INSULIN DOSING

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  • INSULIN DOSING



  • ACRONYMS AND DEFINITIONS

    • ADA - American Diabetes Association
    • Basal Insulin - Long- and Intermediate-acting insulins used to supply constant blood levels of insulin activity
    • Carb- carbohydrate
    • DM1 - Type 1 diabetes
    • DM2 - Type 2 diabetes
    • FDA - U.S. Food and Drug Administration
    • Hypoglycemia - low blood sugar
    • Multidose insulin regimen - Insulin regimens that involve a basal insulin and a premeal insulin given at meals
    • Premeal Insulin - also called “prandial” insulin. Rapid and short-acting insulins given at mealtime for short burst of insulin.
    • Total daily dose of insulin - Sum of premeal and basal insulin given in a day
    • Units/kg/day - units of insulin per kilogram of body weight per day
    • USDA - United States Department of Agriculture
    • 1 kilogram = 2.2 pounds

  • IMPORTANT POINTS ABOUT DOSING INSULIN

  • Overview
    • There are a number of different ways to dose insulin
    • No detailed guidelines for dosing insulin have been issued by professional associations
    • The appropriate method for individual patients will depend on a number of factors including patient education, patient motivation, diabetes control, and resources

  • Low blood sugar (Hypoglycemia)
    • The main concern in most patients when initiating an insulin regimen is the occurrence of low blood sugars
    • Patients need to understand that when they are starting and adjusting insulin, there is an increased risk for low blood sugars
    • A number of things can affect this risk including variations in eating patterns, sensitivity to insulin, and variations in activity level

  • Measures to help prevent low blood sugars
    • Start low and go slow - patients naïve to insulin should start at the lower end of dosing ranges
    • When using a multidose regimen, adjust only one of the regimens every 3 days and alternate between the two (see below for more)
    • The correction factor can help to keep blood sugars from running too high while the insulin regimen is being adjusted
    • Try to avoid insulin doses outside of the regimen as this may lead to overcorrections
    • In a multidose regimen, it is important to consume a consistent diet of three meals a day while keeping the number of carbohydrates in each meal about the same

  • INSULIN CATEGORIES

  • For dosing purposes, insulins can be divided into two categories:
    • Basal insulins
    • Premeal insulin (prandial insulin)

  • BASAL INSULINS
    • Basal insulins provide a steady concentration of insulin in the bloodstream over a number of hours
    • They do not act quickly

    • Basal Insulin include the following intermediate and long-acting insulins:
      • Humulin® N (NPH)
      • Novolin® N (NPH)
      • Basaglar® (insulin glargine)
      • Lantus® (insulin glargine)
      • Levemir® (insulin detemir)
      • Toujeo® (insulin glargine)
      • Tresiba® (insulin degludec)

  • PREMEAL INSULINS
    • Premeal insulins provide a burst of insulin that acts quickly
    • They are typically used 5 - 30 minutes before meals

    • Premeal insulins include the following rapid and short-acting insulins:
      • Humalog® (insulin Lispro)
      • Novolog® (insulin Aspart)
      • Humulin® R (Regular)
      • Novolin® R (Regular)


  • BLOOD SUGAR GOALS

TimingGlucose goal (mg/dl)
Fasting
(no calories for 8 hours)		75 - 99
Premeal80 - 120
2 hours post-meal< 140

  • ADA ALGORITHM FOR INITIATING INSULIN IN TYPE 2 DIABETES

  • In 2015, the ADA published an algorithm for dosing insulin in Type 2 diabetes. The algorithm is summarized in the table below.
  • There are a number of ways to dose insulin, and other approaches are detailed on this page

  • Reference [24]
ADA algorithm for initiating insulin in type 2 diabetes
Step 1 - start with basal insulin

  • Initial dose: 10 units/day OR 0.1 - 0.2 units/kg/day
  • Adjust dose: increase dose by 10 - 15% or 2 - 4 units once or twice weekly to achieve fasting blood sugar goal
  • If hypoglycemia occurs: decrease dose by 10 - 20% or 4 units

