PHARMASTE · POCKET GUIDE
Diabetes
& insulin management
Focused adult pharmacy study guide. Use the exact medicine, device, indication, renal function and individual treatment plan. This is not a dosing protocol, a complete diabetes guideline, or a substitute for patient-specific care. Pregnancy, pediatrics and specialist diabetes technology need additional guidance.
1. Start with the person and the pattern
- Individualize targets with hypoglycemia risk, comorbidities, function, preferences and treatment burden. An A1C below 7% is a usual starting goal for many nonpregnant adults, not a universal requirement.
- Review fasting, postmeal and overnight readings, food intake, medicines, injection technique and access to supplies. A1C alone hides variability and low-glucose episodes.
- Fasting control with persistent postmeal elevation calls for a meal-related treatment review. Repeatedly escalating basal insulin can increase overnight lows.
- When CGM readings do not fit symptoms, check capillary glucose promptly and follow the individual safety plan. Keep a working glucose meter available.
Pause & recall
Fasting glucose is at goal but after-dinner readings are high. Why might more basal insulin be the wrong response?
Sources: ADA Standards of Care in Diabetes—2026, section 6 · ADA Standards of Care in Diabetes—2026, section 9 · ADA Standards of Care in Diabetes—2026, section 7
2. Match treatment to the clinical goal
| Decision | Practical checkpoint |
|---|---|
| Cardiorenal benefit | Assess ASCVD, HF and CKD. Choose agents with demonstrated benefit for the specific condition; these benefits need not depend on an elevated A1C. |
| Empagliflozin | Separate HF/CKD indications from glycemic effectiveness at low eGFR. Assess volume status and ketoacidosis risks. Withhold at least 3 days before surgery or prolonged fasting if possible; resume when stable and eating. |
| GLUMETZA (metformin ER) | Initiation is not recommended at eGFR 30–45; contraindicated below 30 mL/min/1.73 m². If function falls below 45 during treatment, reassess continuation. For labeled contrast-risk situations, hold, reassess eGFR at 48 hours and restart only if stable. |
| OZEMPIC injection | Start 0.25 mg weekly for 4 weeks, then 0.5 mg weekly; later escalation depends on the indication and response. A personal or family history of MTC, or MEN 2, is a contraindication. Do not exchange oral and injectable doses. |
| Incretin duplication | Do not routinely combine a DPP-4 inhibitor with GLP-1-based therapy; review discontinuation of the DPP-4 drug. |
Pause & recall
How can a medicine remain useful for kidney protection when its glucose-lowering effect is weaker?
Sources: ADA Standards of Care in Diabetes—2026, section 9 · JARDIANCE U.S. prescribing information, revised January 2026 · GLUMETZA U.S. prescribing information, revised August 2026 · OZEMPIC injection U.S. prescribing information, revised May 2026
3. Calculate from the prescribed plan
| Task | Worked example |
|---|---|
| Weight-based basal dose | Ordered 0.2 units/kg × 80 kg = 16 units daily. This calculates an order; it does not select a dose for every patient. |
| Meal coverage | At 1 unit per 12 g carbohydrate: 60 g ÷ 12 g/unit = 5 units. |
| Correction | At 1 unit per 40 mg/dL above a 130 target: (250 − 130) ÷ 40 = 3 units. Check active insulin, exercise, food and the written plan before combining doses. |
| Infusion rate | 100 units in a final 100 mL = 1 unit/mL. An order for 3 units/hour requires 3 mL/hour. Use the hospital protocol and monitoring. |
| Supply | Count prescribed doses plus device safety tests and other specified losses. Check each pen’s capacity, usable increments, package rules and product-specific in-use life. |
Pause & recall
What assumptions must be checked before adding a correction dose?
Sources: ADA Standards of Care in Diabetes—2026, section 9 · ADA Standards of Care in Diabetes—2026, section 16 · LANTUS U.S. prescribing information, revised May 2025
4. Treat the device as part of the medicine
- Check the exact insulin, concentration, device and dose window. TRESIBA U-200 FlexTouch delivers 2-unit increments; its window already shows units. Do not calculate a volume conversion or withdraw pen insulin into a syringe.
- Never share insulin pens, even after changing needles. Rotate injection sites and avoid abnormal or lumpy tissue.
- LANTUS must not be mixed or diluted. HUMALOG is taken within 15 minutes before or immediately after a meal; do not extend this instruction to all insulin formulations.
- For adults who miss TRESIBA, the label permits taking the daily dose during waking hours when discovered, with at least 8 hours between consecutive injections. Other products and pediatric patients have different instructions.
- Check each product’s storage and discard interval. Do not assume every insulin pen has the same in-use life.
Pause & recall
Why can a correct number of units still be impossible to deliver with a particular pen?
Sources: TRESIBA U.S. prescribing information, revised July 2022 · LANTUS U.S. prescribing information, revised May 2025 · HUMALOG U-200 patient information
5. Recognize and respond to hypoglycemia
- Below 70 mg/dL calls for action. Below 54 mg/dL is clinically significant; severe hypoglycemia is defined by needing assistance because of altered function, not by one glucose cutoff.
