Insulin dose pdf

The 7-year, randomized ORIGIN trial assessed the cardiovascular effects of insulin glargine versus standard care in more than 12, individuals with diabetes or pre-diabetes and found no increased risk of all-cancer-combined or of cancer mortality among glargine-treated individuals A recent review of large epidemiologic studies did not find evidence of an increased risk of malignancy among glargine-treated patients when compared with other insulin therapies However, mortality was not temporally associated with severe hypoglycemia.

The results of ACCORD support less aggressive diabetes management among patients at high risk for a cardiovascular event. The 7-year, randomized ORIGIN trial assessed the cardiovascular effects of insulin glargine versus standard care in more than 12, individuals with diabetes or pre-diabetes and found no increased risk of cardiovascular events or of cardiovascular mortality among glargine-treated individuals Autoimmune beta cell destruction results in a progressive decline in insulin production in patients with type 1 diabetes who eventually require insulin for survival.

Patients with type 1 diabetes generally require a replacement dose of 0. Intensive insulin therapy defined as 3 or more insulin injections daily or insulin pump therapy is indicated for patients with type 1 diabetes to provide better glycemic control with less glucose variability than 1 or 2 daily injections, and reduce the development and progression of microvascular and macrovascular complications 69 , 97 , The slowly progressive beta cell loss in patients with type 2 diabetes means many patients with type 2 diabetes will eventually require insulin therapy to attain adequate glycemic control.

When initiating insulin therapy in patients with type 2 diabetes, basal insulin is often used in combination with other non-insulin antihyperglycemic medications a patient is taking. An intermediate or long-acting insulin e. Basal insulin is effective at lowering HbA1c when added to oral hypoglycemic agents starting at a dose of 10 U daily or 0.

When used in patients uncontrolled on oral agents, basal insulin lowers HbA 1c 1. Basal insulin, by suppressing hepatic glucose output during the night, will control the fasting blood glucose FPG , while the other antihyperglycemic medications continue to control postprandial glucose levels throughout the day A starting dose of 10 units of basal insulin is commonly utilized, though starting a dose of 0.

In patients whose fasting glucose levels become well controlled with basal insulin, but whose glucose levels rise significantly high later in the day with a persistently elevated HbA1C, prandial insulin is indicated. At this point, the patient is experiencing beta-cell failure. If the patient is taking an insulin secretagogue e. However, other agents not having a predominantly insulin-stimulating effect should be continued.

Before starting a patient on insulin, or adjusting their current insulin therapy, it is important to establish glycemic goals tailored to the patient. The American Diabetes Association currently recommends individualized glycemic goals In the DCCT, retinopathy initially worsened during the first year in patients with type 1 diabetes who received intensive therapy This was associated with rapid lowering of glucose levels.

Thus, in patients with proliferative retinopathy or those with underlying non-proliferative diabetic retinopathy and a high A1C e. A functioning pancreas releases insulin continuously, to supply a basal amount to suppress hepatic glucose output and prevent ketogenesis between meals and overnight, and also releases a bolus of insulin prandially to promote glucose utilization after eating. Physiologic replacement requires multiple daily injections 3 or more or use of an insulin pump.

Providing basal-bolus insulin regimens allows patients to have flexibility in their mealtimes and achieve better glycemic control. When insulin is given once or twice daily, insulin levels do not mimic physiologic insulin release patterns. For people with type 2 diabetes, in whom bolus insulin replacement is not as critical, once or twice daily basal insulin injection regimens often work well with reasonable glycemic control achieved.

In patients with type 2 diabetes, a starting daily basal insulin dose can be calculated by multiplying 0. The basal insulin dose in type 2 patients is adjusted to attain a target fasting glucose level. If glycemic control is suboptimal, then more prandial insulin injections can be added before other meals NPH Figure 5a , insulin glargine Figure 5b , or insulin detemir are most often given at bedtime however insulin glargine and insulin degludec can be administered anytime of the day ; or for patients who eat large amounts of carbohydrates at dinner, an insulin mixture, regular and NPH or a premixed insulin, can be given prior to dinner Figure 5c.

