March 2009

Saskatchewan Insulin Adjustment Module March, 2009

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Saskatchewan Insulin Adjustment Module March, 2009

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TABLE OF CONENTS
Introduction ........................................................................................................... 5 Development Background .................................................................................... 5 Purpose .............................................................................................................. 5 Developing the Policies, Procedures and Learning Package ..................................... 6 The Outcome ...................................................................................................... 6 Revisions for 2009 ............................................................................................... 7 How To Use the Template.................................................................................... 8 Resource Personnel ........................................................................................... 11 Policy For Transfer Of Medical Function For Basic Insulin Dose Adjustment (IDA)....... 12 Purpose ............................................................................................................ 12 Personnel ......................................................................................................... 12 Policies ............................................................................................................. 12 Procedures........................................................................................................ 15 Policy Appendix .................................................................................................... 16 Appendix A - Advanced Certification................................................................... 16 Appendix B - Sample Physician/Registered Nurse Signature Sheet ......................... 16 Appendix C - Sample Competency Performance Checklist...................................... 17 Competency Performance Checklist.................................................................... 18 Appendix D – Detailed Competencies For Self Assessment .................................... 19 Appendix E - Sample Progress Report ................................................................ 28 Appendix F - Commonly Asked Questions and Answers......................................... 29 Learning About And Procedures For Insulin Dose Adjustment ................................... 33 Endogenous Insulin ........................................................................................... 33 Exogenous Insulin ............................................................................................. 35 Insulin Approved For Use in Canada.................................................................... 35 Potential Adverse Effects of Subcutaneous Insulin Use.......................................... 36 Drugs That May Inhibit or Potentiate Insulin Action .............................................. 36 Insulin Requirements ......................................................................................... 37 Practical Aspects Of Insulin Management................................................................ 38 Variables Influencing Glycemic Control [Procedure] ............................................. 38 Useful Therapeutic Approaches Useful in The Prevention and Treatment of Hypoglycemia [Procedure] ................................................................................. 40 Causes Of Fasting Hyperglycemia ....................................................................... 41 Switching to a Long-Acting Basal Insulin Analogue [Procedure] ............................. 43

..................................................................................................................................................................................................................Saskatchewan Insulin Adjustment Module March...................................................................... 51 Use of Correction Factors ...................... 50 Variable Insulin Dose Adjustments ..................................... 63 Answers to Practice Cases ......................................... 81 References ............................................................................................ 51 Teaching Procedure For Self-Adjustment of Insulin ......... 47 Insulin Dose Adjustments (IDA) [Procedure]............................................................................................ 45 Carbohydrate Counting ......................................................................................................................................... 95 Additional Resources .................................. 2009 Page 4 Insulin Regimens And Adjustments ...................... 97 Client Handouts on Insulin/Insulin Adjustment .............................................................................................. 45 Insulin Regimens.............................................. 97 Diabetes and Pregnancy.................................... 48 Pattern Management ........................................................................... 60 Practice Cases ................................... 98 .......................................................................................... 97 Acknowledgements .................................................................................

