patient, and it said 50 units T ID of a bolus insulin, that should be a huge red flag, because 50 is a gigantic dose, but if a patient is very tolerant and very resistant to insulin, that might actually be a legitimate dose for them. So you really have to know a little bit more about your patient and their history, because absolutely people get harmed from insulin, especially if they don't know what they're doing, or the person who prescribed it didn't have a full understanding of how to dose that product. Dr. Khyati Patel 07:00 No, that's absolutely correct. Switching gears a little bit. You know, we talked about type two patients and insulin initiation. Let's talk about type one patient. We talked about how we need to give them insulin in a physiologic manner, right? So we need to give them a basal, but then whenever they eat a meal, we need to give them a bolus insulin too. So we use a concept called total daily dose, and that's, again, a certain number of units per kilogram. And so for normal type one patient, we're looking at anywhere between point five to point six units per kilogram per day. And that's, that's their total dose for the day. Dr. Sean Kane 07:38 And then how is that split up between of that total dose, how much of that turns into basal how much turns into bolus? With meals, usually Dr. Khyati Patel 07:45 50/50 approach. So 50% of that total daily dose should be given as a basal dose, and the rest of the dose should be given as the bolus dose before meal. Speaker 1 07:56 And again, Dr. Patel, as you had mentioned before, we can take that 50% that's bolus, and we can really divide that up into two to three doses, depending upon the number of meals a patient is eating. I know, for example, I have to be careful assuming there's a lot of my patients. We either eat one meal a day or two meals a day, where, I think, you know, assume three is a normative diet. You realize it really is important to tailor it to that individual Absolutely. Dr. Sean Kane 08:18 And as we talked about, these are rapid acting insulin. So you're going to take them either immediately prior to your meal or even during your meal. In most cases. Is that correct? Dr. Khyati Patel 08:27 That is correct. So bolus insulins could be either short acting or rapid acting. If it's short acting, which is the regular insulin we're going to inject about 30 minutes before, if it's rapid acting, normally 10 to 15 minutes before a meal. There has been some studies of these rapid acting insulins and seeing whether these can be injected after a meal. And so glulisine has in their labeling that it can be injected up to 20 minutes after finishing a meal, which is surprising to a lot of people, or immediately after completing a meal for aspart, but Fiasp, which is the fast insulin aspart, which starts working right away, that can be taken at least even 20 minutes after starting a meal. Dr. Sean Kane 09:09 Now, in terms of a 1c and glycemic goals, is there a really big difference between doing it before, during or immediately after a meal? No. Dr. Khyati Patel 09:17 So when we look at the efficacy of doing it after meal, the A1C levels, as well as the postprandial glucose levels, were not very statistically different. And when we look at the safety parameters, like, Oh, I'm going to inject it after, so I'm going to have low blood sugar episode, the hypoglycemic episodes were pretty similar whether they were injected before or after. And some studies even did patient satisfaction collection, survey, collection, and they found that patients were more satisfied when they injected afterwards, because they could gauge how much they had completed of a plate. If you're considering a younger kid who's running around and mom has to run around or dad has to run around to feed the child, it's very convenient to injected after the fact, gauging, okay, this is how much meal they have completed today. I think what you Speaker 1 10:05 pointed as, there's some, definitely some patient specific factors, not only the satisfaction, but I think also the ability to, you know, to remember, to take it, just kind of getting into that routine and being consistent with it, is, if you can take it, you say, you know, I've got that food sitting there. It's starting to smell great. It's coming right on the table, boom, you know, I'll do my shot now. Or somebody, as you said, knows that I'm, you know, after that meal. I know my consistency of the meal I just ate. I'm gonna do the insulin right after it. So I think it comes down to a comfort and routine for that individual. Dr. Khyati Patel 10:31 And that is correct. That is correct. So if you take this total daily dose, example of type one dosing, and apply it to our 80 kilogram patient earlier, who's eating three meals a day? Let's say we go with the lower range, right? Point five units times 80, that's 40 units of total insulin doses. 