University of Virginia Health System

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Glargine Initiation Protocol in Type 2 Diabetes Insulin

Indications:

• 1. Patients on maximum recommended doses of combined oral agents with HgA1c >8%.
• 2. Patients on monotherapy who are not candidates for combined oral agents with HgA1c>8%.
• 3. Patients checking blood glucose at least once a day fasting.

Physician Orders:

• 1. Continue oral agents and add 10 units glargine at bedtime.

• 2. On a weekly basis, if the average fasting glucose is equal to or greater than 120 mg/dl and there has been no hypoglycemia (less than 80mg/dl) of 2 values or more weekly, increase the dose by the following:

• 3. The patient is contacted weekly for the average of the past weeks fasting blood glucose results.

• 4. Repeat the process until fasting glucose is less than 120 mg/dl and there has been no hypoglycemia (less than 80 mg/dl) of 2 values weekly.

• 5. Document progress of insulin adjustment and fasting blood glucose on long acting Insulin Initiation Protocol Tracking Form and Encounter Note. Communicate with physician as needed and report patient's progress every 3 weeks.

• 6. Once the patient has achieved target fasting blood glucose, without hypoglycemia as above, send summary note to physician stating target fasting blood glucose goal met. Encourage patient to continue to monitor blood glucose and guidelines for self-adjustment. If blood glucose values out of range despite patient self-adjustment, ask patient to notify physician.

•7.      Hyperglycemia:

• If the patient's blood sugar is greater than 300 mg/dl, with polyuria, polydypsia, weight loss and/or moderate or more ketones, immediate treatment is needed by MD and arrangements should be made accordingly for larger doses of insulin and fluids. ER referral or urgent clinic visit may be necessary.

Glargine Initiation Protocol in Type 2 Diabetes Insulin

•8.      Hypoglycemia:

• If the patient has a pattern of mild hypoglycemia at the same time of day that can not be explained by food or activity pattern, adjust the dose of insulin down by 10%, starting with at least a 2 unit titration. If the patient has blood glucose equal to or less than 60 mg/dl or needs help to recover from hypoglycemia, titrate insulin dose down by 20% and contact physician. Assess, teach, and reinforce necessary skills to treat mild episodes.

• If the patient experiences severe hypoglycemia, immediate, more aggressive titration down may be needed. If a single event occurs with an explained cause, such as too much insulin, skipped meal, unplanned exercise, insulin may not need adjustment. If one or more unexplained severe episodes have occurred, RN will document in patient's record and contact physician immediately.

•9.      Patient Education:

• Assess for family's knowledge of glucagon administration, hypoglycemia treatment and then intervene accordingly.

• Patients need to be advised on the importance of more frequent testing of blood sugars, with some 0300 readings and monitoring themselves for symptoms for the next 24 hrs after an episode of hypoglycemia (if the next hypoglycemia episode is within 24 hrs, glucose levels can drop much lower before hormonal counter-regulation and autonomic symptoms occur).

•10.  Follow-up:

• In all cases, request that the patient call in blood sugars weekly for further insulin titration instructions. Document progress on Diabetes Encounter Form and Insulin Adjustment Tracking Form. Keep physician informed of progress every 3 - 4 weeks. If the patient does not follow up with blood glucose results as agreed the protocol will be discontinued. Attempt to call patient three times and document on Diabetes Encounter Form and Insulin Adjustment Tracking Form. A termination letter will be sent to the patient and the referring physician.

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