Quick insulin dosing reference for residents

Dept of Pediatric EndocrinologyStony Brook Children’s Hospital

Timing and Duration of Action of Insulin

Preparations

Onset Peak Duration

Rapid Acting

Lispro (Humalog) 15-30 30-90 min 3-5 hours

Aspart (Novolog) 15-30 min

1-3 hours 3-5 hours

Intermediate Acting

NPH 1-4 hours

5-10 hours

10-16 hours

Long Acting

Glargine (Lantus) 1-2 hours

None 20-24+ hours

Detemir (Levemir) 1-2 hours

None (?) 8-23 hours

Twice daily Insulin dosing

For two times a day injections…..› 2/3 of total daily dose in the am

1/3 rapid acting 2/3 NPH

› 1/3 of total daily dose in the pm 1/3 to ½ rapid acting 1/3 to ½ NPH

Dawn Phenomenon

Elevated blood glucose in the morning due to normal nocturnal secretion of GH and cortisol

Or waning of insulin action from the prior evening dose of NPH

Correct by increasing evening dose of NPH, may be limited by hypoglycemia in middle of night: preventable by changing NPH to pre-bedtime

Rebound hyperglycemia Peak activity of NPH

causes unrecognized hypoglycemia in middle of the night

Counterregulatory hormones causes exaggerated rise in blood glucose resulting in hyperglycemia in the morning

Solution: the evening dose of NPH should be decreased to eliminate hypoglycemia at night

Multiple Daily Injections ½ of total daily dose given as glargine (Lantus)

Rapid acting insulin to cover meals and correct high BGs› Insulin to carb (I:C) ratio can be determined by

dividing 450 by the total daily insulin dose› Typical I:C for toddler 1:30 grams; teenager 1:5-8 grams› Insulin Sensitivity Factor (ISF) : 1800 rule is used:

divided by the total daily insulin dose › If someone’s TDD= 30 units

1800/30= a 60 point drop per unit of insulin› Correction formula: (Current BG minus Target BG)/ISF

Adjusting Insulin Doses Example 1

Breakfast LunchDinne

rBedtim

e2am

110 92 210 129 78

102 135 199 132 121

99 81 168 117 101

119 123 208 165 132

107 62 257 137 125

7 year old who takes Humalog and NPH at breakfast and dinner has the following blood glucoses. Do you want to make any changes to the insulin plan? If so, at which injection time, which insulin, and do you want to give more or less?

Adjusting Insulin Doses Example 1

Breakfast LunchDinne

rBedtim

e2am

110 92 210 129 78

102 135 199 132 121

99 81 168 117 101

119 123 208 165 132

107 62 257 137 125

7 year old who takes Humalog and NPH at breakfast and dinner has the following blood glucoses. Do you want to make any changes to the insulin plan? If so, at which injection time, which insulin, and do you want to give more or less?

ANSWER: The dinner time blood glucoses are all high; increase AM NPH

Adjusting Insulin Doses Example 2

Breakfast Lunch Dinner Bedtime 2am

187 123 158 12965

(juice)

199 134 116 143 88

176 103 132 165 57 (milk)

212 152 128 18672

(juice)

169 108 142 152 93

5 year old who takes Humalog and NPH at breakfast and dinner has the following blood glucoses. Do you want to make any changes to the insulin plan? If so, at which injection time, which insulin, and do you want to give more or less?

Adjusting Insulin Doses Example 2

Breakfast Lunch Dinner Bedtime 2am

187 123 158 12965

(juice)

199 134 116 143 88

176 103 132 165 57 (milk)

212 152 128 18672

(juice)

169 108 142 152 93

5 year old who takes Humalog and NPH at breakfast and dinner has the following blood glucoses. Do you want to make any changes to the insulin plan? If so, at which injection time, which insulin, and do you want to give more or less?

ANSWER: The majority of the overnight numbers are low so decrease the evening NPH

Adjusting Insulin Doses Example 3

Breakfast Lunch DinnerBedtim

e2am

184 113 132 128 192

205 124 98 114 188

175 73 193 132 201

187 95 117 105 177

154 136 124 129 215

15 year old who takes Novalog at meals breakfast and Lantus at bedtime has the following blood glucoses. Do you want to make any changes to the insulin plan? If so, at which injection time, which insulin, and do you want to give more or less?

Adjusting Insulin Doses Example 3

Breakfast Lunch DinnerBedtim

e2am

184 113 132 128 192

205 124 98 114 188

175 73 193 132 201

187 95 117 105 177

154 136 124 129 215

15 year old who takes Novalog at meals breakfast and Lantus at bedtime has the following blood glucoses. Do you want to make any changes to the insulin plan? If so, at which injection time, which insulin, and do you want to give more or less?

ANSWER: The overnight and first morning blood gluocoses are high. Increase Lantus