Insulin Dosing Flashcards
Average TDD insulin type 1
-0.4-1 unit/kg/day
-higher amts during puberty, menses, medical illness
Insulin dosing in newly diagnosed type 1
-lower dose
-0.2-0.6 units/kg/day
BG testing type 1
-QID
-before meals and hs
-sometimes at 3 am
Basal-Bolus Dosing
-50-70% basal
-30-50% bolus divided among meals
Basal doses
-1-2 doses glargine or degludec
-1-2+ doses NPH
-important
-will keep ketoacidosis in checj
Bolus insulin doses
-Ultra or short acting before meals
-TID
-nothing at bedtime unless late night eaters
Carb counting
-1 unit insulin for 15g
intermediate + short acting dosing
-less common
-2 injections qd of mix
-split daily dosing:
am: 40%NPH + 15% shortacting
pm: 30%NPH + 15% short acting
-move NPH dose to bedtime if hyperglycemia occurs at night
Moving intermediate to HS
-Breakfast: L/A/G/N/R
-lunch: o
-dinner: L/A/G/R
-bedtime: N
Other insulin regimens
-pre-mix
-pump
pre-mix injections
-70/30 - 0 - 70/30 - 0
-75/25 - 0 - 75/25 - 0
Insulin pump
-rapid acting insulin
-basal rate constant
-bolus calculated baseed on glucose levels, carbs, insulin
Medtronic Mini-Med 770G
-pump
-close to artificial pancreas
-correct bolus or reduce insulin
-adjustable target
-fewer alarms
-not 100% automatic
-pt 2yo<
Insulin dosing type 2
-long or intermediate acting + oral agents
-bedtime dose
-suppress hepatic glucose production at night
-eventually can discontinue sulfonylurea once pt is on basal bolus regimen
Starting basal dose type 2
-0.1-0.2 units/kg/day
0.2-0.3 if A1c over 8%
-10-15 units
Adjusting dose type 2
-inc by 2 units every 3 days to reach FBS goal
-140-180+: add 10-20% TDD
-110-139 add unit
-less than 40-70: dec 10-20% - 20-40%
Eventual basal-bolus dosing type 2
-add bolus esp pt on more than 0.5 units/kg/day
-start w 10% basal dose or 4 units ultra/short acting w largest meal
-start one meal at a time or all 3 based on severity of readings
-adjust dose by 10-15% every 3-4 days
-can pull some from basal dose if needed to prevent hypoglycemia
more insulin dosing type 2
-1-2 units insulin every 15g carb/meal
-mixes can be used
-average dose often >1unit/kg/day
Mixes in type2
-N/R - 0 - N/R - 0
-N/R - 0 - R - N
-L/A/G instead regular too
General insulin dosing principles
-inc/dec dose q2-4 days
-target FBS (A1c >10)first then PPG (A1c<10)
-pt can be taught how to adjust their own dose for exercise/meals
Adjusting / Indivdualizing insulin doses
-carbohydrate ratio
-sensitivity factor
-overall principles
Insulin to carb ratio
-guide for how much insulin one needs to cover an amount of carb in a meal or snack
Average insulin to carb ratio
-1unit: 10-15g carbs adults
-1unit: 20-30g carbs children
calculating insulin:carb ratio
-total carbs/day for 3-day
-establish avg carb intake amount per meal
-g of carbs/amt of bolus given
-60g/6unit= 1:10 ratio
-check blood sugar pre/post meal to determine effectiveness
-rule of 500
rule of 500 to calc insulin:carb
-500/TDD = g/1unit
-500/40 units = 1:12.5g
-for 60g = 5 units insulin to cover meal
more than one insulin:carb ration might be needed
-physical activity
-body weight
-insulin needs
-type of meal
Insulin sensitivity factor (correction factor) CF or ISF
-rule of 1800 (1500 in case they on regular insulin)
-1800/TDD
-estimates how much 1 unit will lower blood glucose
-1800/90units = 20mg/dL lowered by 1 unit
-used most to add to a dose of prandial insulin when BG elevated
-caution just using to correct hyperglycemia often
CF/ISF
=x:50>150
-add x units for every 50 over 150 (BG)
-x from rule of 1800
-50/20 = 2 units
-2 units for every 50mg/dL above 150
-if u give an hs dose, maybe half it
Fasting hyperglycemia causes
-bedtime eating
-not enough insulin
-Somogyl effect
Fasting hyperglycemia tx
-if once daily basal, inc dose or change to BID
-if BID, inc supper/bedtime dose
-if basal-bolus, inc basal or PM bolus depending on hs readings
Prelunch hyper glycemia tx
-add/inc shortacting to am dose
predinner hyperglycemia tx
-inc am basal or add short acting at lunch
-inc short-acting dose if applicable
bedtime hyperglycemia tx
-add/inc dose short acting at dinner
Fasting hypoglycemia tx
-dec evening insulin dose
-check timing of AM test and dose
Pre lunch hypoglycemia tx
-dec/omit shortacting dose in AM
Pre-dinner
-dec lunch bolus
-dec AM basal
Bedtime hypoglycemia
-add bedtime snack
-dec predinner shortacting
-dec predinner intermediate if give in the early afternoon
How to adjust insulin type 1
-2 units dec BG 50mg/dL
how to adjust insulin type 2
-4 unit dec BG 50mg/dL
how to adjust insulin
-dec dose for low readings (2 or 4 units)
-can calc their correction factor to adjust dosage
Somogyi effect
-nocturnal HYPO w rebound HYPER
-check BG at 3 am
-move NPH from dinner to bedtime or add bedtime snack
Sick days not eating
-continue insulin
-let doc know they are sick
-stress will inc insulin need
-maintain fluid intake
-test BG q4h
-test for ketones
-can admin more insulin
seek med attention if
-ketones present
-BG>250
-SOB
-fruity breath
-thirst/urination
-mental changes
-vomiting
other patient information
-double check insulin label before purchasing insulin
-never freeze or leave in sunlight
-purchase correct syringes
when to change to a concentrated form
-problems w large doses
-advantages of concentrated forms
-consider w TDD 200-300
Other insulin dosage forms
-Afrezza (nasal)
-oral tablets
-sprays
-patches
-once weekly
Insulin Icodec
-insulin w fatty acid chain to last long
-approved in EU
-t1+2dm: daily dose *7 round to nearest 10, titrate by 20
-t2dm (naive): 70qweek titrate by 20
Teplizumab
-mAb
-delays progression of type 1 diabetes