50% of that, which would be 20 units, should be given as a basal insulin. Let's say I'm going to go with Lantus, for example, and then the rest of the 50% which is the 20 units, then further, should be divided into three boluses. Again, our patient is eating three meals, so anywhere between six to seven units. You can also, you know, ask patient maybe their lunch is just, I don't know, a couple yogurt and, you know, maybe some carrots. Probably smaller units there, versus the breakfast and the dinner. Dr. Sean Kane 11:17 And clearly that highlights the importance of actually checking your blood glucose and keeping a log, right? Because when that patient comes in for their next visit, let's say they do get a little bit hypoglycemic after their lunch. That is too small. Of course, you're going to adjust that. And if they are high for dinner, then you're going to adjust that separately, right? Dr. Khyati Patel 11:35 That's absolutely right. I mean, nowadays we have so many methods of checking blood glucose, you know, the new monitors, there's CGM type from freestyle, you know, that's even approved in type two patients who are on a base level as insulin therapy. And it produces really nice charts. And it kind of gives you an idea of like, gap in therapy, like this is the time period where you need to intervene and give or correct the insulin doses. So either with that or just the regular finger sticks, you know, we ask patients to check blood glucose and adjust the insulins accordingly. Speaker 1 12:09 So one, I guess, example we can do is, for talking about basal initially, is, you know, looking at those trends, and again, having that data in a nice chart. Dr. Patel you mentioned it's so great, just to show the patient, as well as working with students trainees, saying, based upon what we've got two to four units of an increase, or perhaps 10 to 15% and then do that every three to four days. And again, can kind of continue working with that patient, or, you know, just make one change and follow up with them again. Depending upon your how fast you are, you're going to see them again. Yep. Dr. Khyati Patel 12:36 And this is specific to titrating the basal insulin. So usually we teach the patient too. If you're confident as a provider that your patient can do this math at home, you can actually teach your patient to titrate the basal insulin at home. So they're going to look at the fasting blood glucose, because that's where the basal insulins efficacy is, you know, located. They're going to take about three to four days worth of blood sugars average. It out if their average is between so and so numbers. You can provide them a scale and say, You inject this many units, or we can just say, every three to four days, you can increase it by two to four units. And for Speaker 1 13:12 students out there, I think it's also been important the next time you see them to reconcile the doses. I've got some patients to where they'll you will tell them to make those changes. If it's too high, make a change by one or two units, they won't do it. And others who kind of go a little bit rogue and make the changes, even though we haven't kind of really discussed it, so it's really important, they say, All right, so based upon our discussion, we said, x, what did you actually do? Dr. Sean Kane 13:32 And I'd say that's pretty true, like for med histories as well. So Warfarin and insulins are like the classic examples where you call the pharmacy, they say, This is what the script was written for, and then you talk to the patient, and it's dramatically different. Those two are very common players where it's different between what the patient actually does and what's in the pharmacy. Yeah. Dr. Khyati Patel 13:52 I mean, there's a upside and downside of teaching patient to titrate their own insulin, because sometimes they take it far and think that I can do whatever I want to do, and I have to still teach my patients in the clinic that, yes, you do have control over titrating. You understand the therapy, but you always have to keep the provider updated that that's what you're doing so we can give you enough day supply. You don't run out earlier, you don't get into insurance not paying for it, and we know that you're doing the calculation correctly and doing the right dose titration, Dr. Sean Kane 14:25 so that makes sense that we should be adjusting based on our fasting blood glucose. Dr. Patel, you mentioned both that that's kind of the therapeutic target of a basal insulin. But also it makes sense that the lowest number of the day, like the trough level, if you will, of your blood glucose, that is going to be equally affected as all of your other glucose numbers. And if that lowest number of the day is really, really low, the basal insulin works on that one just like it works on all of your other glycemic values, right? So if you're already low, you can't drive them any lower with that basal insulin. Unknown Speaker 14:53 That's a good way to put it. Yep, I agree with that, right? Speaker 1 14:56 So we kind of said two to four unit increase, or 10 to 15% if we want to. Go up on the dose, I'm assuming, then the reverse is true. If they're if they're low, we kind of back off around the same amounts. Yeah. Dr. Khyati Patel 15:05 So if they're complaining of frequent hypoglycemia, you know, let's say at the fasting time or at bedtime, then we can lower the dose by about 10 to 20% and Dr. Sean Kane 15:15 that makes sense. So in terms of that basal insulin go up or down by smaller increments. What about the bolus insulin with meal times? How do we typically monitor that and adjust it Dr. Khyati Patel 15:25 so we can again throw the dart in the dark and just increase the dose by one to two units, or again, 10 to 15% every three to four days. That's just a blank titration, if you were to go with the correction method, which we don't have time to cover here today. But there is a way to find how many units of correction patient needs add that to existing dose, and we can give that to patient too. We do teach type one patient how to do carbohydrate calculation. And there is a way to dose or change the insulin dosing based on the carbs ingested. So for example, if their dinner is, you know, piece of chicken, some broccoli, carrots and side of brown rice, they're not going to be needing whole lot of insulin, versus