Chapter 21 (Insulin Adjusting the InsulinDosage · 222 Chapter 21 – Adjusting the Insulin Dosage...

TOPICS:Medications(InsulinAdjustments)Monitoring TEACHING OBJECTIVES: 1. Discuss when and how to adjust

insulin doses.2. Integrate factors which

influence insulin dose into a“thinking” scale.

3. Demonstrate the application ofdose adjustment to blood sugartrends.

LEARNING OBJECTIVES:Learner (parent, child, relative orself) will be able to:1. Describe when and how to

increase or decrease insulindoses.

2. Explain insulin adjustmentsusing blood sugar records.

3. List two factors which affectblood sugars and describe theappropriate insulinadjustments.

Chapter 21

Adjusting theInsulin Dosageand “Thinking”Scales

BLOOD SUGAR GOALS (suggested ranges)

It is our general goal to have blood sugar levels in theranges listed below (also see Chapter 7). These ranges arewhen no food has been eaten for at least two hours. Theyapply to fasting in the morning as well as for two hours afterany meal or snack.

Under 5 years of age = 80-200 mg/dl (4.5-11.1 mmol/L)

5-11 years of age= 70-180 mg/dl (3.9-10.0 mmol/L)

12 years and above= 70-150 mg/dl (3.9-8.3 mmol/L)

A person who has difficulty recognizing low blood sugarsor who has severe insulin reactions may be asked to keep theblood sugar at a slightly higher level. Families and the diabetescare provider should discuss the desired range. This rangeshould be written down for future reference. It is important toremember that this is a target goal. If at least 50 percent ofthe sugar values are in the target range at each time of day,the HbA1c level will usually be good. Not all blood sugarvalues will be in the target range. The exception to this isduring the “honeymoon” period shortly after diagnosis. Ifmore than half of the values are in range and the HbA1c is stillhigh, blood sugars at other times of the day should be done.

221

222 Chapter 21 – Adjusting the Insulin Dosage and “Thinking” Scales

Chapter 7 gives suggestions for other times –including two hours after meals.

After six to 12 months of dealing withdiabetes, many families and older teens beginmaking some of their own insulin adjustments.This should be discussed with the diabetes careprovider at a clinic visit. If the decision ismutually agreeable, guidelines for insulinadjustments should be discussed.

ADJUSTING THE INSULINDOSAGE

The first step in learning to adjust insulin isto know the times of action of the insulins used.Refer to the figures in Chapter 8 and Table 1 inthis chapter to review the times of action ofvarious insulins.

The three rapid-acting insulins are:

1. Humalog

2. NovoLog

3. Apidra

All these have similar activity (Chapter 8).They can be used interchangeably.

Changes in insulin dosage are best consideredunder four categories:

A. Reducing the Insulin Dose

B. Increasing the Insulin Dose

C. Insulin Adjustments for Food andCorrection Factor

D. Insulin Adjustments for People ReceivingLantus Insulin

A. Reducing the Insulin Dose(TO PREVENT LOW BLOODSUGARS: Tables 1, 2 and 3)

Responding to trends in the blood sugarlevels

Reducing a specific insulin dose should be doneif:

✔ frequent (> 2 per week) blood sugar valuesbelow 60 mg/dl (3.3 mmol/L), which weconsider is the level of true hypoglycemia,or below 70 mg/dl (3.9 mmol/L) in apreschooler

✔ all blood sugars in a day are below thedesired lower limit. The insulin dosesshould be reduced with the next injection.

We do not know why blood sugars willsuddenly be low for a day or longer in a personwho has been stable. Most often this is due toincreased physical activity, eating less food oropening new bottles of insulin. Also, NPHinsulin has variable absorption from day-to-day.

How much the insulin is reduced depends onthe age and size of the person and the dose beinggiven. Sometimes all that is needed is to omit orreduce the rapid-acting insulin for a few days.

When are the low values occurring?

● If the low values occur before dinner, themorning NPH insulin can be reduced byone or two units.

