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Insulin Adjustment Workbook Complete
Insulin Adjustment Workbook Complete
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TARGET THERAPY
Staying on Target TM
This workbook will help you learn new skills so that you can you live a
healthier life with your diabetes. What is Basal-Bolus? introduces
flexible insulin therapy, (also called intensive therapy) as a way to correct
your blood glucose levels. Terms to Learn First gives you the definitions
that you will need. Making Bolus Insulin Changes, outlines how to
make changes to rapid and short acting insulin doses. Putting it All
Together gives you a plan to get started. Adjusting for Basal Insulin,
explains changing long acting insulin doses. Trouble-Shooting, tells
what to do when you are having a hard time. Problem-Solving and
Exercises gives you a chance to practice what you learned. Use this guide
as you work with your diabetes health care team to help you avoid the
complications of diabetes.
BD provides this workbook for informational purposes only. It is not intended to be a substitute for professional
medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified healthcare
provider with any questions you may have regarding a medical condition. Never disregard professional medical advice
or delay in seeking it because of something you have read in this workbook
INTERACTIVE TABLE OF CONTENTS
To go directly to the topic of interest, click on the link below.
MAKING BOLUS INSULIN CHANGES ......9 ADJUSTING THE BASAL DOSE ..............34
Understanding How Insulin Works ............10 Testing the Nighttime Basal ......................35
1
WHAT IS BASAL-BOLUS?
1 All glucose values used in this workbook are plasma values. If you use a blood glucose meter that reads whole
blood values, you should decrease them by about 10%. 2
Deciding on your insulin dose This insulin is released as a squirt
according to the amount of carb or a pulse that is called a bolus. In
you expect to eat and the exercise someone without diabetes, a bolus of
or activity you plan insulin keeps blood glucose levels in
range after meals.
Although some people can have frequent
or severe hypoglycemia (low blood Figure 1 shows normal insulin delivery
glucose) with this therapy, most people in a person without diabetes. The top
have less because there is a better match portion shows the blood glucose curves
between their insulin and food. You can during a day in which someone eats
adjust flexible therapy for your lifestyle, three meals. The bottom portion shows
eating and sleeping schedules and the blood insulin levels for the same
physical activity. You will learn to match three meals. In basal-bolus therapy, the
your insulin to your food, exercise, and insulin doses and times are designed to
adjust for high or low blood glucose match normal insulin delivery as closely
when it happens. as possible.
Figure 1
Normal Insulin Delivery Normal Insulin Delivery in People
A diabetes-free pancreas releases a small without Diabetes
Blood Glucose
happen:
If you have type 1 diabetes, your pancreas
1. Blood glucose rises.
cannot make insulin. To use flexible
2. The pancreas releases an extra burst
therapy with basal-bolus insulin, you will
of insulin that in turn helps to deliver
decide how much insulin to take to keep
blood glucose into the bodys cells,
blood glucose within your goal range.
where it is used for energy.
3
TERMS TO LEARN FIRST
4
TERMS TO LEARN FIRST
5
NOTE: For an algorithm to work you Ultralente - occasionally used as
need to eat the same amount of food basal insulin, does have some peak
and carbohydrate every day. (If you action. (See Peak Action.)
always have a sandwich with 2 slices of Short or rapid-acting insulin (see
bread, a piece of fruit, a glass of milk below) given by an insulin pump
and a small bag of chips for lunch, this tiny amounts of rapid acting insulin
method will be fine.) If you eat a big are delivered throughout the day
salad one day and a plate of spaghetti and night. This is the best example
the next, these foods have different of basal insulin and may be closest
effects on your blood glucose and you to imitating the way the pancreas
would need different doses of insulin, so normally works. Another advantage
this is not the best way for you to decide is that basal rates on a pump can
how much insulin to take before meals. be changed to meet your needs at
different time periods of the day
Basal Insulin Works steadily day
and night.
and night to keep your blood glucose
within your goal levels. Taken as an Bolus Insulin Taken before you
injection, basal insulin is long acting and eat and to correct for a high blood
works around the clock. Taken via insulin glucose, it is released in a squirt or pulse.
pump, a very small amount of basal This allows the insulin to provide a rapid
insulin is released constantly at fractions burst of action. Bolus insulin acts as the
of a unit per minute. The goal is to extra insulin that is released by a
match the amount of insulin with the normal pancreas to help your body use
low level of glucose produced by your the glucose from a meal or snack. The
liver. This helps your blood glucose levels extra insulin will bring your blood glucose
remain stable day and night - even if you levels down before they climb too high.
dont eat anything. Types of basal insulin Types of Rapid-acting insulin used for
include: bolus insulin are:
6
Insulin Adjustment and Insulin Sensitivity Factor
Pattern Management (ISF) and Correction
Adjusting insulin doses based on a ISF is the amount that one unit of
pattern of blood glucose readings over rapid- or short-acting insulin will
three days or more is called Pattern lower your blood glucose reading.
