II. Precautions
- Insulin sensitivity varies throughout the day as well as with Puberty, pregnancy, illness and aging
- Insulin doses are adjusted for planned Exercise, current Blood Glucose, and expected Carbohydrate intake
III. Protocols
IV. Protocol: Goal Blood Glucose for Type I and Type II Diabetes
- Hemoglobin A1C <7%
- Goal: >50% of Blood Sugars in range
- Pre-meal Blood Glucose 70-120 mg/dl
- Two hour post-prandial Blood Glucose <160 mg/dl
- Bed-time Blood Glucose 100-140 mg/dl
V. Evaluation: Blood Sugars
- Monitoring pointers
- Be consistent in monitoring
- Aim for 50% of Blood Glucoses in target range
- Look for consistent pattern in Blood Sugars for >3 days
- Compare Blood Sugar for same time each day
- For each time of day:
- Calculate Blood Glucose range
- Calculate median Blood Glucose
- Consider eating and activity patterns during day
- Ignore spurious values
- Adjust only one Insulin dose at a time
- Correct Hypoglycemia first
- Correct highest Blood Sugars next
- Maintain a 50:50 mix of Basal to Bolus Insulin
VI. Evaluation: Adjustment of Insulin
- Adjustment factors (for lows and highs)
- Adjust Insulin in small steps at a time
- Adjustment steps based on Insulin amount
- Adjustment steps based on diabetes type
- Type I Diabetes Mellitus: 1-2 units change
- Type II Diabetes Mellitus: 2-4 units change
- Correction protocol for Hypoglycemia
- General measures to consider
- Increase Carbohydrate preceeding low
- Carbohydrate at prior meal or
- Snack or
- Pre-exercise Carbohydrate
- Adjust Exercise timing during the day
- Increase Carbohydrate preceeding low
- Basal insulin (e.g. Lantus) adjustment
- Blood Glucose low in AM
- Decrease Basal insulin (Lantus)
- Blood Glucose low in AM
- Rapid acting Insulin (e.g. Lispro) adjustment
- Blood Glucose low before lunch
- Blood Glucose low before dinner
- Blood Glucose low before bedtime
- General measures to consider
- Correction protocol for Hyperglycemia
- General measures to consider
- Decrease Carbohydrate preceeding high
- Carbohydrate at prior meal or
- Stop or decrease snack
- Increase Exercise prior to meal
- Decrease Carbohydrate preceeding high
- Adjust Insulin based on Carbohydrate Count
- See Insulin Adjustment with Carbohydrate Counting
- One Unit covers each 10-15 grams Carbohydrate
- Add 1-2 units for every 50 mg/dl Glucose >150
- Indications to adjust Basal insulin (e.g. Glargine)
- All Blood Glucoses >200 mg/dl
- Increase Basal insulin by 0.1 units/kg
- All Blood Glucoses high (within 50 mg/dl)
- Increase Basal insulin per adjustment above
- Pre-supper Blood Glucose high
- Adjust Basal insulin per adjustment above
- Fasting (AM) Blood Glucose high
- Perform 3 am Blood Sugar checks
- Critical to distinguish 3 AM low BG from high BG
- Dawn Phenomena (relative Insulin deficiency)
- Increase Basal insulin by adjustment above
- Somogyi Phenomena (Rebound Hyperglycemia)
- Decrease Basal insulin by adjustment above
- Dawn Phenomena (relative Insulin deficiency)
- All Blood Glucoses >200 mg/dl
- Indications to adjust Bolus Insulin (e.g. Lispro)
- Two hour post-prandial >40-60 mg/dl over premeal
- Increase rapid acting Insulin before meal
- Blood Glucose low before meal
- Decrease rapid Insulin before prior meal
- Two hour post-prandial >40-60 mg/dl over premeal
- General measures to consider
- Average Insulin doses after titrating from start
- Type I Diabetes Mellitus: 0.7 units/kg
- Type II Diabetes Mellitus: 1.2 units/kg