● If the reactions are in the early morninghours, the evening NPH or Lantus (given atany time of the day) can be reduced by oneor two units.

● If the values are still low the next day,reduce the insulin again.

Think about what time of the day thereactions are occurring and which insulin ishaving its main action at that time of day.Reduce the insulin that is working at thattime by one or two units.

Sometimes the values are high the day after

Chapter 21 – Adjusting the Insulin Dosage and “Thinking” Scales 223

the insulin dose is reduced. This is because theinsulin-balancing hormones may require a dayor two to adjust. It is important to be patientwhen a dose is reduced, and DO NOT GOBACK UP ON THE DOSE just becauseblood sugars are a bit higher. Wait a few daysto let the balancing hormones re-adjust beforedeciding to go back up on the dose.Remember that even though we suggestwaiting a few days to make further changes ifthe blood sugar is high, this is NOT necessary ifit is low. It is OK to make a furtherreduction the next day if values are still low.

Thinking ahead to prevent lows(reactions)

Although discussed in more detail inChapter 6, families need to “think ahead” toprevent lows. Reduce the insulin dosageduring days of high excitement and activity orwhen eating less. When children stayovernight at a friend’s house (or have afriend spend the night) there is often anincrease in activity and less sleep. More energyis expended, and it is wise to reduce the p.m.insulin dose and/or the Lantus dose.

The following can all lead to low blood sugars:

✔ school trips and field days

✔ family picnics and playing with cousins

✔ long hikes or bike trips

✔ spending the night with a friend

✔ vacations to places like Disneyland® or thebeach

✔ deciding to begin a diet

✔ when school is out and the weather is nice,children will play outside after dinner. Theevening rapid-acting insulin almost alwayshas to be reduced.

✔ getting cold when playing outside in coldweather (not wearing enough warmclothing)

Temporary reductions in dosage of insulinsacting at the time of activity or excitement canhelp to prevent problems. If there arequestions about reducing the insulin dosage,call the diabetes care provider during officephone hours. (Save home calls and pager callsfor emergencies.) Remember it is generallybest to err on the safe side. Alterations in theinsulin dose for sick-day and surgerymanagement are discussed in Chapter 16,“Sick-day and Surgery Management.”

Table 1The Four Time Periods of Insulin ActivityPeriod 1: a.m. Humalog/NovoLog Works primarily from breakfast (B) to lunch (L)

Apidra/Regular

Period 2: a.m. NPH Works primarily from lunch to dinner (D)

Period 3: p.m. Humalog/NovoLog Works primarily from dinner to bedtime (BT)Apidra/Regular

Period 4: p.m. NPH (evening) Works primarily from bedtime to the Lantus (anytime) following morning (NPH) or all day (Lantus)

Period: 1 2 3 4


Responding to severe insulin reactions

If a severe insulin reaction occurs, it isimportant to call the diabetes healthcareprovider before giving the next scheduledinsulin shot. The stores of balancing hormones(e.g., adrenaline) are reduced with a severereaction and there is a greater risk for morereactions. The insulin dose should be reducedtemporarily. It is important to prevent a severereaction from occurring again. Sometimes it ishelpful to schedule a clinic appointment todiscuss this.

B. Increasing the Insulin Dose(TO TREAT HIGH BLOODSUGARS: Tables 1, 2 and 4)

Understanding why more insulin isrequired

An insulin dose may need to be increased:

✔ if the blood sugars have been above thedesired range for three or four days in a rowand there is not an obvious illness or stressthat will soon go away

✔ when children grow, their insulin needsgenerally increase by one unit for every twopounds gained. Also, when growthhormone levels increase, insulin activity isblocked.

✔ because in some people their own pancreasgradually makes less insulin

✔ in the winter when many people exerciseless and their insulin needs increase

✔ during times of high stress or during menses(menstrual period)

✔ if HbA1c values are high (reflecting bloodsugars over the past three months)

✔ during an illness, there may be a temporaryneed for more insulin (especially if ketonesare present). This is discussed in Chapter16, “Sick-day and Surgery Management.”