Management, or Pattern Control. It is used to calculate your correction
If your blood glucose is too high or too or supplemental dose.
low at certain times of the day or night, Correction dose is the amount of
an adjustment to your insulin dose may insulin you need to correct a high
be needed. In this case it is helpful to blood glucose level and bring it into
look for patterns in your blood glucose the range your blood glucose should
readings over three days or more. For fall into most of the time.
example, take a look at Jeans blood
Once you know your ISF, you can give
glucose readings before dinner for the
yourself the right dose of insulin to keep
past three days:
you within your blood glucose goals. The
ISF is different for different people and
JEANS THREE-DAY BLOOD GLUCOSE RECORD
your Diabetes Team will help determine
(Goal 90 mg/dl-130 mg/dl)
it for you. For instance, if your blood
Breakfast Lunch Dinner Bedtime
glucose at lunch is 200 mg/dl and your
98 mg/dl 129 mg/dl 250 mg/dl 150 mg/dl
goal is 90-130 mg/dl, you will learn to
89 mg/dl 105 mg/dl 225 mg/dl 111 mg/dl
take a correction dose, an extra amount
102 mg/dl 88 mg/dl 240 mg/dl 138 mg/dl
of rapid- or short-acting insulin to bring
your high blood glucose down to the
You can see that her dinner numbers are all range your blood glucose should be in
too high. The problem may be related to most of the time. Correction is usually
how much carbohydrate (carb) she ate at required before a meal, so you will need
lunch, snacking, schedule or basal insulin. to add or subtract this dose of insulin to
However, it is most likely that her food at the amount of insulin needed for your
lunch did not match her pre-lunch bolus. carbohydrate intake. The correction dose
She ate too much carb for her insulin bolus is extra insulin if your blood glucose is
dose. For more information on Pattern too high or a lower insulin dose if your
Control or Pattern Management, see the blood glucose is to low.
BD Publication: Pattern Control.
7
EXAMPLE: Using Lauries ISF, she would divide
Calculating Lauries Correction Dose 25 mg/dl by 50 to find that she would
Lauries ISF is 1 unit of rapid or short need to subtract 0.5 units of rapid or
acting insulin for every 50 mg/dl of short acting insulin to her meal-time
blood glucose. dose to correct the blood glucose to
Her target pre-meal blood glucose is 100 mg/dl.
100 mg/dl, but her pre-dinner blood Amount of glucose
over target = correction dose
glucose reading is 250 mg/dl. ISF
She is 150 mg/dl over her target level.
Current blood glucose target blood [-25
50
= -0.5 units
]
glucose = amount of glucose over target
[250 mg/dl 100 mg/dl = 150 mg/dl]
Peak Action The time when insulin
Using Lauries ISF, she would divide
is working the hardest to bring blood
150 mg/dl by 50 to find that she
glucose down. It is essential to know
would need to add an extra 3 units
when your insulin peaks so that you can
of rapid or short acting insulin to her
prepare for possible low glucose levels at
meal-time dose to correct the blood
these peak times. Types of insulin with
glucose to 100 mg/dl.
Amount of glucose peak action times are:
over target = correction dose
ISF
Name of Type of Peak Action
[150 = 3
50 ] Insulin Insulin
Humalog, Rapid 30 min. to
If Lauries pre-dinner blood glucose was Novolog, 1 1/2 hours
75, she would reduce her insulin dose in Apidra
8
MAKING BOLUS INSULIN CHANGES
9
MAKING BOLUS INSULIN CHANGES
Your first step in learning how to make when they are at their peak and the
these adjustments should be to consult length of time they last. It is important
with your Diabetes Team. This section to understand these differences in order
will give you the tools you need to adjust to make the best decisions possible when
your bolus insulin effectively using adjusting your insulin dose. By knowing
flexible insulin therapy. which insulin peaks and is active you will
know which insulin to change if you are
Understanding How
having hypoglycemia (low blood sugar)
Insulin Works
or hyperglycemia (high blood sugar).
Different types of insulin work at
View the chart(s) and graph(s) below to
different speeds. Their action can be
help you understand the actions of many
described as basal (steady and long-
different types of insulin including
acting), bolus (rapid burst of action) or
Humalog, Novolog, Regular, NPH,
somewhere in between. They also act
Ultralente, Lantus, etc.
differently in how fast they start working,
10
Insulin Action Type of Insulin Onset of Action Peak Action Duration
LONG ACTING Ultralente Approx. 12 to 18 hours Approx.
(Use for basal 4 to 8 hours 24 to 28 hours
insulin taken
in injection or Lantus 2 to 4 hours No peak, stable 24 hours
in a pump to act
through day and
night to keep
blood glucose
levels stable)
6AM 9AM Noon 3PM 6PM 9PM MidN 3AM 6AM 9AM
Fill in the chart/graph below to show the action of the types of insulin you are taking now:
11
Blood Glucose Monitoring:
When to Test
12
Making Changes Using How to Evaluate Your Blood
Pattern Management Glucose Record:
You can learn to adjust your insulin Record your blood glucose levels in
dose by looking at your pre-meal blood column format (as below) to more
glucose levels over three or more days to easily identify a pattern. Many of the
see if you notice any special pattern. In data management software programs
the following example and throughout will do this for you automatically
the workbook, assume that the blood when you download the data.
glucose goals recommended by the Look at the readings by group
American Diabetes Association are in use according to the time of day.
(pre-meal plasma values of 90-130 mg/dl, Select the blood glucose readings
blood glucose 2 hours after meals less by group that are out of your goal
than 180 mg/dl.)2 and a target of range.
100 mg/dl.
2 American Diabetes Association, Standards of Medical Care for Patients With Diabetes Mellitus. American
Diabetes Association: Clinical Practice Recommendations, Diabetes Care. 27:Supl:10, 2005.
13
Q&A PRACTICE PROBLEMS
A Janes pre-breakfast, pre-lunch and pre-supper readings are in goal blood glucose
range, but her bedtime readings are all high and out of range.
