diabetestalk.net

Npo And Insulin Administration

Brief Overview Of The Consequences Of Inpatient Hyperglycemia

Brief Overview Of The Consequences Of Inpatient Hyperglycemia

Mean Glucose & In-Hospital Mortality in 16,871 Patients with AMI (Reference: Mean BG 100-110 mg/dl) Kosiborod M et al. Circulation 2008:117:1018 Investigators evaluated 16,871 acute myocardial infarction (MI) patients hospitalized from January 2000 to December 2005. Using logistic regression models and C indexes, 3 metrics of glucose control (mean glucose, time-averaged glucose, hyperglycemic index), each evaluated over 3 time windows (first 24 hours, 48 hours, entire hospitalization), were compared with admission glucose for their ability to discriminate hospitalization survivors from nonsurvivors. Models were then used to evaluate the relationship between mean glucose and in-hospital mortality. In unadjusted analysis, higher mean hospitalization glucose was strongly associated with higher in-hospital mortality. As shown in the figure on the left, when mean hospitalization glucose was analyzed in increments of 10 mg/dL, there was a clear J-shaped relationship between glucose values and mortality rates. Although in the normal glucose range, patients without recognized diabetes had a lower mortality rate than patients with diabetes, their risk increased much more steeply at higher glucose levels, surpassing the risk of patients with diabetes at approximately 130 mg/dL. After multivariable adjustment, the nature of these relationships persisted. As shown in the figure on the right, higher mean hospitalization glucose continued to be strongly associated with higher in-hospital mortality. There was a statistically significant, gradual increase in the odds of in-hospital mortality with each 10-mg/dL incremental rise in mean hospitalization glucose levels above the threshold of 120 mg/dL. The odds of death associated with higher mean glucose rose steeply in patients without r Continue reading >>

An 18-year-old Patient With Type 1 Diabetes Undergoing Surgery

An 18-year-old Patient With Type 1 Diabetes Undergoing Surgery

Description of Case An 18-year-old Caucasian male with type 1 diabetes presented to the emergency department complaining of severe left knee pain and swelling after sustaining a knee injury that occurred during a high school football match. Joint effusions were visible and palpable above the left knee, and there was significant loss of smooth motion of the knee, passively performed. Plain X rays showed no signs of fractures. The patient had had type 1 diabetes for six years, and his insulin regimen consisted of insulin glargine, 35 units at 8:00 p.m., and insulin lispro, 23 units at 8:00 a.m. and 16 units at 8:00 p.m. The patient had no apparent complications related to type 1 diabetes. On examination he was alert, his pulse was 76 bpm regular, and his blood pressure was 118/66 mm Hg. Recently, the patient had had frequent episodes of both hyperglycemia and hypoglycemia. However, he had never developed diabetic ketoacidosis (DKA). His recent HbA1c was 9.5%, demonstrating inadequate glycemic control. The patient was referred to an orthopedic surgeon, and arthroscopy was scheduled a few days later. A complex tear of the medial meniscus extending to the articular surfaces was diagnosed. Partial meniscectomy was recommended. (This procedure usually takes about one hour—nonetheless, the preoperative preparation for general anesthesia and the postoperative recovery may add several hours to this time.) When Would You Have This Patient Report to the Hospital? The Day before Surgery or the Morning of Surgery? This patient should be hospitalized no later than the evening before surgery, given his history of frequent episodes of hypo- and hyperglycemia and his poor glycemic control. This should allow for final optimization of glucose control before surgery. Ideally, frequent con Continue reading >>