if their dinner is the spaghetti and meatballs, right? So they might have to do some titration based on the carb load, and they're taught how to carb count and adjust the insulins accordingly. Dr. Sean Kane 16:31 We mentioned for the basal insulin, we're looking at that lowest level, that fasting blood glucose. I assume we're looking at like a mealtime insulin with the bolus adjustment correct? Dr. Khyati Patel 16:41 That's correct for bolus adjustment. We're looking at the two hour postprandial glucose. I mean, I've seen some providers go off of the pre prandial numbers to adjust the bolus insulins as well. My opinion, in my practice, I like to stick to the postprandial values in order to adjust the mealtime insulin rather than pre prandial values. Speaker 1 17:03 So another important thing to note, though, is about converting again because of formularies or insurances or even hospital purchasing agreements, sometimes it is necessary. I know it aren't enough facility to kind of bounce back and forth between different kind of formulations. And I know that is something that, again, for me, it's, it's been, it's sometimes it's frustrating, because we have to figure out, Okay, what's the you know, can we do a one to one? What do we need to adjust? And so, Dr. Patel, what are some tips there out there, if somebody does find that they have to adjust based upon a formulary consideration. Dr. Khyati Patel 17:33 So, you know, if it's a hospital related formulary issues, you know, P&T committees will put out, you know, tables to say this is what the conversion process that you can use for those who are on the outpatient side and needing conversion. There is an excellent chart available at the pharmacist letter.com but at the same time, you can go to these specific insulins package insert and also find recommendation on insulin conversions. Dr. Sean Kane 17:59 So at least in my neck of the woods. We typically don't do a ton of these bolus mealtime insulins, and instead, we pursue what's called a sliding scale approach, which is where we adjust the patient's dose based on their current glycemic value, as opposed to what they're going to eat or more the history about what their insulin requirements have been historically, Dr. Khyati Patel 18:21 yeah, so sliding scale is something, you know, widely used in the inpatient setting, contrary to, you know, what we do in the outpatient side. And basically it utilizes multiple bolus insulin doses. So if patient's on fixed bolus dose prior to meal, that treatment is, you know, basically stopped prior to starting the sliding scale, insulin and patient's blood glucose is checked throughout the day, and if their blood glucose falls between certain range, a certain number or certain units of bolus insulin is administered. Dr. Sean Kane 18:56 So for example, like in the ICU, a typical order might be two to 10 units of insulin, lispro, and we check the patient's glucose every six hours, and we give them between two and 10 units every six hours, based on how high their blood glucose gets. Now, on the outpatient side, there are some issues with this, and maybe Dr. Patel, you could explain why this is not a preferred therapy on the outpatient side, Dr. Khyati Patel 19:21 yeah, you know, and that drives me to discuss more about some of the advantages and disadvantages of using the sliding scale insulin, right? So when you are looking at advantages of using it, it allows clinicians to remove medications like Metformin in the event of patient having, you know, renal insufficiency or Aki, or if they're undergoing some sort of contrast dye mediated tests and stuff, or remove sulfonylurea in patients who may be suddenly made NPO for a procedure or surgery the next day or something like that. So you remove those medication, but you have to then give something control the blood sugar, and that's where the sliding scale comes. In play? Speaker 1 20:00 Yeah, I've seen sometimes too is, again, is when they're in the middle of, you know, adjusting other medications. Want to kind of leave things for a second, and then just, let's follow along. What are the sugars actually showing? There's question about what a patient was actually taking, and you want to kind of start off from scratch, do flexible based on the blood sugar checks, what actual meals are they're consuming. Because, again, dietary change is going to be vastly different in an inpatient setting versus outpatient, and possibly maybe even reducing hypoglycemia again, if that variable nutrition intake, or if they're NPO, and if that's totally changing where they were a big heart beater before, and that's just not feasible right now, then you want to be careful giving them the same dose of that insulin. For example. Dr. Khyati Patel 20:38 The reason we don't use sliding scale on the outpatient side, to answer your question, Dr. Kane, is because sliding scale is more of a reactive approach. You know, you're trying to put out the fire after the fire has occurred already, versus, you know, on the outpatient side, we want to take more of a preventative approach. We want to make sure the fire doesn't happen at all, right? So we're trying to give enough insulin to make sure that the surge in blood glucose doesn't happen. That would be the proactive approach, which is not what the sliding scale insulin is. Dr. Sean Kane 21:09 And of course, another disadvantage, especially in the outpatient side, is that you're having to check your blood glucose very frequently, even if you're that kind of type two diabetic patient, that maybe you wouldn't have to check it as often now you do so that