14
Q What is Different About Toms Three-day Blood Glucose Pattern?
Pre-meal goals 90-130 mg/dl Post-meal goals < 180 mg/dl
15
range without any insulin changes. glucose levels and do it carefully!
Always make insulin dose changes only If you are unsure, consult with your
after a full examination of the blood Diabetes Team.
Record Your Blood Glucose for the Past 3 Days and Pick Out the Patterns You See
Pre-meal blood glucose goals:________ Post-meal blood glucose goals:________
Based on your results, fill out the answers 7. Are you experiencing hormonal
to the following questions: changes (such as those during
1. Do you see a consistent pattern? menstruation or perhaps related to
________________________________ any medication you may be taking)?
2. Which insulin is affecting the pattern ________________________________
of your glucose levels?_____________ 8. Is your pattern of values before
3. What kind of change might have breakfast out of the goal range?____
helped bring your blood glucose (If YES, this indicates that you need
levels into goal range?_____________ to change your basal insulin. Please
4. Do you want to wait a few more days refer to p. 37 for a discussion of this
before you make any change to see if topic.)
there really is a pattern?____________
HINT:
5. Have you experienced changes in
Some people find it easier to use a
your stress and/or activity levels over
computer program to identify blood
the past three days?_______________
glucose patterns. If you are interested
6. Have your food choices or amounts
in this type of a program, contact your
been different than usual for you?
meter manufacturer for information
________________________________
on how to obtain one.
16
Correcting for Blood Glucose be 100 mg/dl, you would make an
That is Out of Range immediate insulin correction. To do
this you would take a certain dose of
Know Your Blood Glucose Goals short or rapid-acting insulin to bring that
In this workbook, the American Diabetes blood glucose value down to 100 mg/dl.
Association (ADA) recommended pre-
meal blood glucose goals of 90 to 130 NOTE:
mg/dl will be used. If you are above 130 Correction doses of insulin are calculated
mg/dl, you will increase your insulin; for each person and may change
if you are less than 90 mg/dl you will throughout the day. People usually
decrease the insulin. Many people use need a bigger correction dose at
a target of 100 and make adjustments breakfast than at lunch and dinner.
if they are above or below this target.
Methods of Correction There are
Correcting The term used for an many ways to correct for an abnormal
immediate change in your insulin dose blood glucose value. The three most
based on one event, such as a: common methods will be discussed here.
Check with your health care professional
Single out-of-target blood glucose to see which method is best for you.
level.
Change in a single meal (you are Correction Method I Fixed Insulin
invited out to a French restaurant Dose Based on Blood Glucose Value.
for dinner). Uses an algorithm (formula) to tell you the
Change in your exercise routine amount of insulin to take based on your
(you are going for a bike ride). blood glucose levels before meals and at
bedtime. The carb you eat at each meal
Correcting means you make a minor should be the same from day to day.
change in your insulin dose based on the
event now, but go back to your usual EXAMPLE:
insulin dose tomorrow. Kens Diabetes Team gives him an
algorithm of blood glucose values and
EXAMPLE: insulin doses. Ken will give the insulin
If you wake up and your blood glucose dose that corresponds to his current
reading is 200 mg/dl but you want it to blood glucose.
17
Kens Algorithm for Correction Method 1
Blood Glucose Values Insulin Dose (Rapid or Short -Acting)
Breakfast Lunch Supper Bed
<50 6 8 9 0
50-69 8 10 11 0
70-89 9 11 12 0
90-130 10 12 13 0
131-160 11 13 14 1
161-190 12 14 15 2
191-220 13 15 16 3
221-250 14 16 17 4
251-280 15 17 18 5
281-310 16 18 19 6
Over 310 18 20 20 8
18
Joes Algorithm for Correction Method II Calculating Your Insulin
Blood Glucose Values Pre-meal rapid or Sensitivity Factor (ISF)
short acting insulin
Your Diabetes Team may use any of the
Less than 60 Subtract 3 units
following methods to help find your ISF:
60-90 Subtract 1 unit
90-130 Take usual dose 1. Insulin/Blood Glucose Formula
130-200 Add 1 unit (One unit of rapid or short-acting
200-250 Add 2 units insulin for every 50 mg/dl increase or
250-300 Add 3 units decrease in your blood glucose level).
300-350 Add 4 units 2. Rule of 1500 - if you are using short-
350-400 Add 6 units
acting insulin (Regular).
Over 400 Add 8 units
3. Rule of 1700 - if you are using rapid-
acting insulin (Humalog, Novalog,
Correction Method III Change in
Apidra).
Insulin Dose Based on Your Insulin
Sensitivity Factor ISF Method I Insulin/Blood
As you learned earlier, your Insulin Glucose Formula
Sensitivity Factor (ISF) tells you how many With ISF Method I, you take one unit
points lower your blood glucose will go for of rapid or short-acting insulin for every
every 1 unit of short or rapid acting insulin 50 mg/dl increase or decrease in your
you take. Method III uses your ISF to figure blood glucose level.
out how much to raise or lower your
EXAMPLE:
insulin dose to bring your blood glucose
Blood glucose target is 100 mg/dl.
back to goal range. If you use Correction
Johns pre-lunch blood glucose is 180
Method III before a meal you will need to
mg/dl and his Insulin Sensitivity is 50.
add the correction amount of insulin to the
His reading shows that he is above
amount of units needed to cover the
his target by 80 mg/dl.
number of carbohydrates you will eat. (See
[180 mg/dl 100 mg/dl = 80 mg/dl]
p. 28 for a discussion of carbohydrates.)