Basal-bolus Insulin

Basal-bolus Insulin

Multiple Daily Subcutaneous Injections (Non-ICU Protocol) What is Basal Insulin? Basal insulin is long-acting and maintains steady, continuous level of insulin during the day and night resulting in better control when no food is eaten at bedtime. Basal insulin is 40-50% of Total Daily Dose (TDD). Per Basal Bolus Insulin: Non ICU Protocol, Basal Insulin may be ordered as: Basal Insulin: Glargine (Lantus): ____ units SubQ at bedtime. Contact physician prior to administration if blood glucose is less than 70. Basal Bolus can be given at any time of the day; it just has to be administered at the same time each day. Per the Garden City Hospital Basal Bolus Insulin: Non-ICU Protocol, basal insulin is scheduled at bedtime. What is Bolus Insulin? Bolus insulin is short-acting insulin to cover nutritional needs. · Nutritional Insulin (50-60% of Total Daily Dose) to cover patients eating meals, tube feeding, or TPN. · Correction Dose Insulin to be administered in addition to scheduled nutritional insulin dose to correct hyperglycemia (May be used alone to establish Total Daily Dose) How is Nutritional Insulin Administered? · If the patient is eating meals or receiving bolus tube feedings, the blood glucose would be checked AC and HS before insulin is administered. Per Basal Bolus Non ICU Protocol, administer Novolog (insulin aspart) at breakfast, lunch, and dinner as ordered by the physician. · Administer Novolog when the food tray is present. · Do not administer Novolog if the patient is not receiving a meal or bolus tube feedings. · Do not administer if the patients blood glucose is <70 mg/dl and symptomatic. Follow the Hypoglycemic Protocol and contact physician. · If the patient is receiving continuous tube feeding or TPN, use Human Regular Insulin per Ba Continue reading >>

Perioperative Management Of The Diabetic Patient

Perioperative Management Of The Diabetic Patient

Perioperative Management of the Diabetic Patient Author: Mira Loh-Trivedi, PharmD; Chief Editor: William A Schwer, MD more... Diabetes mellitus (DM) is an increasingly common medical condition affecting approximately 8% of the population of the United States. Of these 25 million people, it is estimated that nearly 7 million are unaware that they have the disease until faced with associated complications. [ 1 , 2 ] The prevalence of DM is even greater in hospitalized patients. The American Diabetes Association conservatively estimates that 12-25% of hospitalized adult patients have diabetes mellitus (DM). With the increasing prevalence of diabetic patients undergoing surgery, and the increased risk of complications associated with diabetes mellitus, appropriate perioperative assessment and management are imperative. An estimated 25% of diabetic patients will require surgery. Mortality rates in diabetic patients have been estimated to be up to 5 times greater than in nondiabetic patients, often related to the end-organ damage caused by the disease. Chronic complications resulting in microangiopathy (retinopathy, nephropathy, and neuropathy) and macroangiopathy (atherosclerosis) directly increase the need for surgical intervention and the occurrence of surgical complications due to infections and vasculopathies. [ 3 , 4 , 5 , 6 ] Infections account for 66% of postoperative complications and nearly one quarter of perioperative deaths in patients with DM. Data suggest impaired leukocyte function, including altered chemotaxis and phagocytic activity. Tight control of serum glucose is important to minimize infection. In addition to postoperative infectious complications, postoperative myocardial ischemia is increased among patients with DM undergoing cardiac and noncardiac su Continue reading >>

13. Diabetes Care In The Hospital

13. Diabetes Care In The Hospital

Consider performing an A1C on all patients with diabetes or hyperglycemia admitted to the hospital if not performed in the prior 3 months. C Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold ≥180 mg/dL (10.0 mmol/L). Once insulin therapy is started, a target glucose range of 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for the majority of critically ill patients A and noncritically ill patients. C More stringent goals, such as 110–140 mg/dL (6.1–7.8 mmol/L) may be appropriate for selected critically ill patients, as long as this can be achieved without significant hypoglycemia. C Intravenous insulin infusions should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin infusion rate based on glycemic fluctuations and insulin dose. E A basal plus bolus correction insulin regimen is the preferred treatment for noncritically ill patients with poor oral intake or those who are taking nothing by mouth. An insulin regimen with basal, nutritional, and correction components is the preferred treatment for patients with good nutritional intake. A The sole use of sliding scale insulin in the inpatient hospital setting is strongly discouraged. A A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. A plan for preventing and treating hypoglycemia should be established for each patient. Episodes of hypoglycemia in the hospital should be documented in the medical record and tracked. E The treatment regimen should be reviewed and changed if necessary to prevent further hypoglycemia when a blood glucose value is <70 mg/dL (3.9 mmol/L). C There should be a structured discharge plan tailored to the individual p Continue reading >>