Resistance to increasing the insulin dose

Some people resist increasing the insulindose. When blood sugars have been runninghigh, the person’s body becomes accustomed tohigher levels. They may feel uncomfortable atlower blood sugar levels. This unpleasantfeeling lasts for a short period and will graduallydisappear. Also, the most frequent fear ofpeople with diabetes (and their familymembers) is of low blood sugars. This isparticularly true if severe reactions haveoccurred. People may resist (sometimessubconsciously) increasing the dose andlowering the blood sugars. An increase in thedose may mean a loss of further insulinproduction in the eyes of some families. Thiscan seem like a time of additional loss.

Knowing which insulin to increase

It is essential to know the times of action ofthe insulins and the desired ranges for the bloodsugars. The insulins working during the fourtime periods are shown in Table 1. When theblood sugars are above the desired range for threeto seven days with no obvious cause, the insulinacting in that time period is increased. Thus:

✔ if the sugars are high before lunch, increasethe morning rapid-acting (Humalog/NovoLog/Apidra) or Regular insulin

✔ if the sugars are high before dinner, increasethe morning NPH or the rapid-actinginsulin or Regular insulin at lunch

✔ if the sugars are high before the bedtimesnack, increase the dinner rapid-acting orRegular insulin

✔ if the sugars are high before breakfast,increase the dinner (or bedtime) NPH orthe Lantus insulin given at any time of theday (see Table 2)

The increases are usually by a half unit for apreschooler or by a unit for an older child oradult. The blood sugars will tend to run loweron the first day of increased insulin. It may behelpful for the family and care provider to fillout Table 2 together.


The dose may need to be increased again asthe balancing hormones adjust. Extra snacks onthe first day of an increased dose are often wise.We often suggest a slice of pizza at bedtime onthe first night if increasing the insulin workingduring the night. If the blood sugars are stillabove the desired range after three to seven days,repeat the increase again. Continue thisprogram until at least half of the blood sugarsat the time of day being worked on are in thedesired range. A general rule is to increase the

dosage slowly. If you are not sure whether tomake further increases in the insulin dose, fax ormail the blood sugars. You can also call to discusschanges with your diabetes care provider. Faxingor mailing in the blood sugar values allows thediabetes care provider time to review and thinkabout recommendations. It saves the need forcopying values over the phone. Sample fax sheetsare included in Chapter 7. This reporting shouldbe done during office phone hours. Save homecalls and pager calls for emergencies.

Table 2Adjusting Insulin DosesDesired range for blood sugars ___________ to _____________.

PATTERN TO FOLLOW FOR CHANGING INSULIN DOSE

Blood sugar levels

If HIGH for 3-5 days

Time of Day Insulin to Increase How Much

• before breakfast dinner or bedtime NPH or by ______ unit(s)Lantus (given anytime)

• before lunch morning rapid-acting or Regular (R) by ______ unit(s)

• before dinner morning NPH: lunch rapid-acting or R by ______ unit(s)

• before bedtime dinner rapid-acting or R by ______ unit(s)

NOTE: Most people wait 3 days between increases in doses.

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

If LOW for 1 or 2 days

Time of Day Insulin to Decrease How Much

• before breakfast dinner or bedtime NPH or by ______ unit(s)Lantus (given anytime)

• before lunch morning rapid-acting or Regular (R) by ______ unit(s)

• before dinner morning NPH or lunch rapid-acting or R by ______ unit(s)

• before bedtime dinner rapid-acting or R by ______ unit(s)

NOTE: If still low after decreasing the dose, making another decrease the next day is fine.

Rapid-acting insulins: Humalog, NovoLog and Apidra. R = Regular insulin.