He should take 1 (1.5 if you measure
REMEMBER: 1/2 units) extra units at lunch.
The ADA recommended pre-meal values If his usual dose of rapid or short-acting
of 90-130 mg/dl as a goal range are used insulin at lunch were 12 units, he
in this workbook. Your Diabetes Team would increase it by one and take
may set a different pre-meal goal for you. 13 or 13.5 units.
19
PRACTICE PROBLEMS: Record yesterdays pre-meal blood
Blood glucose target: 100 mg/dl glucose readings.
Susans pre-lunch blood glucose
Take your highest pre-meal blood
is 205 mg/dl.
glucose and subtract your target goal:
Her reading shows that she is above
[_______ ________ mg/dl = _________.]
her target by 105 mg/dl Target Goal
[205 mg/dl 100 mg/dl = 105 mg/dl]
Divide your answer by 50 and add the
Q How many extra units should number to your usual insulin dose:
Susan take? [__________ divided by 50 = _________.]
105 mg/dl = 2 units
50 Add to your usual pre-meal dose.
A She should take 2 extra units. In this
case she should take a total of 14 units. If You Had a Low Blood Glucose
Yesterday, Figure out the Insulin
Bobs pre-lunch blood glucose Dose You Need:
is 60 mg/dl. Record yesterdays pre-meal blood
His reading shows that he is below his glucose readings.
lower target by 40 mg/dl
Take your lowest pre-meal blood glucose
[100 mg/dl 60 mg/dl = 40 mg/dl]
reading and subtract your target goal:
Using ISF Method I he would:
[_______ ________ mg/dl = _________.]
40 mg/dl = .8 units Target Goal
50
This will be a negative number.
Round .8 units to 1 unit
Decrease his insulin dose by 1 unit. Divide your answer by 50 and subtract
Take a total of 11 units. the number from your usual insulin dose.
[__________ divided by 50 = _________.]
Find Your Correction Dose for the
Highest Pre-Meal Blood Glucose you Subtract from your usual pre-meal dose.
had yesterday:
The corrections above using ISF Method I
ISF = 50 mg/dl Target = _____ mg/dl should bring your blood glucose back to
Pre-Breakfast Pre-Lunch Pre-Dinner normal at the next meal if you make no
20
other changes. Although any single meal EXAMPLE:
may not correct properly, if after a few Calculate Ritas ISF Using the Rule of
days they do not, you may have the 1500.
wrong ISF or the wrong carb-to-insulin If Rita took 10 units of Regular insulin at
ratio for you. Work with your Diabetes breakfast, 12 at lunch, 13 at supper, and
Team would have to adjust the ISF and 15 units of Lantus at bedtime, her total
carb-to-insulin ratio. would = 50 units a day.
ISF Method II Using the Rule of Dividing 50 units into 1500 would = 30.
1500 To get a good first guess at your
So as a first guess, each unit of insulin
insulin sensitivity, divide the sum of all of
would lower Ritas blood glucose by
your daily insulin doses into 1500.3
30 mg/dl. (See Rule of 1500 box below)
Rule of 1500
1) Add all insulin doses 2) Divide sum of insulin 3) Answer = ISF
doses into 1500
10 units Insulin Regular Insulin Sensitivity Factor =
12 units Insulin Regular 1500 = 30 mg/dl 1 unit of short or rapid -
13 units Insulin Regular 50 units of insulin acting insulin will lower
+ 15 units Insulin Lantus blood glucose 30 mg/dl
50 units
Fill in all the insulin doses you take in one (your total units of insulin/day)
day and add them up:
Total units/day
3 Klingensmith, GJ. American Diabetes Association, Intensive Diabetes Management, Third Edition, 2003.
p. 107. 2003. 21
Fill in your pre-meal blood glucose Fill in the table below with your
values from yesterday and calculate calculations using your own
your adjusted insulin dose using the information:
steps below:
Usual Insulin Adjusted
Pre-Breakfast Pre-Lunch Pre-Dinner Dose Insulin Dose
Pre-Breakfast
Pre-lunch
Pre-dinner
Circle your high pre-meal blood glucose.
Rule of 1700
1) Add all insulin doses 2) Divide sum of all insulin 3) Answer = ISF
doses into 1700
10 units Insulin Humalog Insulin Sensitivity Factor =
12 units Insulin Humalog 1700 = 34 mg/dl 1 unit of short or acting
13 units Insulin Humalog 50 units of insulin insulin will lower blood
+ 15 units Insulin Lantus glucose 34 mg/dl
50 units of insulin/day
Now you try it using the 1700 rule. Figure out your adjusted insulin dose
based on your pre-meal blood
PRACTICE: Calculate Your ISF Using
glucose readings:
the Rule of 1700.
Target Goal = ______________
Using the chart below, fill in all the
Pre-Breakfast Pre-Lunch Pre-Dinner
insulin doses you take in one day and
add them up:
# of units Type of insulin
Fill in your pre-meal blood glucose values
from yesterday in the chart above.
Total units
Subtract your target goal from your high
per day = blood glucose reading.