Two-thirds of the insulin dose is typically given in the morning before breakfast and one-third is given before dinner. Premixed insulins can be used or a mixture of a short-acting insulin e. For patients who experience nocturnal hypoglycemia when NPH is administered at dinner with a short-acting insulin, moving the NPH dose to bedtime helps reduce the risk for nocturnal hypoglycemia Conversely, NPH at dinner can result in fasting hyperglycemia due to dissipation of insulin activity and the early morning rise in counter-regulatory hormones cortisol and growth hormone the dawn phenomenon.

Moving the NPH dose to bedtime can also help resolve this problem Figure 6b. An obvious limitation to using premixed insulin is reduced flexibility in dosing; if the dose is adjusted, both types of insulin in the mixture will be adjusted. Many different types of regimens are possible with multiple daily injections. Regular, insulin aspart, glulisine and lispro are used to provide prandial insulin.

NPH, insulin glargine, insulin detemir, and insulin degludec are used to provide basal insulin. Insulin pump or continuous subcutaneous insulin infusion CSII therapy is another option for intensive insulin therapy using only rapid-acting insulin. Insulin pump therapy is indicated in patients with type 1 diabetes, and in those with markedly insulin-deficient type 2 diabetes Patients initiated on insulin pump therapy need to have been trained in the components of intensive diabetes management or will not gain significant benefit from conversion to insulin pump therapy.

The components of intensive diabetes management include knowledge of carbohydrate counting and adjustments in the insulin bolus dose based on the carbohydrate content of meals and snacks, the measured glucose level, and the amount and duration of exercise. Some insulin pumps are able to deliver insulin boluses in as low as 0. The basal insulin infusion can be delivered in as low as 0.

Basal rate requirements are typically higher in the early morning hours to counter the dawn rise in glucose levels and lower in the afternoon when patients are more active and overnight when patients are at rest.

Temporary basal rates can be programmed to be increased during times of inactivity or illness when insulin requirements are higher, and decreased when physically active and insulin requirements are reduced. The bolus calculator function of insulin pumps helps patients determine insulin bolus doses required for the carbohydrate content of foods and the measured glucose level. This function is especially helpful when a patient needs to determine the amount of supplemental insulin required to correct a high postprandial glucose level.

The pump takes into account the active insulin remaining from the pre-meal bolus insulin-on-board , and recommends a reduced corrective supplemental insulin dose, thereby preventing insulin stacking and hypoglycemia. Potential benefits of insulin pumps include less weight gain, less hypoglycemia, and lowering of hemoglobin A1c levels when compared to multiple daily injections - The addition of continuous glucose monitoring to patients on insulin pumps has been shown to further improve glycemic control and reduce the frequency of symptomatic and severe hypoglycemia.

Insulin pumps are available with a threshold suspend function which can discontinue the basal insulin infusion for up to a period of 2. This prevents a further decline in glucose levels. The timing of the pre-meal insulin bolus can be reduced when the measured glucose level is low and lengthened when hyperglycemia is present before eating.

To best match the insulin action with the glycemic effect of meals, regular insulin is optimally given 30 minutes before the meal and the rapid-acting insulins minutes before the meal. Insulin pumps and multi-dose insulin injection regimens using basal analog insulin combined with a rapid-acting insulins provide patients with the greatest flexibility of varying the time of meals without sacrificing an increased risk of hypoglycemia, when compared with NPH-based insulin regimens.

Insulin doses should be adjusted to achieve glycemic targets. Hypoglycemia that is frequent or severe should prompt an immediate reduction in the responsible insulin dose. Increases to insulin doses should be based on the occurrence of consistently high glucose levels at a particular time of day, rather than periodic glucose elevations that are more likely diet-mediated.

When a dose of intermediate or long-acting insulin is adjusted, it is recommended to wait at least days before further changes in the dose to assess the response Basal insulin can be started either using 10 units or 0. The FPG is used to adjust the intermediate NPH , long-acting insulin glargine, detemir, or degludec given in the evening. Algorithms provided to patients to adjust their basal insulin dose based on fasting glucose levels have been shown to improve glycemic control An example of a forced titration schedule is show below Table 4 :.

Lower dose adjustments are used for more insulin sensitive patients usually type 1 patients and higher doses for more insulin resistant patients usually those with type 2 diabetes. A simple algorithm for patients with type 2 diabetes recommends adjusting the basal insulin dose by 2 units every 2 to 3 days if fasting glucose levels are consistently above the target upper range The rule of can be used to approximate the amount that 1 unit of supplemental insulin will lower the glucose, also termed the insulin sensitivity factor ISF , using the total daily dose TDD of insulin:.