you know how much insulin you need to give on that sliding scale, right? Dr. Khyati Patel 21:25 It involves, you know, a lot of checking, lot of resources, and let's, most of all talk about the evidence for efficacy, right? Does sliding scale insulin work or not? Dr. Sean Kane 21:37 And at least on the inpatient side, most of the data for glycemic control in the hospital setting is actually with insulin drips, not with sliding scale insulin. And of that data, it's incredibly controversial. We could actually have an entire podcast episode just on critically ill patient glycemic control. But suffice it to say, we're a little bit more comfortable with hyperglycemia, certainly, than we were a decade ago, and where our glycemic goals are also different on the inpatient side versus the outpatient side. So generally speaking, we want to maintain glucose values less than about 150 to 180 we typically don't discriminate between fasting blood glucose and postprandial glucose. We just want any number that we find to be less than 150 to 180 and again, very controversial kind of beyond the scope of what we can go into depth within this podcast. Yeah. Dr. Khyati Patel 22:25 And another reason not to give this sliding scale to patients on the outpatient side is because they have to carry this chart with them, right? And there is more risk of insulin dosing error, rather than giving them a fixed dose. And say, you know, as long as your meals don't vary greatly in amount of carbohydrate, you're okay to use a fixed dose insulin prior to meal. So again, it could be five minutes before breakfast, seven before lunch, and 10 before dinner, but at least they will remember that five, seven and 10 better than carrying a table and be like, Wait, what was my blood sugar? You know, oh, did I inject this or not inject this? Dr. Sean Kane 23:03 Just consider how complicated that could get for someone who either can't read or has very poor health literacy, just to be able to understand different ranges, where the number falls within that range and how much to give, it's a huge opportunity for error versus just a fixed dose. Like you said, Dr. Khyati Patel 23:18 Yeah, that's very true. And there are a couple different types of sliding scales that the hospital or the practice site that you work at may utilize. We have some low dose sliding scale that does, you know, two units of increment based on the blood sugar value, but we can have medium dose or even aggressive dose sliding scale where increments of four or six units can be considered. Dr. Sean Kane 23:41 So clearly, there's a lot to go into the dosing, let alone the storage the different kinds of insulins. This is a huge educational effort when talking to a patient, especially a newly diagnosed diabetic patient, in terms of what is going on with all of this stuff. So Dr. Patel, what are some of the key things that you consider with overall education, when you encounter that diabetic patient, you Dr. Khyati Patel 24:04 know it is very overwhelming when we are starting somebody on insulin therapy, not only they have doubts whether this is the right approach for them, but sometimes they're not ready to change that lifestyle, right? And there are a lot of myths and controversies about what patients perceive as the insulin therapy is. I've heard patients in my clinic saying, Oh, my brother was put on insulin, and soon after he lost his eyesight, little that they know that they were on the verge of losing the eyesight, and their blood sugar was really uncontrolled, and they had to be put on insulin. So first and foremost, you should open up the floor and ask patients, what general questions do you have about insulin, right? Because unless you address their burning questions, they're not going to listen to the amazing you know, patient education material you have or the plan that you have. So first, try to address their questions. Try to remove some of those controversies and myths, if possible, then overall education for insulin can include things such as, you know, explaining different options for delivery vial syringe is kind of like an outdated method. Most people prefer pen, and most insurances covered pen as just as the same tier level as the vial and syringe method. Dr. Sean Kane 25:21 Dr. Patel, when you say pen, does that mean both disposable and kind of the refillable ones? Or which ones do you more commonly see in clinical practice? Dr. Khyati Patel 25:30 A more common ones to be seen are the one that are, you know, you use it, finish it and you throw it away. Those that are fancy ones where you can keep, you know, refilling the cartridges and keep it with you. It's up to patient's choice too, and they're willing to pay for that. There are some options available for them too. And then making sure that, you know, we're educating on proper insulin injection technique. Where does it go? What degree angle, how many seconds after injecting, they have to leave the syringe inside, you know, etc, etc. Speaker 1 26:01 Another component, again, I think we've already talked about, is the storage of it. Again, is we've talked a little bit about, you know, the beyond you stating, and you know, the concerns about, you know, store in the refrigerator, and concerns about freezing, how long can we leave it out at room temperature, for example, versus, you know, needing to new vial. We've talked about differences in terms of with some of the pre mixed insulins. The idea that we can note, we have to be careful using cloudiness as a marker for whether or not the insulin has gone bad. So these are all things that, again, need to people