Peri-operative Glycemic Control

Peri-operative Glycemic Control

The challenge of peri-operative glycemic control Surgery and general anesthesia frequently lead to imbalances in glucose control, both intra-operatively and in the peri-operative period. These imbalances can occur in diabetic and non-diabetic patients and involve a complex relationship between patient factors such as baseline glucose control and underlying comorbidities and surgical/operative factors such as procedure complexity and type of anesthesia. The post-operative period brings additional challenges such as unpredictability in nutritional intake, hyperalimentation, and later, post-surgical complications such as sepsis. Peri-operative hyperglycemia has been identified as a risk factor for morbidity and mortality. Intensive insulin therapy (IIT) has been shown to decrease post-operative infection rates and improve mortality in cardiac surgery patients. However, IIT has also been linked to increased incidence of severe hypoglycemia and related adverse events. Furthermore, the generalizability of specific blood glucose targets over a wide patient population is unclear; initial research showing improved outcomes with IIT in cardiac surgery patients has not played out in other patient groups. The Hospitalist physician deals with peri-operative glycemic management in several settings. In the pre-operative clinic the Hospitalist must assess the surgical suitability of patients with disorders of glucose control. Patients with baseline diabetes have increased incidence of post-operative morbidity and mortality largely due to increased cardiovascular complications and poor wound healing. Also in the pre-operative setting, the Hospitalist is expected to formulate a plan for management of glucose control in the days leading up to surgery. In the inpatient peri-operative sett Continue reading >>

Overview

Overview

Increasing data show a strong association between hyperglycemia and adverse inpatient outcomes. The American Diabetes Association and the American College of Clinical Endocrinology recommend all glucose levels be below 180-200 mg/dL in non-critically ill patients. Since hospitalizations are unstable situations, even patients who are well controlled on non-insulin agents as outpatients are usually best managed with insulin while they are inpatients. Insulin may be safely administered even to patients without previously diagnosed diabetes. As long as the prescribed doses are below what is normally produced by the pancreas, the patient will not become hypoglycemic. If the glucose level drops, endogenous insulin secretion will reduce to compensate. The total daily insulin requirement in insulin-sensitive patients (e.g., type 1 diabetes mellitus [T1DM]) is approximately 0.5-0.7/units/kg/day. Insulin requirements in patients with insulin-resistant type 2 diabetes may vary greatly and can exceed 1-2 units/kg/day. A conservative estimate for initial insulin therapy in any inpatient with hyperglycemia is to start with the T1DM dose (i.e., approximately 0.5-0.7 units/kg/day). · Effective inpatient insulin regimens typically include 3 components · Basal insulin (e.g., scheduled NPH, insulin glargine [Lantus], or insulin detemir [Levemir]), which is used to manage fasting and pre-meal hyperglycemia. Generally half of the total daily insulin dose. · Nutritional or prandial insulin (e.g., scheduled regular insulin, insulin lispro [Humalog], insulin aspart [Novolog], or insulin glulisine [Apidra]), which controls hyperglycemia from nutritional sources (e.g., discrete meals, tube feedings, total parenteral nutrition [TPN], IV dextrose). Generally half of the total daily insuli Continue reading >>

Clinical Correlations

Clinical Correlations

Commentary by Mary Vouyiouklis MD, Fellow, and Ann Danoff MD, Director, Division of Endocrinology, Diabetes and Metabolism, NYU Medical Center Welcome to Case 3 of ourspecial diabetes series intended to highlight the essentials of diabetes care in the inpatient setting. For the next several weeks, we plan to present individual cases followed by some management questions and answers. 3A. Mr. Mejia is a 30 year old man with Type 1 diabetes who is admitted for shortness of breath. He is made NPO for an imaging study the following morning. His usual insulin regimen is 10 units of rapid acting insulin qAC and 18 units of glargine qHS. You are covering for your co-intern and the nurse calls you asking you if you need to make any adjustments given that he is now NPO. What do you do? Discontinue the qAC but continue the qHS. Discontinue the qAC and half the qHS dose. Discontinue all and start a sliding scale. 3B. Mr. Mejia becomes hypoxic and unfortunately has to be intubated. He now is given continuous tube feeds. What are the adjustments (if any) that need to be made now? Patients with type 1 diabetes have an absolute requirement for insulin, therefore basal insulin replacement is an absolute requirement to prevent ketoacidosis, even when they are NPO. In this instance, the patients qHS dose is providing < 50% of his/her TDD therefore it is reasonable to continue with this and to hold the pre-meal bolus dosing while the patient remains NPO. Although patients with T2DM may not be at risk for DKA, if insulin is not administered when they are NPO, these patients should receive to 2/3rds of their basal insulin dose, depending upon degree of previous glycemic control, as assessed by report of fingerstick monitoring and/or recent HgA1C results. An insulin drip would be ideal for a Continue reading >>

