Long-Acting/Basal Insulin (DO NOT HOLD IF NPO)

• Insulin is needed even when a patient is not eating to control gluconeogenesis

• patients should NOT become hypoglycemic if basal insulin is dosed appropriately

• Type 2 DM:

  • • Patient should take 80% of the usual dose of long-acting basal insulin (Glargine or Detemir) the evening before the procedure

    • If the patient is on NPH (intermediate-acting basal): give the usual dose of bedtime NPH night before the procedure and decrease the usual dose of morning NPH by 50%  

• Type 1 DM: CANNOT HOLD BASAL INSULIN as this puts these patients at risk of DKA by the morning

  • • Patient should take 80% of the usual dose of long-acting basal insulin (Glargine or Detemir) the evening before the procedure

    • If the patient is on NPH (intermediate-acting basal): give the usual dose of bedtime NPH the night before the procedure and decrease the usual dose of morning NPH by 50%

BASAL INSULIN DOSING OPTIONS:

•  40-50% of calculated TDDI (total daily dose of insulin)

•  For patients with known basal insulin dosing, start with 80% of home dose

•  Weight-based dosing for type 1 diabetes 0.2 – 0.25 units/kg.

•  Weight-based dosing for type 2 diabetes 0.1 – 0.2 units/kg.

•  Weight-based dosing for patients with renal dysfunction 0.1 – 0.15 units/kg.

•  Fasting patients with type 1 diabetes should receive 80% of home basal dose when NPO.

  • Never discontinue basal insulin completely in patients with type 1 diabetes!

•  Fasting patients with type 2 diabetes should receive 50% of home basal dose when NPO.

Nutritional Insulin (HOLD IF NPO)

• Covers carbohydrate intake from food, dextrose in IV fluids, tube feeds, TPN

• Examples: 

  • • Rapid-acting: Aspart, Lispro, Glulisine

    • Short-acting—regular 

• On the morning of the procedure, do NOT give nutritional insulin as the patient is not eating

• Patient can continue correctional (SSI) insulin, if that is part of their regimen

• If the procedure is scheduled for the afternoon and the patient can eat in the morning, they can cover their mealtime insulin as usual (i.e. 14:30 PM procedure, the patient can eat before 06:30 AM)

NUTRITIONAL INSULIN DOSING OPTIONS:

•  50 -60% of TDDI split equally over each meal

  • Hold if meal is held

  • Discontinue if patient is made NPO

  • Give 50% if 50% of meal is eaten

•  Order an insulin-to-carbohydrate ratio (ICR)

  • Rule of 500: 500/TDDI = ICR

Oral Hypoglycemic Agents: 

• Administer medications that do not contribute to hypoglycemia

  • • Metformin*, DPP4-IVs (-gliptins), GLP1s (-tides) 

• Sulfonylureas (Glimepiride, Glyburide, Glipizide) and SGLT2s (Canagliflozin, Dapagliflozin, and Empagliflozin) should be HELD if the patient is NPO

Metformin and Metformin-containing drugs.

• Category 1 – In patients with no evidence of Acute Kidney Injury (AKI) and with eGFR≥30 mL/ min/1.73m2, there is no need to discontinue metformin either prior or following the intravenous administration of iodinated contrast media, nor is there an obligatory need to reassess the patient renal function post the test or procedure.

• Category 2 – In patients taking metformin who are known to have AKI or severe chronic kidney disease (CKD stage IV or stage V; i.e., eGFR < 30, or are undergoing arterial catheter studies that might result in emboli (atheromatous or other) to the renal arteries, metformin should be temporarily discontinued at the time or before the procedure, and withheld for 48 hours after the procedure and reinstituted only after renal function has been re-evaluated and found to be normal. 

  • For patients receiving Metformin, intravascular administration of iodinated contrast media can result in lactic acidosis. This rare complication occurs if the contrast medium causes renal failure and the patient continues taking Metformin. Therefore Metformin must be withheld if the patient is in category 2 after administering an iodinated contrast medium for 48 hours (during which the contrast-induced renal failure becomes clinically apparent) to avoid this potential complication. If renal function is normal at 48 hours, Metformin can be restarted

• Patients on Metformin (or an oral hypoglycemic agent containing Metformin) should follow up with their prescribing provider regarding the timing of restarting Metformin