  • If blood sugars are still uncontrolled after fasting target is achieved or if insulin dose is > 0.5 units/kg/day, proceed to Step 2
    • Alternatively, may consider adding GLP-1 analog
Step 2 - add premeal insulin before largest meal

  • Initial dose: 4 units OR 0.1 units/kg OR 10% of basal dose
    • If A1C < 8%, consider decreasing basal insulin dose by same amount
  • Adjust dose: increase dose by 1 - 2 units or 10 - 15% once or twice weekly to achieve pre- and postprandial goals
  • If hypoglycemia occurs: decrease dose 2 - 4 units or 10 - 20%

    Alternative regimen - change basal insulin to twice daily premixed insulin
    • Initial dose: divide basal dose and give as premixed insulin twice daily (2/3 AM and 1/3 PM OR 1/2 AM and 1/2 PM)
    • Adjust dose: increase dose by 1 - 2 units or 10 - 15% once or twice weekly to achieve pre- and postprandial goals
    • If hypoglycemia occurs: decrease dose 2 - 4 units or 10 - 20%

  • If blood sugars are still uncontrolled, proceed to Step 3
Step 3 - add premeal insulin before ≥ 2 meals

  • Initial dose: 4 units OR 0.1 units/kg OR 10% of basal dose before each meal
    • If A1C < 8%, consider decreasing basal insulin dose by same amount
  • Adjust dose: increase dose by 1 - 2 units or 10 - 15% once or twice weekly to achieve pre- and postprandial goals
  • If hypoglycemia occurs: decrease dose 2 - 4 units or 10 - 20%

  • STARTING INSULIN IN TYPE 1 DIABETES (DM1)

  • ADA RECOMMENDATIONS
    • The ADA recommends the following for DM1 patients:
      • Multidose injections (3-4 a day) of basal and premeal insulin, or insulin pump therapy
      • Patients should match premeal insulin to carbohydrate intake, premeal blood glucose levels, and anticipated activity [10]

  • GENERAL DOSING GUIDELINES
    • Daily dose of insulin
      • Insulin dosing in DM1 will vary based on patient's age, weight, and residual pancreatic insulin activity
      • DM1 patients will typically require a total daily insulin dose of 0.4 - 1.0 units/kg/day
      • DM1 patients may experience a "honeymoon phase" after starting insulin where lower doses are effective [7,13]

    • Determining doses of basal and premeal insulin
      • After the total daily dose is determined, insulin is typically administered as follows:
        • Basal insulin - given as half of the total daily dose
        • Premeal insulin - half of the total daily dose divided into thirds and given before each meal
        • NOTE: When first starting therapy, it is recommended that the initial basal dose be reduced by 20 - 30% to prevent low blood sugar (hypoglycemia) [11,19]

        • Example:
          • Patient weighs 80kg
          • Total daily dose = 80kg X (0.5 units/kg/d) = 40 units per day
          • Basal insulin = 1/2 X 40 units = 20 units of basal per day*
          • Premeal Insulin = 1/2 X 40 units = 20 units ÷ 3 = approximately 7 units before each meal
          • * If patient is just starting therapy, the initial basal dose should be reduced by 20 - 30%. In our example: 20 units X 0.20 = 4 units, so initial basal dose would be 20 - 4 = 16 units

  • STARTING INSULIN IN TYPE 2 DIABETES (DM2)

  • OVERVIEW
    • Insulin therapy in DM2 can range from simple once-a-day doses of basal insulin to multidose regimens similar to DM1 therapy
    • In DM2, insulin is often added to oral medications

  • GENERAL DOSING GUIDELINES
    • Basal insulin only
      • Starting basal dose in DM2 patients
        • Starting dose of 0.15 - 0.3 units/kg/day is typically safe [1,4,15]
        • Starting with a flat dose of 10 units of basal insulin a day has also been shown to be safe [15]
      • Typical dosing range
        • Most patients will require a basal insulin dose in the range of 0.40 - 0.60 units/kg/day [12,13,14,15]