Managing Glucose Levels In Hospital Patients

Managing Glucose Levels In Hospital Patients

Managing glucose levels in hospital patients Author: Stacey A. Seggelke, MS, RN, ACNS-BC, BC-ADM, CDE, Over the last 25 years, more than twice as many patients have been discharged from U.S. hospitals with a diagnosis of diabetes mellitus (DM). In 2006, the number reached an estimated 5.2 million. The increase stems from many factors, including the overall rise in obesity, which parallels the increase in type 2 diabetes. Typically, about 25% of hospital patients have a diagnosis of DM or hyperglycemia during their hospital stay. Historically, managing hyperglycemia in the hospital has been seen as secondary to managing the admitting diagnosis. But a growing body of literature supports targeted glucose control, because hyperglycemia in hospital patients can prolong lengths of stay, increase the infection risk, and raise mortality. This article, which addresses glucose management in hospital patients who arent critically ill, is based largely on guidelines from the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE). Generally, hyperglycemia in hospital patients is classified as known DM, newly diagnosed DM, or stress hyperglycemia. Known DM applies to patients with preexisting type 1, type 2, or gestational diabetes. Newly diagnosed DM refers to patients newly diagnosed during their hospital stay who meet ADA diagnostic criteria. A hemoglobin A1c (HbA1c) level of 6.5% or higher indicates DM and reflects an average blood glucose (BG) level of 140 mg/dL. The HbA1c test indicates the average BG level over the preceding 2 to 3 months; an elevated HbA1c level indicates the patients BG level was high before admission. Hospital patients with HbA1c levels of 6.5% or higher usually are classified as newly diagnosed, even though th Continue reading >>

Targets For Protective Action Of Insulin

Targets For Protective Action Of Insulin

fuel and energy metabolism glucose free fatty acids reactive oxygen species nutritional status coagulation pathway inflammatory pathway endothelium protection against vessel wall inflammatory processes vasodilatory action heart host defenses against infection Noncritically ill Fasting glucose < 126 mg /dL and all random glucoses < 180 - 200 mg /dL Critically ill Blood glucose levels should be kept as close to 110 mg /dL as possible and generally < 140 mg /dL These patients require an intravenous insulin protocol that has demonstrated efficacy and safety in achieving the desired glucose range without increasing risk for severe hypoglycemia Deciding whether to maintain the ambulatory treatment plan in the hospital 8 12 6 10 The Pattern of Insulin Requirement during Normal Health, Meal Plan, and Activity is Not Necessarily Reproduced in the Hospital Scheduled subcutaneous insulin Which pattern of carbohydrate exposure describes the patient ? Discrete meals Negligible carbohydrate Continuous carbohydrate exposure Transitional meal plan / grazing Daytime grazing / overnight enteral feedings Constructing a profile for scheduled subcutaneous insulin …. 6 pm 12 am 6 am 12 pm Glargine NPH SQ Regular Lispro / Aspart / Glulisine Requirement for exogenous insulin during prolonged fasting may disappear in type 2 DM, but even during prolonged fasting it is absolute in type 1 DM type 1 DM type 2 DM requirement for exogenous basal insulin vs time fasting A Bad Practice: 70/30 Insulin plus Sliding Scale Scheduled or routine 0800 & 1700 Q4HRS, or 0200, 0600, 1000, 1400, 1800, 2200 This means 8 shots daily. There is a risk of stacking, & BG tests fail to synchronize: 0200, 0600, 0800, 1000, 1400, 1700, 1800, 2200 Sample “consistent carbohydrate†meal plan order with †Continue reading >>

Inpatient Insulin Therapy: Benefits And Strategies For Achieving Glycemic Control: Case-based Strategies For Optimizing Insulin In The Hospital Setting