- For most alert adults able to swallow: take 15 g fast-acting glucose, recheck after 15 minutes and repeat if still low. AID users may need a smaller amount under their own plan.
- An unconscious person must not receive food or drink by mouth. Use prescribed rescue glucagon and call emergency help. For BAQSIMI, place on the side; active inhalation is unnecessary. Follow the product instructions for repeat dosing and recovery.
- Recurrent lows require regimen reassessment, education and a prevention/rescue plan even if A1C seems satisfactory.
Pause & recall
What changes when a person cannot swallow safely?
Sources: ADA Standards of Care in Diabetes—2026, section 6 · BAQSIMI U.S. prescribing information
6. Identify an emergency; monitor treatment
- DKA involves significant ketosis and metabolic acidosis. It can occur without marked hyperglycemia, particularly with an SGLT2 inhibitor. Vomiting, abdominal pain, rapid breathing or confusion need urgent assessment.
- HHS combines marked hyperglycemia, hyperosmolality and dehydration with little significant ketosis or acidosis. It is an emergency, not merely an elevated glucose reading.
- In adult DKA with potassium below 3.5 mmol/L, replace potassium and defer insulin until potassium is above 3.5. Use monitored protocols for fluid, insulin and electrolyte treatment.
- As DKA glucose falls below 250 mg/dL, add dextrose and adjust insulin per protocol while continuing to resolve ketosis and acidosis. Glucose normalization alone is insufficient.
Pause & recall
Why does glucose below 250 mg/dL not prove that DKA has resolved?
Sources: ADA/EASD and partner societies: Hyperglycemic crises consensus, 2024 · JARDIANCE U.S. prescribing information, revised January 2026
7. Connect insulin to nutritional intake
- Type 1 diabetes requires basal insulin even when NPO, with individualized adjustment and monitoring. Hold nutritional meal coverage when food is not given; use the ordered correction plan.
- For noncritically ill adults needing subcutaneous insulin with poor intake, basal plus correction is generally preferred. With adequate intake, include nutritional coverage. Prolonged correction-only treatment is discouraged for most patients.
- At transitions of care, confirm the exact regimen, devices, access to monitoring and rescue supplies, and clear follow-up instructions.
Pause & recall
What part of insulin therapy is still necessary in type 1 diabetes while fasting?
Abbreviations
- A1C
- glycated hemoglobin
- CGM
- continuous glucose monitoring
- AID
- automated insulin delivery
- ASCVD
- atherosclerotic cardiovascular disease
- HF
- heart failure
- CKD
- chronic kidney disease
- eGFR
- estimated glomerular filtration rate
- SGLT2
- sodium–glucose cotransporter 2
- GLP-1
- glucagon-like peptide 1
- DPP-4
- dipeptidyl peptidase 4
- DKA
- diabetic ketoacidosis
- HHS
- hyperosmolar hyperglycemic state
- NPO
- nothing by mouth
- IV
- intravenous
- MTC
- medullary thyroid carcinoma
- MEN 2
- multiple endocrine neoplasia type 2
Sources & verification
Sources checked September 28, 2026. Includes the 2026 ADA Standards, current product labeling and the 2024 adult hyperglycemic-crisis consensus. Doses and clinical decisions require current, patient-specific verification.
- ADA Standards of Care in Diabetes—2026, section 6 https://diabetesjournals.org/care/article/49/Supplement_1/S132/163927/6-Glycemic-Goals-Hypoglycemia-and-Hyperglycemic
- ADA Standards of Care in Diabetes—2026, section 9 https://diabetesjournals.org/care/article/49/Supplement_1/S183/163934/9-Pharmacologic-Approaches-to-Glycemic-Treatment
- ADA Standards of Care in Diabetes—2026, section 7 https://pmc.ncbi.nlm.nih.gov/articles/PMC12690173/
- JARDIANCE U.S. prescribing information, revised January 2026 https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=faf3dd6a-9cd0-39c2-0d2e-232cb3f67565
- GLUMETZA U.S. prescribing information, revised August 2026 https://www.accessdata.fda.gov/drugsatfda_docs/label/2026/021748s031lbl.pdf
- OZEMPIC injection U.S. prescribing information, revised May 2026 https://www.novo-pi.com/ozempic.pdf
- ADA Standards of Care in Diabetes—2026, section 16 https://diabetesjournals.org/care/article/49/Supplement_1/S339/163925/16-Diabetes-Care-in-the-Hospital-Standards-of-Care
- LANTUS U.S. prescribing information, revised May 2025 https://products.sanofi.us/lantus/lantus.pdf
- TRESIBA U.S. prescribing information, revised July 2022 https://www.novo-pi.com/tresiba.pdf
- HUMALOG U-200 patient information https://pi.lilly.com/us/humalog-u200-ppi.pdf
- BAQSIMI U.S. prescribing information https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=32ba41fa-4158-40af-8cb2-03693c248994
- ADA/EASD and partner societies: Hyperglycemic crises consensus, 2024 https://link.springer.com/article/10.1007/s00125-024-06183-8
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