Basal and Meal Time InsulinCase Study Davida F. Kruger, MSN,APN-BC,BC-ADM

Certified Nurse PractitionerDivision of Endocrinology, Diabetes, Bone and

Mineral DisordersHenry Ford Health System

Detroit, Michigan

Betty• 56 years old• Weight 182 lbs, b/p 136/82• Metformin 100omg BID• glyburide 10 mg BID • MNT, working on portion size and

learning carb counting• SMBG, usually twice daily but has been

checking when feels low or high• Wants to improve her A1c which has been

running between 7.8 and 8.4.

Fix The Fasting FirstBB LL SS HSHS

SaturdaySaturday 198198 156156

SundaySunday

176176

168168 199199

MondayMonday 184184 170170 179179

Basal Insulin Replacement Basal Insulin Replacement TherapyTherapy

Time (hours)s.c. injection

Normal Insulin Secretion at Meal Time

Ch

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NPH Insulin

Insulin Glargine/Detemir

Start a Basal Insulin“Treat to Target”

Continue oral agent(s) at same dosage Do NOT stop insulin secreting agent

Add single, evening insulin dose (0.1 - 0.2 U/kg)10 - 20 unitsGlargine, Detemir or NPH (bedtime)

Increase insulin dose every 3-4 days as neededIncrease 3 - 5 U if FBG >150 mg/dL

Increase 1 - 2 U if FBG = >110,<150 mg/dL Treat to target FBG (usually <120 mg/dL)Determine maximum insulin increase till

call clinic 6-596-59

Starting Basal InsulinStarted Betty on 10 units at 10 PM of

Glargine.Focus on fasting blood glucoseIncrease 1-2 units every 3 days until FBS at

target with out hypoglycemiaCan us 3/0/3 rule Ask patient their comfort levelCall clinic when patient taking XX units

Glargine Started…Is Premeal Coverage Needed?

BB

prepre

2 hr2 hr

postpost

LL

prepre

2 hr2 hr

postpost

SS

prepre

2 hr2 hr

postpost

MM

16u 16u GG

109109 188188 142142 200200 155155 189189

TuTu 116116 135135 118118 177177 179179 202202

WW 120120 154154 132132 167167 162162 190190

ThTh 9797 127127 122122 154154 177177 211211

BettyTaking 30 units of glargineNo issues with low blood glucoseWorking on learning carbohydrate counting

and portion sizesBlood glucose monitoring increased to look at

2 hr post prandial blood glucoseA1c 8.2 %

Bolus Insulin Replacement Bolus Insulin Replacement Therapy Therapy

Time (hours)s.c. injection

Normal Insulin Secretion at Meal Time

Ch

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Rapid-acting Analogue

Regular insulin

Apidra

Humalog

Novolog

Insulin lispro or aspart Insulin glargine

Basal-Bolus Insulin Therapy: Insulin Glargineat HS and Mealtime Lispro or Aspart

B DL HS

Insu

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Adapted with permission from Leahy J. In: Leahy J, Cefalu W, eds. Insulin Therapy. New York, NY: Marcel Dekker Inc.; 2002:87

Traditional “Sliding Scale”An arbitrary insulin dosing algorithm

based only on pre-meal blood glucose valuesPre-Meal BG (mg/dl)Pre-Meal BG (mg/dl) Insulin Dose (units)Insulin Dose (units)

Less than 151Less than 151 00

151-200151-200 22

201-250201-250 44

251-300251-300 66

301-350301-350 88

351-400351-400 1010

Adjusting meal insulinSliding scale not specific to patient needs

Not flexible for carbohydrate in mealsBreakfast meal may need more insulin –

hormonal influenceNo meal insulin if less than 100mg/dl??Use of correction insulin??