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C. Insulin Adjustments forFood and Correction Factor

When choosing a dose of rapid-actinginsulin, thinking about the blood sugar leveland the food to be eaten is always important.To make dose decisions a bit easier, manyfamilies and care providers choose a correctionfactor which can be added to the insulin doseto cover carbohydrate eaten (if they are carb-counting). The correction factor refers to theunits of insulin needed to correct a blood sugarlevel. The goal is to return the blood sugarlevel into the desired range. A correction factoris generally used when Humalog/NovoLog hasnot been given within the previous two hours.The most common correction dose is one unitof rapid-acting insulin per 50 mg/dl (2.8mmol/L) of glucose above 100 mg/dl (5.5mmol/L). Corrections may be to 150 mg/dl(8.3 mmol/L) during the night. However,every person is different. A preschooler may dobetter with one unit per 100 mg/dl (5.5mmol/L) above 200 mg/dl (11.1 mmol/L).The person or family will need to find out whatworks. It is a helpful way to get the bloodsugar back on track.

If food is to be eaten at the time of doingthe correction (e.g., time for lunch or afternoonsnack), the insulin to cover the food can beadded to the correction dose. For example, inTable 5, if a person planned to eat three carbchoices (45g of carbohydrate) and their I/Cratio (Chapter 12) was 1:15, the dose of rapid-acting insulin would be three units. If theirblood sugar was 250 mg/dl (13.9 mmol/L),the correction factor would be two units. Thetotal dose to be taken would be five units (threeunits plus two units). If no food were to beeaten, then the dose to be taken would just bethe two unit correction factor.

If the correction dose is to be given after anexercise induced high sugar, it should bereduced by half. (Delayed hypoglycemia mayfollow as adrenaline levels decrease and sugargoes back into muscle – see Chapter 13.) Also,if a correction is to be done at bedtime, manypeople use half of the usual dose. Prevention oflows during the night is important.

Correction insulin doses are also discussedin Chapter 26 on insulin pumps. Insulin-to-carbohydrate (I/C) ratios are also discussed inChapter 12 on food management.

Table 5Example of Insulin Adjustments

Blood Sugar Correction Factor* Carb Choices** Total Unitsmg/dl mmol/L Units of Insulin (15g carb) of Insulin

150 8.3 0 1 1

200 11.1 1 2 3

250 13.9 2 3 5

300 16.7 3 4 7

350 19.4 4 5 9

* Assuming a correction factor of one unit of rapid-acting insulin per 50 mg (2.8 mmol/L) above150 mg/dl (8.3 mmol/L).

** One Carb choice = 15g carbohydrate. In this example, one unit of insulin is given for each 15gcarb choice.


D. Insulin Adjustments forLantus InsulinIn Chapter 8 you can find:

✔ The most common ways we currently useLantus insulin.

✔ A method to determine the starting Lantusdose.

✔ An example for Lantus given at dinner or inthe evening (Figure 1). The dose of Lantusis increased or decreased until most of themorning blood sugars are in the desiredranges.

These ranges are:

Under five years of age = 80-200 mg/dl (4.5-11.1 mmol/L)

5-11 years of age = 70-180 mg/dl (3.9-10.0 mmol/L)

12 years and above = 70-150 mg/dl (3.9-8.3 mmol/L)

Most people will adjust up or down by oneor two units of Lantus insulin (or one-half unitfor toddlers) every two or three days untilmorning values are in the ranges listed above.

As stated in Chapter 8, Figure 1, we oftenuse a mixture of Humalog/NovoLog/Apidra(H/NL/AP) and NPH in the morning. TheH/NL/AP dose may be the same dose aspreviously used. The NPH dose is about one-half the previous NPH dose that had beengiven in the morning. The amount of NPH isadjusted up or down until the sugar levels atdinnertime are mostly within the ranges listedabove. Table 6 provides an algorithm that maybe helpful in adjusting insulin dosages.