_______ ________ mg/dl = _________
Divide 1700 by your total units of insulin/day. Target Goal
24
Correcting for Known Both methods require that you learn how
Changes in Meals or Exercise to count carbohydrates. In addition, you
also need to learn how sensitive your
You have learned to adjust insulin to stay insulin dose is to the carb you eat. This
within your blood glucose goals. Insulin is called your Carb:Insulin Ratio. For
doses are also commonly adjusted for information about carb counting, see the
changes in diet or exercise. Changing BD Publication Carbohydrate Counting:
your insulin dose based on what you will Eat to Win and talk to your diabetes
eat and the activity you plan to do is educator.
often called insulin dosing.
Calculating Your Carb:Insulin Ratio
Correcting for a Change in Meals A carb:insulin ratio is the amount of
Since most people do NOT eat the same rapid or short acting insulin you need
thing every day, you need to learn how to match or cover the amount of
to calculate your short or rapid acting carbohydrate you eat. Your ratio
(bolus) insulin for different meals and depends on how sensitive your blood
different amounts of carbohydrates. glucose is to insulin. The more you
If you are not sure about which foods weigh, the less sensitive your body is
are carbohydrates, discuss this with to insulin. The more sensitive you are
your diabetes educator. As with insulin to insulin, the more carbohydrate that
correction for out-of-goal blood glucose, will be covered by one unit of insulin.
different methods are available for insulin Knowing your ratio and how to
dosing for a change in the food that is calculate your mealtime insulin to
usually eaten at meals. One method match the carbohydrate in your meal
involves adding or subtracting insulin for gives you the greatest flexibility with
more or less food. Another way is to improved glucose control. You will
take a certain amount of insulin for a be much freer to eat what you want,
specific amount of carbohydrate. Check when you want, with fewer concerns
with your Diabetes Team to see which about high or low blood glucose.
method they recommend for you.
25
Method I: A Quick and Easy Way Keep Detailed Records for About
to Start One Week
Before you begin, keep the following The best way to find your carb:insulin
guidelines in mind. Use 1 unit of insulin ratio is to use the following Food and
for every 15 grams of carbohydrate Carbohydrate Counting Record below
(1:15). Some people will need more and write down:
insulin (1 unit for every 10 grams of
1. Everything you eat and how much
carbohydrate). Others will need less
you eat - you will need to weigh and
insulin and use 1 unit for every 20 grams
measure! (If you know how to count
of carbohydrate. Most people with type
carbs, include them. Otherwise, use
1 diabetes have ratios between 6 and
tables or a calculator to figure out the
10, but you may want to start with
carbs in all of the food you eat and
a very sensitive level of 15 grams of
record each amount.)
carbohydrate per unit of insulin and
2. Your insulin dose for each meal.
see if this works for you.
3. Your blood glucose levels before
Method II: The Rule of 500:5 the meal.
Add up all the insulin given for 24 hours 4. Your blood glucose records after
and divide it into 500. The answer is the meal. (Your blood glucose level
your carb:insulin ratio. should increase about 50 mg/dl
2 hours after you eat. If it is much
EXAMPLE:
higher or lower than that, your
Your total insulin dose is 50 units.
Insulin:Carb ratio will need to
500 divided by 50 = 10
be adjusted.)
Your carb: insulin ratio is 10:1
NOTE:
Again, this is a starting point, you
If you have never used a carb:insulin
need to start with this ratio and adjust
ratio, discuss this with your Diabetes
it based on your blood glucose records.
Team and let them guide you through
Your Diabetes Team can guide you in
this process. Also, like the ISF, you may
this process.
have a different carb: insulin for each
meal. Typically, this ratio is lower at
breakfast.
5 Warshaw, H.S. and Kulkarni, K., Complete Guide to Carb Counting. P. 146. American Diabetes Association 2001.
26
Food and Carbohydrate Counting Record
Brkfst AM Carb BG before BG 2 hours Insulin Comments:
time: PM goal: meal after meal
gms
28
Method II Insulin Dosing Based on Correcting for a Known Change
Carb:Insulin Ratio in Exercise
Unlike Method I, you do not have a Exercise lowers your blood glucose levels.
usual amount of food that you take or If you have started an exercise program
a usual insulin dose. You simply use and your blood glucose levels are too low
the Carb:Insulin Ratio to determine and you are using an insulin pump, you
your dose. will need to adjust your basal insulin.
(See Adjusting the Basal Dose p. 37).
EXAMPLE:
This is the hardest of the adjustments
Marys Carb:Insulin Ratio is 10:1
because everyone responds to exercise
Mary is meeting an old friend at a
differently. If you are giving bolus
favorite restaurant and she is planning
injections of insulin, you should lower
to eat a 90-gram lunch. To figure out
your bolus dose before exercise. An
her insulin dose, knowing that her ratio
example of how to do this can be found
is 10:1, all she has to do is to divide
on p. 37.
the number of carb by her ratio as
follows: Try to measure your exercise by intensity
(how hard you work) and how much
90 grams of carbohydrate divided
time it takes. Think of your exercise
by 10 units of insulin = 9 units of
as mild, moderate or intense.
Humalog
Mild exercise you will not sweat at
room temperature, no matter how
[ 10
90 = 9 units of Humalog ] long you do it.
Moderate exercise you will sweat
after 15-30 minutes.
Intense exercise you will start to
sweat almost right away.
