T1D management in the hospital

Type 1 and LADA
1

I’m attempting to anticipate and prepare for successful management of my diabetes in the hospital. I’m a well-controlled T1D using an animal-based way of eating and dosing insulin with DIY Loop. My A1Cs for many years have been < 5.6, low glucose volatility, and use < 30 insulin units per day.

What I’m trying to prepare for is the circumstance where my cognitive ability and/or physical ability are impaired such that the hospital takes me off of Loop and puts me on MDI. Hospitals are notorious for running blood glucose high as they wish to avoid hyperglycemia.

I’m aware of the many reasons that patients run high blood sugar in the hospital including post surgical healing, injury, and steroid medications to name a few. Those are known “wild cards” that I must deal with. What I’m trying to manage is deliberate and unnecessary under-dosing of insulin.

High blood glucose, in these circumstances, I believe, run an unnecessary risk of hospital aquired infections as well are delayed healing from an injury or surgery. I just can’t forget how hard it is to control BGs when a bacterial infection occurs.

The hospital that I will most likely be admitted to luckily has an “endocrinology consult service” comprised of staff from the diabetes clinic that I’ve been seeing 4x/year for the last 8 years. I’ve verified that the hospital formulary only has 1 basal insulin, Glargine (Lantus). It uses Lispro (Humalog) as its nutrition/correction insulin.

If it were my choice, I would not pick Glargine as my basal insulin, but this is not a fight I choose to make. Instead, I want to get some real world experience with Glargine, have the results of my experimentation inserted into my record, and move on with life.

I’m a 71 year old single man. My adult daughter (she lives nearby) has power of attorney for health for me. In addition to experimenting with the hospital formulary insulin, I want to write a few pages of instruction that I can give my daughter who can then advocate for me. Things like, “patient must be given basal insulin, at least once per day, regardless of whether he is eating or not.”

This seems like diabetes 101 to me, yet I’ve run into plenty of T1D ignorance in health care professionals. To be fair, doctors and nurses are under tremendous pressure in the hospital and I think the patient and their advocate must be careful observers and diplomatically engage the staff. We play a critical role in the whole equation.

If you’ve read this far, thanks. My questions relate to the use of Glargine. My recent 14-day daily average of DIY Loop basal insulin was 15.1 units. What would be a good 1x/day starting dose?

I’ve heard that many people have had better success with Glargine, dosing 2x/day. I’ve read that people often dose at bedtime and upon arising. Anyone have success with this regimen?

2

I suggest you try it at home first and work out the details before your hospital stay. On MDI, there is no stopping the insulin once you inject so be aware of that risk if you don’t eat etc.
if I were you I would start at 15, and split the dose. 7.5 at breakfast and 7.5 at night along with your meal boluses.
I have an odd metabolism where if I split my dose, I end up going low while I’m sleeping, at the same time I have a significant predawn spike at 3:30 am.
Not sure if they have a keto diet available in the hospital, but you might be able to bring in your own food depending on hospital rules and your doctor, a meal that you already know how to dose might be exactly what you need.
I like Lantus as a basal insulin, but I definitely prefer a pump on humalog.
For. Short stay it won’t matter if you go a little higher than normal, there is no way the hospital staff will allow you to keep tight control as generally thay treat lows at 85 mg/ dl.
I had a conversation with a nurse many years ago when she brought me orange juice after a fingerstick of 82, and I told her it’s was perfect and she said my doctor ordered it.
Keep in mind she brought that juice 45 min after the test.
If you and or your daughter can manage your sugars on your own , I highly recommend it

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Thanks, Timothy. It’s my intention to try this new protocol (to me) at home, long before any hospitalization. I have no imminent hospital stay on the horizon, I just want to run through some scenarios so that I can comment in writing and hopefully make my daughter’s life a little easier.

I understand the difficulty you faced with the split dose Lantus and the dawn phenomena. These are the things I’d hope to learn with trial and error.

Yeah, if there’s any way I can manage on my own, that’s what I’d do. I’d have a hard time dealing with a “doctor-ordered orange juice to treat an 85 ‘low’ 45-minutes after the low,” sheesh! Did that nurse have a serious look on her face?

4

You have to know in advance that nurses are overworked. They also don’t really always understand the reality.
This nurse had doctors orders and she showed me that they are to treat anything under 85. I took the OJ but I didn’t drink it
The fact that it took 45 min was just the reality. Same as insulin coming after food was delivered so I would stare at my food until my insulin was injected. But that only happened once, the other 2 times, I managed my insulin and testing all on my own and they would just ask me what I took for the record

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5

This!

I probably should have posted my comment that referenced this issue here instead.

As to glargine, I’ve posted before about how I dislike it, but if that’s all that’s available, ok*. You know it’s not a flat curve, but as you say, hospital stays amplify so many other variables, not least of which are the steroid possibilities you mention, so in the end, it’s really about bolus management of highs.

Basic instructions, however archaic to you and most others here, are probably good, kept short and simple for her to be able to share with hospital staff, and additional detail just for her. If your daughter’s anything like you, she’ll be a highly knowledgeable advocate if/when needed :slightly_smiling_face:

*Can’t recommend dosage but since it sounds like you can experiment beforehand, that’s certainly the best way to find out imho. Twice a day would help flatten the overall curve for sure, but now you’re adding complication to the hospital regime so that’s a consideration too.

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I’m working on my written instructions meant for my daughter in her role as advocate. Yet I do need to make her aware of the challenges of dealing with a professional staff that is often short of any mastery of diabetes and distracted by a hyper-phobia of hypo-glycemia.

My daughter does not know the complete details of managing glucose but she does have more diplomatic skills than me. That could make her more effective!

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