    • Multidose regimen
      • Patients already on a basal regimen can use their total daily basal insulin dose as a starting point
      • Patients not on insulin can use 0.2 - 0.3 units/kg/day as a starting point
      • After the total daily dose is determined, insulin is typically administered as follows:
        • Basal insulin - given as half of the total daily dose
        • Premeal insulin - half of the total daily dose divided into thirds and given before each meal
          • NOTE: When first starting multidose therapy, it is recommended that the initial basal dose be reduced by 20 - 30% to help prevent low blood sugar (hypoglycemia) [4,11,15]

        • Example:
          • Patient currently uses 60 units of basal insulin a day
          • Patient is switching to a multidose regimen
          • Basal insulin = 1/2 X 60 units = 30 units of basal per day*
          • Premeal Insulin = 1/2 X 60 units = 30 units ÷ 3 = approximately 10 units before each meal
          • * If patient was just starting therapy, the initial basal dose should be reduced by 20-30% In our example: 30 units X 0.20 = 6 units, so initial basal dose would be 30 - 6 = 24 units

  • ADJUSTING BASAL INSULIN

  • OVERVIEW
    • There a number of ways to adjust basal insulin
    • A common and straightforward method is presented here

  • ADJUSTING BASAL INSULIN REGIMENS
    • This method can be used for the following:
      • Adjusting once-a-day basal regimens in DM2
      • Adjusting basal insulin in multidose (basal and premeal) regimens in DM1 and DM2

    • Steps:
      • 1. Measure fasting blood sugar (no calories for 8 hours) for previous three consecutive days
      • 2. Calculate the average of the three fasting blood sugars
      • 3. Adjust basal insulin dose based on the table below
      • 4. Repeat steps 1-3 until target range (80 - 99) is achieved

Reference [12]
Fasting blood sugar (mg/dl)
average over 3 days		Adjustment to basal insulin dose
(units of insulin)
≥ 180add 8 units
160 - 179add 6 units
140 - 159add 4 units
120 - 139add 2 units
100 - 119add 1 unit
80 - 99no change
60 - 79subtract 2 units
< 60subtract 4 or more units
  • ADJUSTING PREMEAL INSULIN (SCALE METHOD)

  • SCALE METHOD
    • With the scale method, premeal insulin is adjusted based on a scale
    • Patients should try to consume the same amount of carbohydrates at each meal (a typical amount is about 60 grams a meal and 15 grams for a bedtime snack)
    • Carbohydrate goals vary by individual (see carbohydrate information below)

    • Steps:
      • 1. Measure blood sugar fasting (pre-breakfast), pre-lunch, pre-dinner, and pre-bedtime snack for previous three consecutive days
      • 2. Average the pre-lunch, pre-dinner and pre-bedtime values separately
      • 3. Adjust the premeal insulin dose based on the table below
      • 4. Repeat steps 1-3 until target range is achieved
      • 5. A Correction Factor (see below) should also be incorporated when blood sugars are checked

Reference [12]
  • If pre-lunch average is not in desired range, adjust pre-breakfast dose
  • If pre-dinner average is not in desired range, adjust pre-lunch dose
  • If pre-bedtime snack average is not in desired range, adjust pre-dinner dose
Premeal blood sugar (mg/dl)
average over 3 days		Adjustment to premeal insulin dose
≥ 180add 3 units
160 - 179add 2 units
140 - 159add 2 units
120 - 139add 1 units
100 - 119maintain dose (desired range)
80 - 99subtract 1 unit
60 - 79subtract 2 units
< 60subtract 4 or more units

  • ADJUSTING PREMEAL INSULIN (CARBOHYDRATE COUNTING)

  • CARBOHYDRATE COUNTING
    • In carbohydrate counting, premeal insulin is adjusted based on the amount of carbohydrates to be consumed in each meal
    • The carbohydrate counting method is used to determine the amount of carbohydrates in a meal
    • An insulin to carbohydrate ratio (ex. 1 unit/10g of carb) is used to calculate the premeal insulin dose
    • A typical starting ratio is 1 unit of premeal insulin for every 10 grams of carbs to be consumed
    • An individual may have different carbohydrate ratios for breakfast, lunch, and dinner because a person's response to insulin may vary throughout the day