In patients on set dose of prandial insulin, post meal glucose variability can be controlled by having patients keep the carbohydrate content of the meal similar at mealtimes from day to day. A more sophisticated type of prandial insulin regimen is one in which a patient doses their prandial insulin based on the number of carbohydrates eaten at the meal.

By learning how to count carbohydrates, and dosing their insulin accordingly, patients are afforded flexibility in the carbohydrate content of their meals. The rule of can be used to approximate the amount of carbohydrates covered by 1 unit of prandial insulin, termed the insulin to carbohydrate ratio ICR , using the total daily dose TDD of insulin:.

This ratio is adjusted based on post meal glucose levels and may be different for each meal. The ICR can also be used for snacks Carbohydrate counting can be challenging for some patients. Education in medical nutrition therapy is critical for patients on insulin. A comprehensive diabetes education class that teaches self-management skills, such as how to dose prandial insulin by matching it to the amount of carbohydrate intake is an excellent resource to facilitate patients in adopting an intensive insulin therapy regimen Exercise improves insulin sensitivity.

The effect of exercise on insulin sensitivity can last for many hours; so more than 1 insulin dose may need to be adjusted. After more prolonged exercise, the bedtime long acting insulin dose may need to be reduced should there be a pronounced fall in overnight glucose levels.

Self-monitoring of blood glucose SMBG allows patients and physicians to recognize glucose trends to guide insulin dosage adjustments. In those using short or rapid-acting inulin, SMBG also provides a patient with the information needed to give an accurate supplemental insulin dose to return a high glucose level back to the target glucose range.

Studies in patients with type 1 diabetes have shown a progressive reduction in hemoglobin A1C levels with more frequent glucose monitoring. Intermittent CGM has been associated with less time spent in hypoglycemia in patients with type 1 diabetes and in patients with type 2 diabetes , , and the real-time CGM has been associated with improved glycemic control, more so when used consistently, and less time spent in hypoglycemia, and less severe hypoglycemia in patients with type 1 diabetes.

Supplemental insulin doses to correct hyperglycemia can be given up to every 4 hours as needed for persistent hyperglycemia, or more often when the insulin on board from is taken into account. For patients using the bolus calculator function of their insulin pump, the recommend bolus dose to correct an elevated glucose level automatically takes into account the insulin still active insulin on board from prior insulin boluses. Goldfine, M. Turn recording back on.

National Center for Biotechnology Information , U. Contents www. Search term. Table 1. Factor Comment Exercise of injected area Strenuous exercise of a limb within 1 hour of injection will speed insulin absorption. Clinically significant for regular insulin analogs. Local massage Vigorously rubbing or massaging the injection site will speed absorption. Temperature Heat can increase absorption rate, including use of a sauna, shower, or hot bath soon after injection. Cold has the opposite effect.

Site of injection Insulin is absorbed faster from the abdomen. Less clinically relevant with rapid-acting insulins, insulin glargine, and insulin detemir. Lipohypertrophy Injection into hypertrophied areas delays insulin absorption.

Jet injectors Increase absorption rate. Insulin mixtures Absorption rates are unpredictable when suspension insulins are not mixed adequately i. Insulin dose Larger doses delay insulin action and prolong duration. Physical status soluble vs. Elimination The kidneys and liver account for the majority of insulin degradation. Table 2. Table 3. Insulin Onset hr. Peak hr. Duration hr. Patient specific onset, peak, duration may vary from times listed in table. Rapid-Acting Prandial or Bolus Insulin Analogs Rapid-acting analogs result from changes to the amino acid structure of human insulin which lead to decreases in hexameric insulin formation after injection into the SQ space.

Intermediate-Acting Insulins NPH NPH Neutral Protamine Hagedorn insulin, was created in after it was discovered that the effects of subcutaneously injected insulin could be prolonged by the addition of the protein protamine. Follow-on Biologic Insulins Relative to the production of other medications, the production of a biologically similar insulin is a more complicated process, which contributes to reduced cost savings in purchasing insulin.

Weight Gain Weight gain is a common side effect of insulin therapy. Local Reactions True allergic reactions and cutaneous reactions are rare with human insulin and insulin analogs. Mitogenic Properties Several retrospective, observational studies have shown correlations between insulin dose and cancer risk for most insulin types human insulin, aspart, lispro or glargine 89 - Non-Physiologic Insulin Replacement When insulin is given once or twice daily, insulin levels do not mimic physiologic insulin release patterns.