The H/NL/AP dosages for meals are bestadjusted by measuring blood sugar levels twohours after the meal. The same sugar levelsgiven above can also apply for the desired valuestwo hours after eating. Others routinely aimfor a blood sugar level below 140 mg/dl (7.8mmol/L) two hours after meals. If the valuesare not in the desired range two hours after

eating, the Insulin to Carbohydrate (I/C) ratiowill need to be changed. If the blood sugarvalue is high, more insulin for carbohydrate inthe I/C ratio will need to be given. Anexample would be to change from 1:15 (1unit/15g carbohydrate) to 1:10 (1 unit/10gcarbohydrate). If the sugar level is below thelower limit, less insulin is needed. An examplewould be to change from a ratio of 1:15 (1unit/15g carbohydrate) to 1:30 (1 unit/30gcarbohydrate). Call your healthcare provider ifyou need help.

Snacks are often not necessary with Lantusinsulin. However, if the blood sugar is below130 mg/dl (7.3 mmol/L) at bedtime, it isusually wise to have a bedtime snack. When theblood sugar is above this level and the person ishaving more than 15g of carbohydrate atbedtime, H/NL/AP may be necessary.


“THINKING” SCALES (AND REPLACING THETERM “SLIDING” SCALES)

It is important to emphasize that “sliding”scales are really “thinking” scales. They givethe person or family ranges of H/NL/APand/or Regular insulin to “think about.” Theblood sugar level SHOULD NEVER be theonly factor considered. Food intake andboth recent and expected exercise also needto be considered with every shot. Anexample would be a five-year-old going out toplay with friends after dinner in the summer.Even if the blood sugar was 200 mg/dl (11.1mmol/L) before dinner, it would be wise toreduce (or omit) the evening dose of rapid-acting insulin. This would also apply if mom(or dad) was making tuna noodle casserole fordinner, and they knew that the five-year-olddisliked tuna noodle casserole. Sliding scalesrequire careful thinking prior to giving eachinsulin shot, and it is better to call them“thinking” scales. Thinking scales fordifferent aged children are often based onwhether they are still quite sensitive to rapid-acting insulin or not as sensitive. Possible scalesshould be discussed with your diabetes careprovider.

Many families adjust Humalog/NovoLog/Apidra and/or Regular (not NPH) insulindosages with every injection. They use athinking scale in which the amount of rapid-acting insulin given is based on:

1. the blood sugar level

2. the expected food intake

3. both recent and expected exercise

4. other factors (e.g., illness)

The range of insulin is usually preset by thefamily and the diabetes care provider workingtogether. The insulin scale can be written downin Table 7. Thinking scales are particularlyhelpful when parents alternate giving injectionsand desire a pattern that both can follow. If theblood sugar is low, the amount is decreased. In

contrast, the dose is increased for higher bloodsugars, if less exercise is expected or if a largemeal is to be eaten. Smaller children obviouslyhave lower dosages than larger children.Children in the first year after diagnosis (whomake more of their own insulin) are usuallymore sensitive to rapid-acting insulins and willhave lower dosages.

Many families now use carbohydratecounting (see Chapter 12) as the method todetermine insulin dosage for food to be eaten.They must still consider the blood sugar level.

Examples are:

✔ subtracting one or two units if the value isbelow 70 mg/dl (3.9 mmol/L)

✔ adding one or two units if the value is above180 mg/dl (10.0 mmol/L)

✔ giving the insulin after the meal, allowingthe insulin dose to be based on the carbsactually eaten (especially for toddlers)

Additional rapid-acting insulin can be addedto this meal dose. The amount added shouldtake into consideration the current blood sugarand any planned activity. If gym occurs one totwo hours after the morning shot, one or twounits of rapid-acting insulin might besubtracted. If it is raining on a summer eveningand exercise is to be less, one or two extra unitsof the rapid-acting insulin might be given.Even if a family is using carbohydrate countingto determine insulin for food intake, they mustuse thinking scales.

One advantage of thinking scales is that theblood sugar level must always be measured ifthe scale is to be used. Sometimes one scale isused for the morning and a different scale forthe evening. As indicated in Table 7, it mayeven be necessary to use one scale for an activeday and a different scale for a quiet day.