29
PUTTING IT ALL TOGETHER
30
PUTTING IT ALL TOGETHER
Toms Calculations:
Insulin needed for carbohydrates 9 units (90 divided by 10)
Insulin needed to correct for high blood glucose (190-100=90) divided by 30 (ISF)=3
31
Your Night Out
Using the Five Steps, calculate the answers in the chart below:
Your Morning Breakfast and Run 2 miles before lunch. Using the five
steps, use the space below to figure out
Lets say you are going to eat 2 slices
your insulin adjustment based on your
of toast (30 grams), a fried egg, hash
plans for breakfast and exercise:
browns (15 grams) and a 1/2 glass of
juice (15 grams). This is a total of (60 Now check the following chart and
grams of carb), but you are going to run see how well you did!
Your Morning Breakfast and Run
Insulin Sensitivity 30
Current BG Target BG 80
_______________________ = __ = + 2.5 U of insulin
Insulin Sensitivity 30
32
After correcting for food, elevated blood Be sure to test for urine ketones
glucose and expected exercise, you if blood glucose levels are over
would take 7 units of short-acting 250 mg/dl.6 Do not exercise when
insulin. you have ketones in your urine.
Eat a carb food if blood glucose levels
IMPORTANT REMINDERS:
are <100 mg/dl.
After adjusting your insulin dose for
exercise you must check to see if the This is a lot to take in at first, but most
insulin given was too much or too people get very good at doing these
little. (Checking your blood glucose calculations and quickly learn to keep
level before, during and after exercise their blood glucose levels very close to
will provide the information you need normal. It is helpful to have a small
to change future doses.) calculator when you begin.
Talk to your Diabetes Team about
how your doses are working for you.
6 American Diabetes Association, Position Statement: Physical Activity/Exercise and Diabetes. American Diabetes
Association: Clinical Practice Recommendations, Diabetes Care. 27:Sup1:1, S58-S62. January 2004. 33
ADJUSTING THE BASAL INSULIN DOSE
34
ADJUSTING THE BASAL INSULIN DOSE
Adjusting the basal dose is more How to Test and adjust The Basal
challenging than changing the bolus Insulin To Normalize Your Morning
dose. Basal insulin is designed to always Blood Glucose
be working in the background to keep 1. Check your blood glucose at bedtime,
your blood glucose steady when you are at 3 AM and in the morning before
not eating. The basal insulin has the you eat.
major job of keeping your blood glucose 2. Pick a day when your bedtime
normal during the night, if you do not glucose is close to your goal range.
eat or if you delay a meal. Insulin used 3. Set your alarm for 3 AM and write down
to provide a basal dose include Lantus your blood glucose value after you test
and Ultralente insulin and the basal (it is too easy to go back to sleep and
setting on an insulin pump. This section forget the reading you got at 3 AM).
will help explain how to make changes Bedtime 3:00 AM Pre-Breakfast
to your basal insulin.
0
Bed 3 AM Fasting
Time
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7. Your graph should look like one of the 6 patterns shown in the next graph
(Figure 5) and labeled A-F.
Figure 5
Patterns of Overnight Blood Glucose Values
400
300
A B C D E F
Blood Glucose
200
100
0
Bed 3 AM Fasting Bed 3 AM Fasting Bed 3 AM Fasting Bed 3 AM Fasting Bed 3 AM Fasting Bed 3 AM Fasting
Time Time Time Time Time Time
8. Select the example that looks the closest to the pattern of your Basal Insulin in
Figure 4.
9. Look up the change in Table 1 below. The table below will indicate the change to
your basal dose that is needed.
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For many people, the suggestion under Testing the Daytime Basal
the column, What to Do will correct the
problem and give an expected normal Your health care provider may ask you
pattern A. In some cases, the pattern to check your daytime basal dose. Here
may require more than one change. are a few methods to use. Follow your
The result of the first, usually safer providers best recommendation for your
change is shown under the column, individual case.
Expected Pattern. You may want to Option I: Skip a meal
make a second change based upon the (the simplest method).
new problem. Talk to your Diabetes Day 1 - skip breakfast, then check
Team about how that change should be your blood glucose every 2 hours,
made. Changing more than one dose of until lunch)
insulin at a time can be complicated and Day 2 skip lunch and check your
should be left to your Diabetes Team. blood glucose every 2 hours, until
How much to change the insulin is dinner
very individual, please check with your Day 3 skip dinner, again checking
Diabetes Team for advice. It is safest to your blood glucose every 2 hours,
make small changes often rather than until bedtime
big changes infrequently. In all cases, if your blood glucose
is rising, your basal is too low; if
it is falling, your basal is too high.
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Option II: See if your basal rises after Measure your blood glucose four
your last bolus has finished working. hours after you take your rapid or
(This only works with rapid or short- short-acting insulin.
acting insulin.) Continue to measure your blood glucose
every hour until you are sure that your
blood glucose is not rising or falling.
Time of Day
Meal
Breakfast - Day 1
Lunch - Day 2
Lunch - Day 3
Option III: Delay a meal and measure have a BIG effect on your blood glucose
the effect on your blood glucose. levels!
Whichever method you choose, decide After you make your adjustments, keep
if you need a change in your basal dose checking your blood glucose closely for
and do it very carefully. Your Diabetes the next few days. You need at least 4
Team may recommend that you collect days to 1 week to see if your adjustment
data over two time periods before resulted in better blood glucose control.
making a change. It is also advised that An adjustment on the basal rate for
this process be used on nights or days an insulin pump may take less time to
when your activity level is similar to your evaluate. Use a chart like the following
usual pattern. Small dose changes can to write down your blood glucose results.