    • Example:
      • 60 grams of carbs to be consumed for lunch
      • Patient's ratio is 1 unit of insulin for every 10 grams of carbs
      • Patient injects 6 units of premeal insulin before eating meal

  • Steps for adjusting an insulin-to-carb ratio
    • 1. Calculate the number of carbs to be consumed in a meal using carbohydrate counting
    • 2. Dose premeal insulin based on number of carbs in a meal (typical starting point is 1 unit of premeal insulin for every 10 grams of carbs)
    • 3. Measure blood sugar fasting (pre-breakfast), pre-lunch, pre-dinner, and pre-bedtime snack for previous three consecutive days
    • 4. Average the pre-lunch, pre-dinner and pre-bedtime snack blood sugar values separately
    • 5. Adjust the carbohydrate to insulin ratio as instructed below:

      • If pre-lunch average is not in desired range (80 - 120mg/dl), adjust breakfast ratio
      • If pre-dinner average is not in desired range (80 - 120mg/dl), adjust lunch ratio
      • If pre-bedtime snack average is not in desired range (80 - 120mg/dl), adjust dinner ratio

      • If average blood sugar is > 120mg/dl, adjust ratio by subtracting 2-3g of carbohydrate

        • Example:
          • Current ratio 1 unit / 10g of carb
          • Pre-lunch average > 120mg/dl
          • Change breakfast ratio to 1 unit / 7g of carb

      • If average blood sugar is < 80mg/dl, adjust ratio by adding 2-3g of carbohydrate

        • Example:
          • Current ratio 1 unit / 10g of carb
          • Pre-bedtime snack average < 80mg/dl
          • Change dinner ratio to 1 unit / 13g of carb

      • If average blood sugar is 80 - 120mg/dl, do not adjust ratio
    • 6. Repeat steps 1-5 until appropriate ratios are determined [3,4]
    • 7. A Correction Factor (see below) should also be incorporated when blood sugars are checked

  • ADJUSTING PREMEAL AND BASAL INSULINS CONCURRENTLY

  • When adjusting premeal and basal insulins concurrently, adjustments to one regimen may affect the other regimen. This can lead to overcorrections and hypoglycemia.
  • Alternating between regimens may help prevent overcorrections

  • Example:
    • Day 3 - adjust basal
    • Day 6 - adjust premeal
    • Day 9 - adjust basal
    • Day 12 - adjust premeal, and so on...

  • CORRECTION FACTOR

  • CORRECTION FACTOR
    • When blood sugar checks are high, a correction factor should be used with premeal insulin
    • The correction factor supplies supplemental insulin to account for the elevated blood sugar
    • Insulin used in the correction factor should not be included in calculations for adjusting premeal or basal insulin
    • There are several methods that can be used to determine the correction factor
    • When first starting therapy, the ideal total daily insulin dose will not be known, so the flat method is preferred over the individual method

  • FLAT METHOD

    • One unit of extra insulin is added for every 25mg/dl that blood sugar is above the upper limit of the desired range

    • Example:
      • Pre-lunch blood sugar is 200mg/dl
      • upper limit of desired range is 120mg/dl
      • 200 - 120 = 80mg/dl above desired range
      • 80mg/dl ÷ 25mg/dl = approximately 3
      • add 3 extra units to premeal dose

  • INDIVIDUAL METHOD

    • The individual method uses a patient's total daily insulin dose to calculate a correction factor
    • The correction factor is calculated differently for regular insulins (Humulin R, Novolin R) and rapid insulins (Novolog, Humalog, Apidra)