This support may require recommendations for appropriate IDA 1 . At present in Saskatchewan only the scope of practice of Registered Nurses permits this type of medication adjustment by Transfer of Medical Function. Learning Module and Procedures 3. representing both urban and rural diabetes education programs. PURPOSE The Transfer of Medical Function policy and procedures template was developed to facilitate and ensure • development and continuing competency for the Registered Nurse who meets the qualifications to adjust insulin • promotion of self-care management and/or enhancing quality of life for people with diabetes • achievement of optimal blood glucose control 1 Many professionals have the capacity to adjust insulin dosages. DEVELOPMENT BACKGROUND 2000. In April 2000 the Saskatchewan Advisory Committee on Diabetes presented its report. With changes in care and practice and to align with current Clinical Practice Guidelines. It is recognized that clients require support while learning to self-adjust their insulin dosage. Practice Case and Answers INTRODUCTION Recent advances in diabetes care have enabled clients using insulin to attain near normal blood glucose control by means of self blood glucose monitoring (SBGM) and self-adjustment of insulin dosage. 2009 Page 5 ORGANIZATION OF THE SASKATCHEWAN INSULIN DOSE ADJUSTMENT (IDA) MODULE The Saskatchewan Insulin Dose Adjustment (IDA) Module was created in 2002. Introduction and Policy Template 2.Saskatchewan Insulin Adjustment Module March. the ability to adjust insulin dosages enables the person with diabetes to enjoy a more varied and flexible lifestyle while maintaining acceptable blood glucose control. A member of the Saskatchewan Pharmaceutical Association audited the process in 2001. For ease of use. The Canadian Diabetes Association facilitated the process. Finally. to the Chief Medical Health Officer and the Deputy Minister of Health. . Objective 5. the 2009 Module is divided into three separate documents: 1. The membership of the group was voluntary and consisted of Certified Diabetes Educators from northern and southern Saskatchewan.4 a working group was formed in 2000. revisions have been made in 2005 and 2009. Diabetes To action Goal 5. This level of self-care is encouraged because the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS) have demonstrated that improved glucose control reduces the risk of long-term complications of diabetes.

Endocrinologist and Professor of Medicine. Boctor. M. Particularly. Therefore. but feel for competence and confidence in implementation of a Transfer of Function. and review of selected literature and web sites. The policy and procedures can also be applied by other health care organizations such as Tribal Councils. PROCEDURES AND LEARNING PACKAGE In the preparation of this material consideration was given to several variables: • needs and safety of clients who will benefit from the Registered Nurse practicing under this Transfer of Medical Function • scope of practice of Registered Nurses • experience needed to perform the procedures • working relationships needed between the Registered Nurse practicing with a delegated medical function and the physician(s) • applicability of a template for Transfer of Function to Health Regions 2 in Saskatchewan • access (or not) by the Registered Nurse to lab data and medical history of clients The following steps were completed in the preparation of the original provincial template (2001): 1.cdecb. 2009 Page 6 DEVELOPING THE POLICIES. 4.Saskatchewan Insulin Adjustment Module March. 3 Certified Diabetes Educator Certification Board www. The policy template continues to suggest two alternatives to equate experience: 2000 hours of practice as a diabetes educator or national certification as a diabetes educator (CDE). 3. we have retained our original recommendation of CDE status or 2000 hours of practice as a diabetes educator. IDA requires that the Registered Nurse already have a sound foundation in the basics as a diabetes educator. Review of the Saskatchewan Registered Nurses’ Association (SRNA) Registered Nurse Scope of Practice documents: Special Nursing Procedures and Nursing Procedures by Transfer of Medical Functions (1993) and Guidelines for Nurses Prescribing and/or Distributing Drugs by Transfer of Function (1997). As a result of above. University of Saskatchewan. Review of existing policies and procedures from Saskatchewan and other provinces. Review of policies and procedures by: • Membership of the Diabetes Educator Section in Saskatchewan • Saskatchewan Registered Nurses’ Association • Dr. 2.ca . the Working Group made decisions about both the policies and the procedures. THE OUTCOME 2 Health Region will be used throughout the document. Development of draft policies and procedures. A few of the most significant decisions are outlined below: Experience: IDA requires clinical experience beyond that of most Registered Nurses. In the 2009 edition of the Module more detailed competencies have been provided (Appendix E). We recognize that CDECB 3 has reduced the qualifying practice hours to write the certification exam from 2000 to 800. Health Regions may choose to adjust the level of required experience for their own policy. more clinical practice and experience are needed. These decisions have been reviewed and affirmed for the 2009 edition of the template.