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TROUBLESHOOTING
39
TROUBLESHOOTING
40
2. Absorption of Insulin 6. Physical Activity
Are your injection sites lumpy Have you changed your physical
or scarred? activity a lot?
Do you have any redness around Are you more or less active than
your injection sites? Are you usual? (If so, this can increase or
having trouble with your insulin decrease your blood glucose levels)
pump infusion site or are you 7. Food
injecting in a scarred area? (This Are you eating more carb and not
could affect how your body is taking enough insulin?
absorbing the insulin and can Is it possible you are not counting
lead to problems with control.) your carbohydrates accurately?
Have you changed how you Are you eating at the same time
give insulin? of day or does it vary?
Have you changed the brand of Are you eating less and taking too
syringe or size of insulin needle? much insulin?
If you are using an insulin pump,
8. Self-Monitoring of Blood Glucose
is the tubing clogged?
and Test Strips
3. Stress Are your test strips outdated or
Are you experiencing unusual have the strips been outside the
stress? vial? (This will make your glucose
Did you know both physical and readings inaccurate.)
emotional stress could affect your Are you checking at the right
blood glucose levels? time of day to understand the
effect of your insulin, food and
4. Infection
physical activity?
Do you have an infection?
Did you clean your hands before
Did you know infections are
checking your blood glucose?
a stress to the body and can
Even small amounts of food
increase blood glucose levels?
residue can affect results.
5. Illness If you answered YES to any of the above
Are you ill? Do you have a fever, questions, correct the problem, give
a cold, or a virus? yourself a few days and see if your
Did you know illness could blood glucose levels out.
increase blood glucose levels? If you answered NO to all of the above
questions, your next step is to sort
41
through your insulin doses.
Which Insulin is the Read the following problem and see if
Problem? it can help you figure out your basal-
bolus questions. Sam takes 19 units of
1. Basal Insulin insulin glargine (Lantus) at bedtime and
Am I taking enough or too much insulin boluses of insulin lispro (Humalog)
basal insulin? in the following amounts: 10 units for
Are my blood glucose levels breakfast; 8 units for lunch, and 12 units for
always too high or too low? dinner. His mealtime carb amounts are 75
2. Bolus Insulin at breakfast; 60 at lunch; and 100 grams
Is my bolus insulin dose correct? at dinner. His insulin/carb ratio is 8:1 and
Are my blood glucose levels his correction dose is 1 unit for every 50
too high or too low 2 hours mg/dl and his target glucose is 100 mg/dl.
after eating? On days 1-3 he always eats his normal
amount of carb. He does not eat an
afternoon snack. Look at his blood glucose
values and insulin doses in the chart below.
8 AM 12 noon 6 PM 10 PM
BG Ins BG Ins BG Ins BG Ins
Day 1 94 10 L 104 8L 205 13 L 150 1 LP
19 G
Day 2 108 10 L 103 8L 197 13 L 155 1 LP
19 G
Day 3 97 10 L 112 8L 215 14 L 125 19 G
Now, read the questions below and circle 2. Which of the following types of
the letter that you think is the correct problems does Sam have?
answer to each question. A. A basal problem?
B. A bolus problem?
1. What is the problem?
C. An eating problem?
A. Blood glucose too low at
breakfast? 3. What should Sam do?
B. Blood glucose too high at lunch? A. Change the basal insulin glargine?
C. Blood glucose too high at supper? B. Change the breakfast bolus?
D. Blood glucose too low at C. Change the lunch bolus?
bedtime? D. Change the supper bolus?
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4. How much of an adjustment is Notice that while his dinner glucose
needed? values were too high, Sam was taking
A. Decrease 1-2 Units a correction dose of 1 unit of insulin
B. Increase 1-2 Units for day 1 and 2. Since his blood glucose
C. Increase 3-4 Units values were too high by about 75 mg/dl
D. Increase 5-6 Units this was not enough and on day 3 he
increased the correction to 2 units of
ANSWERS:
insulin lispro (Humalog).
1. C Sam has detected that he is
always too high at supper. If you have remaining basal-bolus
2. B This is a bolus pattern that questions, check back with your
requires adjustment. Diabetes Team.
3. B He should change his lunch bolus
4. B He should increase his lunch bolus
(insulin lispro Humalog) by 1 Unit.
He should check back in 3 days to
see if this was enough.
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PROBLEM SOLVING AND EXERCISES
44
PROBLEM SOLVING AND EXERCISES
Use the problems and exercises in B. Increase the daytime basal rate
this section to help you reinforce and by 0.2 units per hour?
strengthen what you have learned C. Set her alarm and check her
about insulin adjustment. The more blood glucose level at 3 AM?
experienced you become at spotting D. Give a bolus at 10 PM?
problems and figuring out the answers,
A Choice C is the correct answer - the
the more rewards you will enjoy from
only way to find out what is happening
practicing basal-bolus insulin therapy!
to Sallys blood glucose level during the
Sallys on Goal at Bedtime but Gets night is to test it at 3 AM. Choice A -
High Readings in the Morning Increasing the basal rate overnight might
Sally has been using an insulin pump for cause hypoglycemia in the middle of the
3 months. Her basal rate is set at 0.7 night. Choice B - Increasing her daytime
units per hour from 10 PM to 3 AM and basal rate would do nothing to help the
her daytime basal rate is 0.5 units per overnight blood glucose levels. Choice D -
hour. She has been going to bed with Giving a bolus at 10 PM could cause a
normal blood glucose values but always problem with hypoglycemia at midnight.
wakes up with blood glucose levels over
Q What should Sally do if she
165 mg/dl. She increased her basal rate
checks her blood glucose at 3 AM
from 10 PM to 3 AM from 0.6 to the
and discovers that it was 60 mg/dl?
current rate of 0.7 units per hour but
A. Lower the 10 PM to 3 AM basal rate?
is still having a problem.