Inpatient Insulin Therapy: Benefits And Strategies For Achieving Glycemic Control: Case-based Strategies For Optimizing Insulin In The Hospital Setting

One common treatment error is to push the dose of basal insulin in order to cover prandial needs. This might go unrecognized if the only blood glucose that is seen in the ambulatory setting is the fasting glucose. The physician might see that the fasting sugar is all right every day and that the A1C is 8.5%. No other sugars are looked at. The basal dose of insulin might have been increased to as much as 72 or more units a day titrating to target to get that fasting reading normal without attention being given to what happened throughout the day. Long-Acting Analog Sometimes Is Misused, Through Forced Titration to a High Daily Dose, Playing Catch-up Overnight for Insufficient Prandial Coverage A patient like this is at some risk upon entering the hospital because under the condition of awaiting surgery or awaiting a procedure, the over treatment with basal insulin might become manifest as a continued downward trend. For Patients Receiving Insufficient Prandial Coverage, Overdoses of Long-Acting Analog (Glargine or Detemir) Established as Home Therapy May Spell Hypoglycemia Once the Patient Is in the Hospital The basal dose has been cranked up to correct hyperglycemia and to create a certain rate of fall of blood glucose. Some kind of strategy has to be put in place prior to admitting a patient of this kind. Unfortunately, the strategy that is used all too often is simply to add on sliding scale when the patient suddenly has a recognized high sugar at bedtime on the evening before a procedure. Glargine or Detemir, Overdosed to Play Catch-up, Plus Sliding Scale! If a patient is being admitted from the office, some patients have their basal needs correctly established. For example, many patients with type 1 diabetes don't need any modification of their basal dose. Continui Continue reading >>

Transitioning Safely From Intravenous To Subcutaneous Insulin

Transitioning Safely From Intravenous To Subcutaneous Insulin

Current Diabetes Reports Authors Kathryn Evans Kreider, Lillian F. Lien Abstract The transition from intravenous (IV) to subcutaneous (SQ) insulin in the hospitalized patient with diabetes or hyperglycemia is a key step in patient care. This review article suggests a stepwise approach to the transition in order to promote safety and euglycemia. Important components of the transition include evaluating the patient and clinical situation for appropriateness, recognizing factors that influence a safe transition, calculation of proper SQ insulin doses, and deciding the appropriate type of SQ insulin. This article addresses other clinical situations including the management of patients previously on insulin pumps and recommendations for patients requiring glucocorticoids and enteral tube feedings. The use of institutional and computerized protocols is discussed. Further research is needed regarding the transition management of subgroups of patients such as those with type 1 diabetes and end-stage renal disease. Introduction Intravenous (IV) insulin is used in the hospitalized patient to control blood sugars for patients with and without diabetes who may exhibit uncontrolled hyperglycemia or for those who need close glycemic attention. Common hospital uses for IV insulin include the perioperative setting, during the use of high-risk medications (such as corticosteroids), or during crises such as diabetic ketoacidosis (DKA) [1,2]. Other conditions such as hyperglycemic hyperosmolar state (HHS) and trauma frequently require IV insulin, as well as specific hospital units such as the cardiothoracic intensive care unit [3,4]. The correlation between hyperglycemia and poor inpatient outcomes has been well described in the literature [5,6]. The treatment of hyperglycemia using an IV Continue reading >>

Management Of Hospitalized Patients With Type 2 Diabetes Mellitus

Management Of Hospitalized Patients With Type 2 Diabetes Mellitus

Suboptimal glycemic control in hospitalized patients with type 2 (non–insulin-dependent) diabetes mellitus can have adverse consequences, including increased neurologic ischemia, delayed wound healing and an increased infection rate. Poor glycemic control can also affect the outcome of the primary illness. If possible, hospitalized diabetic patients should continue their previous antihyperglycemic treatment regimen. Decreased physical activity and the stress of illness often lead to hyperglycemia in hospitalized patients with type 2 diabetes. When indicated, insulin is given either as a supplement to usual therapy or as a temporary substitute. The overall benefit of the traditional sliding-scale insulin regimen has been questioned. Insulin supplementation given according to an algorithm may be a logical alternative. Any antihyperglycemic regimen should be administered and monitored in a manner coincident with the intake of food or other sources of calories. Factors that can alter glycemic control acutely, including specific medical conditions and medications, should be identified and anticipated. Diabetes mellitus is a common secondary diagnosis in hospitalized patients. In 1988, diabetes was one of the diagnoses recorded for 2.8 million patients discharged from hospitals in the United States. Altogether, these patients spent 24.5 million days in hospitals. Diabetes was the secondary diagnosis in more than 80 percent of these patients, with the most frequently listed primary diagnoses being circulatory and cardiovascular diseases.1 Patients with diabetes are hospitalized twice as often as those who do not have this disease, and they are likely to stay in the hospital 30 percent longer.2 Furthermore, annual insurance claims for inpatient care are four times higher amon Continue reading >>