Starting Meal Time Insulin Stop insulin secreting agentAdd Bolus insulin before meals (REG or analog). Do

not need to do all meals at once, look at patterns, fix what is broken first

For all meals Add 10 units and redistribute total dose 50/50

Pt taking 30 units Lantus already Add 10 units to a new total dose of 40 units 50% will be new basal (20 units) 50% in divided doses will be the meal time bolus (i.e. 7/6/7)

Carb counting and correction factorsBG checks a must! Do not know where goingSAFETY

Total Daily InsulinTotal daily insulin requirement is calculated

by body weightT1: need about 0.6 units/kg (range 0.4 - 0.8)T2: need about 1.2 units/kg (range 1 – 1.4)

BGs at goal without hypoglycemia.40-50% basal (background)50-60% bolus (meal doses)

Calculating “Basal–Bolus” Insulin

Calculate TDDT1: need about 0.6 units/kg (range 0.4-0.8)T2: need about 1.2 units/kg (range 1 – 1.4)

Basal dose: 40 – 50% of TDDBolus dose: 50-60% of TDD:

Divide equally for three meals ORSensitivity Factor = 1700/TDD

1 unit will drop BG by XX points

Carbohydrate Ratio = 500/TDD 1 unit for every XX gm carbs

(Pt BG – target) / (SF) = CORRECTIONNow add carb ratio for meal.

For Example250 pound T2DM (114 kg) Calculated TDD: 114 x 1.2 = 137 u/dayBasal Dose: 68 units a day (50% of TDD)Bolus Dose: (other 50% of TDD)

Isocaloric meals: 68/3 = 23 units before each meal

Carbohydrate ratio: 500/137 = 3 1 unit for every 3 grams of carbs

Insulin Sensitivity: 1700/137 = 12 1 unit will lower BG 12 mg/dL

What’s the dose range?Type 2: 0.3 to 1.2 units/kg

“Thin type 2’s” are more insulin deficient“Heavy type 2’s” are more insulin resistant

Most pts with T2DM need insulin doses of 1 to 1.2 units/kg to achieve an A1c <7% (basal dose of 0.5 to 0.6 units/kg per day)

HypoglycemiaMost common side effect of insulin therapyGlucose levels less than 70 mg/dl are treatedSymptoms of hypo are treated regardless of

glucose levelUsual treatment is 15 gm glucose/ wait 15

min and repeat if needed ( Rule of 15/15)

Hypo TreatmentLiquid glucose preferred to solid

Orange juice is better than a piece of cakeSimpler forms of sugar are better than

sugars with fatJelly beans are better than chocolate

All patients need to carry on them a hypoglycemic treatment at all times

Know What Insulin is WorkingTesting Times

AM (fasting) indicates action of evening basal or intermediate insulin

Pre- lunch indicates action of AM short actingPre-supper ………………….pre lunch short

acting HS……………………pre-supper short acting

Carb CountingReferral to dietitianFlexible and adaptableMeal specificProvide web sites and carb counting booksRead labels

Betty: Book knowledge and the patient before you

Weight 182 lbs/83 kgWill need up to 1-1.4 units per kg/body

weightGo low and slow, use blood glucose to direct Figure dose needed then decide on which

meal (s)Look at A1c to help guideBasal Insulin now30 units at 10 PM, FBS are

well controlled, concentrate on 2 hour ppPrevent hypoglycemia

Betty: ContinuedBasal insulin 30 units1 unit per kg/body weight is 83 units TDD53 units/3 meals is 18 units per meal Start with breakfast and dinner, add lunch as

needed, if no breakfast, add at lunch and dinnerORCarb counting and sensitivity factor:500 ./. 83 = 6 1 unit to cover 6 grams carb 1700 ./. 83 = 20 1 unit of insulin to drop

20mg/dl Blood glucose goal is 100mg/dl before meals

ExampleInsulin SensitivityBlood glucose before meal is 180mg/dlGoal is 100mg/dl180-100 = 80 (correct for)80 ./. 20 = 4 units (insulin sensitivity)Carb CoverageDinner meal: 2 Hambugers, 2 rolls, ½ cup

applesauce, ½ cup green beans, ½ cup cornApprox 60 grams of carb1 unit covers 6 grams of carb = 6 units of

meal time unsulin Total for this meal: 10 units meal time insulin

PearlsOnce insulin sensitivity and carb ratios

determined not as difficulty as it may appearWhen patients consume less and blood

glucose improve less risk of hypoglycemiaBlood glucose monitoring is keyConsider Continuous Blood Glucose

Monitoring as an aid Lack of understanding of Nutrition is often

what prevents patients from getting to treatment goals

Insulin dosing is a moving target……..