Twice-Daily Insulin Regimen Split-Mixed and Pre-Mixed Regimens Two-thirds of the insulin dose is typically given in the morning before breakfast and one-third is given before dinner. Insulin Pump Therapy Insulin pump or continuous subcutaneous insulin infusion CSII therapy is another option for intensive insulin therapy using only rapid-acting insulin.

Adjustment of Intermediate to Long-Acting Insulin When a dose of intermediate or long-acting insulin is adjusted, it is recommended to wait at least days before further changes in the dose to assess the response An example of a forced titration schedule is show below Table 4 : Table 4.

Forced Titration Algorithm. Table 5. Basal insulin Forced Titration Algorithm:. Time Breakfast Lunch Dinner Bedtime Blood Glucose Extra units of Short or Rapid-acting insulin Extra units of Short or Rapid-acting insulin Extra units of Short or Rapid-acting insulin Extra units of Short or Rapid-acting insulin 0 0 0 0 2 2 2 0 4 4 4 2 6 6 6 4 8 8 8 6 10 10 10 8 Over 12 12 12 Carbohydrate Counting In patients on set dose of prandial insulin, post meal glucose variability can be controlled by having patients keep the carbohydrate content of the meal similar at mealtimes from day to day.

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Insulin pump therapy in the 21st century. Strategies for successful use in adults, adolescents, and children with diabetes. Postgrad Med. Pickup J, Keen H. The insulin to carbohydrate ratio may vary during the day. Example: 1. Also, there are many variations of insulin therapy. You will need to work out your specific insulin requirements and dose regimen with your medical provider and diabetes team.

Self-assessment Quiz Self assessment quizzes are available for topics covered in this website. To find out how much you have learned about Insulin Therapy, take our self assessment quiz when you have completed this section. The quiz is multiple choice.

Please choose the single best answer to each question. At the end of the quiz, your score will display. What is an intensive insulin regimen?

When you are intensively managed with insulin your medical provider will prescribe an insulin regimen for you, but these are the general principles: Your insulin regimen will include: 1. A basal or background insulin dose 2.

A bolus insulin dose to cover the sugar or carbohydrate in your food This will be presented as an insulin to carbohydrate ratio I:CHO. The I:CHO tells you how many grams of carbohydrate can be covered by one unit of rapid acting insulin 3. A high blood sugar correction bolus insulin dose to bring your blood sugar back into the target range. This will be presented as a correction factor.

This correction factor refers to how much your blood sugar will drop after 1 unit of insulin rapid acting insulin. With an insulin pump, insulin aspart, glulisine or lispro provide both basal and bolus insulin replacement.

Sliding Scale Therapy Sliding scale therapy approximates daily insulin requirements. The term "sliding scale" refers to the progressive increase in pre-meal or nighttime insulin doses. Sliding scale insulin regimens approximate daily insulin requirements. You take the same long-acting insulin dose no matter what the blood glucose level. Points To Remember! As the nighttime scale only considers the amount of insulin required to drop your blood sugar level back into the target range, it should not be used to cover a bedtime snack.

In other words, while the foods may change, the time and the carbohydrate content of the meal should not vary. Try not to vary the timing, type or duration of activity. However, to be successful, it requires a strict adherence to a consistent schedule of meals and activity, and following your prescribed diet.

There are many variations to these regimens. Check with your provider and diabetes team to determine which one is best for you. Insulin Treatment Tips Know which situations might require a change in dosage. If you're sick or gain weight, you might need a higher insulin dose; if you exercise more or lose weight, you might need a lower one. New kinds of insulin and delivery systems are always being developed that could change your dose and schedule.

The expiration date applies to unopened, refrigerated insulin. Read the label. Do not miss any doses of insulin. Contact your doctor to discuss specific instructions in case you miss a dose of insulin. Keep a record of all medicines and doses with you. Include non-prescription medicines, herbs, vitamins, minerals and dietary supplements. Share this list with all your health care providers, and if possible, bring all your medicine bottles to your visits.

Try to use only one pharmacy so the pharmacist has a record of all your medicines to reduce risk of duplicating medicines and harmful drug interactions.

Learn about your medicines. Know the purpose of each medicine, and familiarize yourself with possible side effects.