It is important to remember that thinkingscales are not “written in stone.” A scale thatworks fine for a few months may have to bealtered if the blood sugars are not in the desiredrange. Always bring the scale along to clinic


Table 6Algorithm for Adjusting Lantus Insulin Regimens1. Lantus dose:

When using only Lantus insulin (no NPH), determine the dose based on the pre-breakfast blood sugar(morning blood sugar goal = 70-180 mg/dl [3.9-10.0 mmol/L])*

If morning blood sugar value is:● 60-70 mg/dl (3.3-3.9 mmol/L) = decrease the Lantus dose by one unit daily changes● < 60 mg/dl (< 3.3 mmol/L) = decrease the Lantus dose by two units }can be made

● 180-240 mg/dl (10.0-13.3 mmol/L) = increase the Lantus dose by one unit wait 2-3 days● > 240 mg/dl (> 13.3 mmol/L) = increase the Lantus dose by two units }between changes

2. Using an a.m. NPH dose

(afternoon or dinner blood sugar goal = 70-180 mg/dl [3.9-10.0 mmol/L])*

If afternoon blood sugar value is:● 60-70 mg/dl (3.3-3.9 mmol/L) = decrease a.m. NPH dose by one unit daily changes● < 60 mg/dl (< 3.3 mmol/L) = decrease a.m. NPH dose by two units }can be made

● 180-240 mg/dl (10.0-13.3 mmol/L) = increase a.m. NPH dose by one unit wait 2-3 days● > 240 mg/dl (> 13.3 mmol/L) = increase a.m. NPH dose by two units }between changes

3. Humalog, NovoLog or Apidra (H/NL/AP)

(two hours after a meal blood sugar goal = 70-180 mg/dl [3.9-10.0 mmol/L])*

If blood sugar value two hours after the meal is:● 60-70 mg/dl (3.3-3.9 mmol/L) = decrease the H/NL/AP dose prior to

the meal by at least one unit ** daily changes

● < 60 mg/dl (< 3.3 mmol/L) = decrease the H/NL/AP dose prior to the can be made

meal by at least two units **}

● 180-240 mg/dl (10.0-13.3 mmol/L) = increase the H/NL/AP doseprior to the meal by one unit wait 2-3 days

● > 240 mg/dl (> 13.3 mmol/L) = increase the H/NL/AP dose prior to between changes

the meal by two units}

*For teens and adults, the healthcare provider may wish the blood sugar goal to be 70-150 mg/dl(3.9-8.3 mmol/L ) rather than 70-180 mg/dl (3.9-10.0 mmol/L).

**If carb counting, subtract or add these amounts, but it may be necessary to talk with the dietitianto change the I/C ratio.

Call your health care provider if you have questions.


visits so the dose can be reviewed with thediabetes care provider. Also, write down thedose of insulin given in each shot on the bloodsugar record sheet (see Chapter 7). This makesit possible for you and the diabetes careprovider to more easily review dosages and howthe scales being used are working.

SUMMARYIn summary, it is important for families to

consistently look at blood sugar levels. TheHbA1c value may be up to one point lower infamilies who record values and look at patterns.They then need to make insulin adjustments toobtain or maintain optimal diabetes control.Keeping a blood sugar and insulin dose log(record) will allow the family to see patternsto make the insulin adjustments. It is mostfrustrating when high blood sugars are obtainedweek after week and no adjustments are made.If a family is uncertain whether changes ininsulin need to be made, fax, e-mail or mail theblood sugar values and insulin dosages to thediabetes care provider to get help. Remember

to bring your log book to the clinic visit. Wehave heard every possible excuse (“My dog atethem,” “I left it at home”). Needless to say, wedon’t believe any of them. As a compromise,consider using the log book for 1-2 weeks out ofthe month. Another helpful time would be ifexercise or schedules change. This will help youknow when you need assistance with insulinadjustments.

DEFINITIONSCorrection factor: Use of a set amount ofinsulin to correct the blood sugar into thedesired range. The most common example isgiving one unit of Humalog/NovoLog/Apidrainsulin for every 50 mg/dl (2.8 mmol/L) above150 mg/dl (8.3 mmol/L) blood sugar level.