    • For Regular insulin (Humulin R, Novolin R)
      • 1. Divide 1500 by the patient's total daily dose of insulin
      • 2. The result will equal the estimated drop in blood sugar (in mg/dl) from 1 unit of regular insulin
    • For Rapid insulin (Novolog, Humalog, Apidra)
      • 1. Divide 1800 by the patient's total daily dose of insulin
      • 2. The result will equal the estimated drop in blood sugar (in mg/dl) from 1 unit of rapid insulin [4,12]

      • Example:
        • Patient's total daily dose of insulin (premeal + basal) is 60 units
        • Patient uses regular insulin as premeal insulin
        • 1500/60 = 25
        • Patient can expect that for every 1 unit of regular insulin they inject, their blood sugar will come down 25 mg/dl

    • Once the correction factor is calculated, the patient can then figure out how much insulin to supplement

      • Example:
        • Patient from above: correction factor is 25 mg/dl
        • Patient checks pre-lunch blood sugar and it is 175 mg/dl (desired range 80 - 120mg/dl)
        • 175 - 120 = 55mg/dl
        • 55/25 = approximately 2
        • Patient would add 2 extra units of regular insulin to premeal dose

  • EXERCISE AND INSULIN DOSING


  • SLIDING SCALE INSULIN

  • Sliding Scale Insulin involves checking the blood sugar and dosing the insulin (typically rapid or short-acting) based on the blood sugar value
  • Doctors use a number of different regimens depending on the patient and their sensitivity to insulin. The example below is a common starting regimen.

Blood sugar (mg/dl)Insulin dose in
units of rapid or short-acting
< 1500
150 - 2002
201 - 2504
251 - 3006
301 - 3508
351 - 40010
401 - 45012
> 45014

  • CONVERTING BETWEEN INSULIN BRANDS AND TYPES

  • Overview
    • It's important to note that patients may respond differently to different insulin brands and types
    • The conversion guidelines presented here are meant to serve as a starting point, but they will not necessarily achieve equivalent results across all patient populations
    • All patients should increase their blood sugar monitoring when switching insulins to determine the effects of the new regimen

  • Converting between rapid-acting (Novolog®, Humalog®, and Apidra®) and short-acting (Humulin® R and Novolin® R)
    • When converting between rapid-acting and short-acting insulins, the dose typically remains the same
    • Rapid-acting insulins act quicker (within 10 - 30 minutes) than short-acting insulins (within 30 - 60 minutes), therefore the timing of the dose should be adjusted
    • Rapid-acting insulins have a shorter duration of action than short-acting insulins (3 - 5 hours vs 6 - 8 hours). This may mean patients switching to rapid-acting insulins from short-acting insulins may require more basal insulin to maintain blood sugar control, and vice versa.
    • Conversions for inhaled insulin are discussed here - inhaled insulin dosing

  • Converting between Lantus/Basaglar (Insulin glargine) and NPH
    • Once-a-day NPH to Lantus/Basaglar
      • Dose remains the same

    • Twice-a-day NPH to Lantus/Basaglar
      • Lantus/Basaglar dose is 80% of total daily NPH dose
      • Example:
        • Patient's NPH dose is 30 units twice-a-day
        • Total daily NPH dose is 60 units
        • To convert to Lantus/Basaglar: 60 units X 0.80 = 48 units
        • Daily Lantus/Basaglar dose will be 48 units [19]

    • Lantus® to twice-a-day NPH
      • Lantus/Basaglar dose would be equivalent to about 80% of daily NPH dose
      • Example:
        • Patient's Lantus/Basaglar dose is 50 units a day
        • To convert to NPH: 50 units = (0.80)(Daily NPH dose); Daily NPH dose = 50/0.80 = 62.5 units
        • Daily NPH dose would be ∼ 62 units given in 2 divided doses
        • NOTE: Patients with hypoglycemia issues may want to leave the initial daily NPH dose the same as the Lantus/Basaglar dose

  • Converting between Lantus/Basaglar (Insulin glargine) and Levemir® (Insulin detemir)
    • Daily dose remains the same [20]