need to be aware of, and that it's going to vary greatly from one insulin to another, right. Dr. Khyati Patel 26:37 And insulin therapy also comes with a little bit of public, you know, health responsibility too. And what I when I say that, what I mean is proper, sharps disposal needs to be taught too. I still hear sometimes patients telling me, I use one pen needle until my entire pen runs out of insulin, right? That's a personal safety issue, and that's not right. But then I've also heard people saying, well, I just Ziploc, you know, all my used needles and then throw them in a regular garbage container when it's full. And that's not right either. So proper sharps disposal according to the individual state guidelines, it's also important to be taught. Dr. Sean Kane 27:12 Then, of course, another thing that we have to talk to our patients about is what to do if your blood glucose number is really, really high or really, really low. Of course, as we mentioned, hypoglycemia is a medical emergency has to be treated absolutely right now. And hyperglycemia, depending on how bad it gets, that can also turn into a medical emergency, which would be rare, but something that a patient needs to be aware of is a potential complication of having a blood glucose of 600 for example, right? Dr. Khyati Patel 27:38 And that goes along with overall education on you know how to check the blood glucose. What are your blood glucose goals, again, approved by the caring provider, and if they need to make alterations in doses, how they would go about doing that. And then kind of includes education on sick day management as well, especially those who are on basal, bolus, continuous insulin type of therapy is, you know what? If they're sick, you know what, how many times do they need to increase their frequency of blood glucose check? Well, they're sick and they have some stomach illness, not keeping anything down. Do they need to keep injecting their mealtime insulin is probably not right. So these kind of things needs to be taught to the patient. So I Dr. Sean Kane 28:22 think this is a really good time to kind of wrap up where we've gone between Episode 86 and 87 clearly, this is a really complicated topic, and we've just barely scratched the surface of diabetes management and monitoring and things like that. One thing I think is important to emphasize is the fact that we have a variety of different kinds of insulins. And as healthcare providers, we have to know, how long does it take to start working? How long does it last for what are the differences in the kinds of insulins that are out there and just being familiar with those different products? Speaker 1 28:51 I think another point to make is looking at the insulin dose needs among different individuals. First and foremost is the idea that insulin dose and even how to adjust and where to start with is different for type one and type two patients, as far as whether you start with basal or basal bolus, for example. But even there, I think the next step is it's not just type one versus type two, but the individual patient has to be considered. What does their diet look like? The number of meals they eat during the day, you know, their fears about hypoglycemia and educational pieces about, you know, erring outside of caution, or, you know, being concerned about pushing things a little more based upon so many patient specific factors, to ask the individual about what they would like to do and really have them drive it. Do they feel comfortable making adjustments on their own? Or would they rather meet more frequently with you as a provider to kind of go through that together? Dr. Khyati Patel 29:38 I think the third thing we discussed was at large, was sliding scale insulin. And we know this is a reactive approach that is used to manage blood sugar, mainly in the hospital settings, but the use, really on the outpatient side, should be discouraged. And last but not the least, you know there are many different insulin delivery options available in order to like Dr. Schuman said, besides considering patient specific factors in order to make sure that therapy is successful and safe for the patient, proper patient education regarding the technique, the storage, the disposal, the monitoring, sick day management, etc, needs to occur. Dr. Sean Kane 30:15 So I think that wraps up things quite nicely. If you want more information, you can visit our website at HelixTalk.com unfortunately, right now the website is locked for an accreditation visit, so we can't update it until mid November. So if you're looking for any previous episodes, just take a look around mid November, and you'll be able to see everything in terms of show notes and things like that. At that point, we are on Twitter at HelixTalk and continue those five star reviews. We love getting those. It really motivates us to keep these high quality episodes going, and we love hearing from the audience about what topics you would find interesting or what you want to hear about in the future as well. With that, I'm Dr Unknown Speaker 30:49 Kane, I'm Dr. Schuman, Dr. Khyati Patel 30:50 and I'm Dr. Patel, and as always, study hard. Narrator - Dr. Abel 30:54 If you enjoyed the show, please help us climb the iTunes rankings for medical podcasts by giving us a five star review in the iTunes Store, search for HelixTalk and place your review there Narrator - ? 31:05 to suggest an episode or contact us. We're online at HelixTalk.com thank you for listening to this episode of HelixTalk. This is an educational production copyright Rosalind Franklin University of Medicine and Science.