Role Of Nursing In The Continuum Of Inpatient Diabetes Care

Role Of Nursing In The Continuum Of Inpatient Diabetes Care

Overview Hyperglycemia in the hospital setting Common Costly Associated with poor clinical outcomes Glycemic targets have been modified 140-180 mg/dL Insulin is the treatment of choice to manage hyperglycemia Hyperglycemia management requires multidisciplinary collaboration Nursing role is critical throughout hospitalization * Importance of Nursing Care for Improving Glycemic Control 24-hour coverage by nursing Nursing often coordinates, and is aware of, the multiple services required by patient Travel off unit, (eg, physical therapy, X-ray) Amount of food eaten (carbohydrates) Patient’s day-to-day concerns Order changes (by various providers) * Moghissi ES, et al. Endocrine Pract. 2009;15:353-369. Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38. Inpatient Glycemic Control Recommendations Identify elevated blood glucose in all hospitalized patients Implement structured protocols for control of blood glucose throughout the hospital Glucose targets: ICU: 140-180 mg/dL for most patients Noncritically ill: Fasting BG <140 mg/dL; random BG <180 mg/dL Create educational programs for all hospital personnel caring for people with diabetes Plan for a smooth transition to outpatient care with appropriate diabetes management * TPN, total parenteral nutrition. Carter L. Oklahoma Nutrition Manual, 12th ed. Owasso, OK: Oklahoma Dietetic Association; 2006. Factors Affecting Blood Glucose Levels in the Hospital Setting Increased counter-regulatory hormones Changing IV glucose rates TPN and enteral feedings Lack of physical activity Unusual timing of insulin injections Use of glucocorticoids Unpredictable or inconsistent food intake Fear of hypoglycemia Cultural acceptance of hyperglycemia * Glucose Control Deteriorates During Hospitalization Hyperglycemic Influences Continue reading >>

To Hold Or Not To Hold: Understanding Insulin

To Hold Or Not To Hold: Understanding Insulin

You’re about to walk into your patient’s room with a syringe full of insulin. The unit secretary shouts, “Hey. The physician just made your patient NPO.” Ugh...now what? Do you give the insulin? Do you hold it? Are you confident that you would know what to do every time? If you don’t, you’re not alone. However, by understanding the different CATEGORIES of insulin, I guarantee you will! There are 3 categories of insulin: Basal, Prandial (bolus), and Correction (sliding scale). Basal (Lantus, NPH, Levemir) This is the insulin your body needs just to meet its basal metabolic functions. Let’s say you decide not to eat for a day. If you’re NOT a diabetic, your cells still need glucose for energy, so your liver continuously kicks out a small amount of glucose (gluconeogenesis) – prompting your pancreas to secrete a small amount of insulin – to feed your body’s cells (energy). Remember? Insulin acts as the key to unlock the door of the cell to let the glucose in. If you ARE a diabetic and decide not to eat, your liver will still kick out glucose but since your pancreas doesn’t secrete insulin (Type I), all of your insulin needs, need to come exogenously (shot) – we need to give you a shot of basal insulin…even when you’re not eating – remember, the liver will still kick out glucose! 24 hours a day – 365 days a year – you have glucose in your bloodstream whether you’re eating it or your liver is kicking it out! Therefore, basal insulin should NEVER be held. Patients with Type I diabetes need basal insulin 24 hours a day. If they are NPO, the general rule of thumb is that they need ½ of their usual dose. For example, if they are on 50 units of Lantus a day, when they are NPO, they need approximately 25 units. Prandial (Novolog, Humalog) Its Continue reading >>

More in blood sugar