  • Converting between Lantus/Basaglar (Insulin glargine) and Toujeo® (Insulin glargine)
    • Lantus/Basaglar to Toujeo
      • When going from Lantus/Basaglar to Toujeo, the daily dose remains the same
      • Expect that a higher daily dose of Toujeo® will be needed to maintain the same level of glycemic control as an equivalent dose of Lantus/Basaglar
      • In a multidose study, the glucose-lowering effect of Toujeo® was about 27% lower than that of an equivalent dose of Lantus® [21]

    • Toujeo to Lantus/Basaglar
      • When going from Toujeo to Lantus/Basaglar, the Lantus/Basaglar dose should be started at 80% of the Toujeo dose in order to avoid hypoglycemia
      • Lantus/Basaglar is more potent than Toujeo, therefore, an equally effective Lantus/Basaglar dose will likely be lower [19,23]
        • Example:
          • Patient's Toujeo dose is 60 units a day
          • To convert to Lantus/Basaglar: 60 units X 0.80 = 48 units
          • Daily Lantus/Basaglar dose will be 48 units

  • Converting between Levemir® (Insulin detemir) and NPH
    • Daily dose remains the same [20]

  • Converting between Toujeo® (Insulin glargine) and NPH
    • Twice-a-day NPH to Toujeo®
      • Toujeo® dose is 80% of total daily NPH dose
      • Example:
        • Patient's NPH dose is 30 units twice-a-day
        • Total daily NPH dose is 60 units
        • To convert to Toujeo: 60 units X 0.80 = 48 units
        • Daily Toujeo dose will be 48 units [19]

  • Converting between Toujeo® (Insulin glargine) and Levemir® (Insulin detemir)
    • Daily dose remains the same [21]

  • Converting between Tresiba® (insulin degludec) and all other long- and intermediate-acting insulins
    • Daily dose remains the same
    • In trials comparing Tresiba to Lantus and Levemir, the glucose-lowering effect of Tresiba was equivalent to both insulins [22]

  • HYPOGLYCEMIA (LOW BLOOD SUGAR)


  • CARBOHYDRATE INFORMATION

  • Carbohydrates and insulin
    • It's important that diabetics who are taking insulin monitor their carbohydrate intake
    • See the links below for more information on dieting and carbohydrates


  • BIBLIOGRAPHY

  • What is PMID?
  • PI = Manufacturer's Package Insert

  • #     PMID
  • 1 - 18945920
  • 2 - PMID: 10332663
  • 3 - PMID: 18364392
  • 4 - Braithwaite S: Case Study: Five Steps to Freedom: Dose Titration for Type 2 Diabetes Using Basal-Prandial-Correction Insulin Therapy. Clinical Diabetes Vol 23:1 p39-43 2005
  • 5 - Kulkarni K: Carbohydrate Counting: A Practical Meal-Planning Option for People With Diabetes. Clinical Diabetes Vol 23:3 p120-122 2005
  • 6 - PMID: 16915796
  • 7 - PMID: 15616254
  • 8 - PMID: 16921608
  • 9 - PMID: 10378067
  • 10 - PMID: 21193625
  • 11 - PMID: 12734137
  • 12 - PMID: 16847295
  • 13 - Herbst K, Hirsch I Insulin Strategies for Primary Care Providers. Clinical Diabetes. Vol 20:1 p1-7 2002
  • 14 - PMID: 17890232 - NEJM DM 2 study
  • 15 - Hirsch I et al. A Real-World Approach to Insulin Therapy in Primary Care Practice. Clinical Diabetes. Vol 23:2 p78-86. 2005
  • 16 - PMID: 18165339
  • 17 - PMID: 12766131
  • 18 - Glucagon PI
  • 19 - Lantus PI
  • 20 - Levemir PI
  • 21 - Toujeo PI
  • 22 - Tresiba PI
  • 23 - Basaglar PI
  • 24 - ADA 2015 Standards of Medical Care in Diabetes, Vol 38, Supplement 1, p. S46


Tag word - Rx Healer  Health - Health Care - Healthcare - Doctor - Hospital - Medicine - Physician - Consultant

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