Sliding scale: Altering the insulin dose basedon the blood sugar levels.

Thinking scale: Altering the insulin doseconsidering factors other than just blood sugarlevels. The other factors might include: foodamount, exercise, stress, illness and menses.

Table 7Suggested “Thinking” Scale for Humalog/Novolog/Apidra(H/NL/AP) or Regular (R) Insulin Dosage

Morning H/NL/AP/R Afternoon H/NL/AP/R Dinner H/NL/AP/R________________________ ________________________ ________________________

Blood Active Not active Active Not active Active Not activeSugar (or not (eating (or not (eating (or not (eatingLevel eating much) normally) eating much) normally) eating much) normally)

______ = __________ __________ __________ __________ __________ __________

______ = __________ __________ __________ __________ __________ __________

______ = __________ __________ __________ __________ __________ __________

______ = __________ __________ __________ __________ __________ __________

______ = __________ __________ __________ __________ __________ __________

______ = __________ __________ __________ __________ __________ __________

NOTE: This table does not apply to sick-day management (see Chapter 16). Call your diabetes care providerAFTER CHECKING THE BLOOD SUGAR AND KETONES if you have questions. Scales may also be usedfor rapid-acting insulin dosages given at other times during the day. Copy this table as often as you wish.


QUESTIONS AND ANSWERSFROM NEWSNOTES

What is meant by “sliding” scalesfor insulin adjustments and whoshould use them?

“Sliding” scales generally refer togiving different dosages ofHumalog/NovoLog/Apidra or

Regular insulin depending on the level of bloodsugar. They should not be used for NPH orLantus. We prefer the term “thinking” scale toemphasize that the blood sugar level, foodintake and exercise must all be consideredbefore each insulin dose is chosen. On someoccasions, illness, stress and menses must alsobe considered. The diabetes care providershould discuss the “thinking” scale for the doseof rapid-acting insulin individually for eachperson. Some people are still making their owninsulin and will need less rapid-acting insulin,particularly at younger ages; see below.

Both of these scales would then need to beadjusted after “thinking” about food intake,exercise, stress, illness or other factors. Somepeople even need a different scale for theirmorning compared with their evening dosage ofrapid-acting insulin. It should always beremembered that the scale may have to be

reduced if heavy exercise has just been done oris about to be done. There is no goodsubstitute for thinking and reasoning! If youdo at least three blood sugar tests per day andwant to try a thinking scale, you should discussthis with your diabetes care provider.

Do the needs for insulin changewith the seasons?

The short answer is “yes.” Toillustrate this, think of summer camp.Nearly every person going to camp

has their routine dose of insulin substantiallyreduced because of all the extra activity. To alesser degree this happens in spring - over aweek or two the snow suddenly disappears, thesunshine appears and children are out playing,bicycling, etc. With the increased activity, lowblood sugars are more likely. Snacks may haveto be adjusted and/or insulin doses may needto be lowered.

In contrast, the opposite happens withgoing back to school in the fall, especially forthose going to new schools. This may be a timeof extra stress as well as reduced activity.Activity is decreased with the eveninghomework. Blood sugars may go up andinsulin doses may need to be raised.

Q

A Q

A

A four-year-old diagnosed at age three might do fine with a thinking pre-meal scale of:

Blood Sugar Units of Humalog/NovoLog/Apidra ormg/dl mmol/L Regular Insulin

< 100 < 5.5 0100-200 5.5-11.1 1201-300 11.2-16.7 2

> 300 > 16.7 3

A 16-year-old who developed diabetes at age three might have an entirely different pre-meal scale:

Blood Sugar Units of Humalog/NovoLog/Apidra ormg/dl mmol/L Regular Insulin

< 70 < 3.9 270-150 3.9-8.3 4151-200 8.4-11.1 6

> 200 > 11.1 8

Chapter 21 (Insulin Adjusting the InsulinDosage · 222 Chapter 21 – Adjusting the Insulin Dosage...

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