B. Eat a big snack at 10 PM?
Q What should Sally do to try to C. Decrease the snack bolus?
bring her morning blood glucose level D. Increase the 10 PM to 3 AM basal rate?
to her goal range of 90-130 mg/dl?
A Choice A is the correct answer.
A. Increase the basal rate from
Sally has pattern D.
10 PM to 3 AM?
Figure 5
Patterns of Overnight Blood Glucose Values
400
300
A B C D E F
Blood Glucose
200
100
0
Bed 3 AM Fasting Bed 3 AM Fasting Bed 3 AM Fasting Bed 3 AM Fasting Bed 3 AM Fasting Bed 3 AM Fasting
Time Time Time Time Time Time
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By lowering the 10 PM to 3 AM A Jack needs 5 units of rapid- or short-
basal rate, Sally can avoid becoming acting insulin for his meal of 60 grams
hypoglycemic at 3 AM. By doing this, of carb with a blood glucose within his
she may find that her fasting blood blood glucose goals.
glucose level normalizes because she will
Q Can you find Jacks bolus dose
not get a rebound high blood glucose in
for the following dinner?
the morning. The other choices will not
Jacks pre-dinner meal blood glucose
result in preventing hypoglycemia at 3
is 212 mg/dl.
AM. If her morning glucose rises higher,
He is planning to eat 2 pieces of
she can increase her 3 AM to 7 AM bolus
bread, a salad with croutons and
dose.
dressing, steak; large baked potato,
Jack Needs Help Figuring Out His side order of peas and broccoli. For
Bolus Dose for Certain Meals dessert he will have 1/2 cup of vanilla
Jack takes a bedtime basal dose of insulin ice cream with a small cookie.
glargine (Lantus) of 20 units and bolus Use this space to figure out Jacks
meal doses based on a carb:insulin ratio bolus dose before peeking at the
of 12 grams of carbohydrate/unit and an following answer!
insulin sensitivity factor (ISF) of 1 unit for
every 40 mg/dl. His goal blood glucose Planned Food (Carbs) _____Carbs
Q What should Jacks bolus dose be Current blood glucose - target blood glucose
_____ mg/dl
for the following breakfast meal?
What is Jack's Insulin sensitivity factor? _____
His pre-meal blood glucose is 112
Divide Jack's blood glucose calculation by
mg/dl. Insulin sensitivity
He will have 2 slices of toast,
_____ U of insulin
1 orange, 1 slice of cheese,
_____ Total Dose
1 cup of milk and coffee.
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A Jack needs 13 units of insulin. Pre-breakfast Pre-lunch Pre-dinner Bedtime
Heres why!
100 70 89 72
His carbs total 120 grams (bread =
85 100 88 65
30 grams, croutons = 15 grams,
68 87 92 60
large baked potato = 30 grams,
90 68 66 80
peas = 15 grams, ice cream and
cookie = 30 grams 83 77 62 79
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Juan Has Had a Change in His Q What Could Have Made Juans
Blood Glucose Levels Blood Glucose Reading So High Over
the Past Four Days?
Juan has had blood glucose levels within 1. His car might have been too hot,
his goal range for the past several causing his insulin not to work.
months on his basal/bolus insulin 2. Juan might have been under a great
regimen of 10 units insulin glargine deal of stress.
(Lantus) and pre-meal insulin doses 3. His blood glucose test strips might
of 6 units of insulin aspart (Novolog). have expired.
He uses an ISF of 1 unit for every 50
mg/dl and a target of 100 mg/dl. A Any or all of the above choices could
be correct. Choice 1 Insulin must
For the past 4 days his blood glucose always be kept at least at room
values have increased to over 140 mg/dl temperature. Juan would have to
consistently. He has not changed open a new bottle and watch his
anything in his routine and is not sick. glucose levels closely. Choice 2 If
He always carries his insulin aspart with Juan is having unusual stress, he might
him in the car so it is available if he need a small adjustment in his insulin
decides to stop and eat. while this is going on. Choice 3
Expired blood glucose test strips could
be giving him inaccurate readings.
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SEE YOU REALLY CAN DO IT!
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SEE YOU REALLY CAN DO IT!
This workbook is only a starting point Like anything new, basal-bolus therapy
and guideline in your move to flexible is not easy at first and you will need help
therapy with basal-bolus insulin in learning how to adjust your insulin
adjustment. The best approach is to for food, activity, sleeping and waking.
consult your Diabetes Team and work However, once you have learned these
on this together. If things go out of skills, you should be able to get your
control, refer back to this how-to diabetes under excellent control and
guide and do some of the exercises. live a more flexible, healthy life.
Written by:
Marjorie Cypress, RN, MSN, C-ANP, CDE
Albuquerque, NM
We wish to acknowledge the following health professionals for reviewing this publication and providing their valuable insights:
BD and BD Logo are trademarks of Becton, Dickinson and Company. 2005 BD.
All other brands are trademarks of their respective owners.
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