as currently written. insulin pumps or pregnancy to make advanced competencies an option. The policy. • any insulin schedule including intensive therapy/multiple injections. The definition of “basic” IDA has been modified to address issues encountered by Registered Nurses who already practice under this delegated medical function. will consider IDA for: • routine situations when the person with diabetes is in the community setting and well. carbohydrate counting and development of carbohydrate to insulin ratios. There are several options for the actual process. Not all diabetes educators will have sufficient exposure to or experience with some of the specialty areas such as pediatrics. This package only applies to the basic competencies. The Transfer of Medical Function is a Region-specific process. customizing of the policy and procedures. as needed. Diabetes. This will be an optional part of the Transfer and RNs should only include this in their Transfer if they have sufficient experience and opportunity to use this aspect of the Transfer. This section of the Module will be available in fall. Pharmacists etc. Registered Nurses and physicians in each Region must agree and be comfortable with the parameters that are Region specific. 2009 Page 7 Basic Competencies: For the template to apply in most/all areas of the province. The Transfer does not include the Registered Nurse doing IDA for clients of other health care providers such as Home Care Nurses. teaches and reviews directly. Canadian Diabetes Association 2008 clinical practice guidelines for the prevention and management of diabetes in Canada. it was decided to define both basic and advanced competencies. 2009. The Registered Nurse. In 2009 the module will contain the option for RNs to add the IDA for clients who must fast for outpatient procedures or tests to their Transfer of Function 5 . Using quality improvement methods. applies only for clients whom the Registered Nurse assesses. who has met the basic competencies.32(suppl 1):S1-S201.Saskatchewan Insulin Adjustment Module March. the usual process for adding and implementing a change to the Health Region or organization’s policy would be followed. Can J. the section is being reviewed with different client situations. The template was revised in 2009 to be congruent with the 2008 Clinical Practice Guidelines 4 and current diabetes care practices. • management of insulin for exercise. Dietitians. 5 . “basic” continues to refer to IDA for adults with either type 1 or type 2 diabetes. 2008. If an organization wishes to extend the Transfer so that the Registered Nurse provides guidance to specific health care professionals then an additional policy will be needed. Region Decisions A critical aspect of the implementation process is the review and. REVISIONS FOR 2009 4 Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. To implement this aspect of the Transfer. by each Health Region. In the policy.

Obtaining the 6 For information about the SIAST diabetes program see http://programs. For example. adjust insulin doses. The Registered Nurse must demonstrate competency to perform IDA. 2. To learn more about IDA a Registered Nurse may do all or some of the following: a. Most health organizations will have guidelines for obtaining the Transfer of Function through a Medical Advisory Committee or a similar process. If you are not familiar with the policies and procedures for a Transfer of Function within the organization. The following steps are helpful in applying the template: 1. who meets the required competencies. only a summary is provided within the procedures section. Some Registered Nurses may find it beneficial to take the Advanced Diabetes Education Certificate program at SIAST 6 . you may have to customize either the policy and/or the procedures to suit the particular organizational policies and/or client needs. consult within the Nursing and/or Medical Departments for advice. An organization may decide to exclude this component of the module from the Transfer of Medical Function. there is also the option of taking a single module through this program such as the one on medications.siast. more detailed reading will be necessary. Implement a process for the Registered Nurse to learn about IDA. To have the appropriate degree of understanding and skill necessary to achieve the competencies IDA. . as the references are very detailed.Saskatchewan Insulin Adjustment Module March.htm Cited 23 December 2008. In some cases. the procedure module and the practice cases. shift work) HOW TO USE THE TEMPLATE The purpose of the template is to provide guidance for Health Regions and other health care organizations to have the Registered Nurse.sk. 2009 Page 8 Situations for IDA considered “advanced” and thus not covered by this module include: • children with diabetes • insulin pumps • sick day management • pregnancy in women with pre-existing diabetes (type 1 or type 2) • gestational diabetes • special circumstances (travel. Review the full module The module includes the policy template. 3. using insulin to carbohydrate ratios and/or correction factors for intensive IDA may not currently be common practice by physicians in the area and the Registered Nurse may not be exposed frequently to this as part of usual IDA. b. As these is a guide. The procedures are written to provide guidelines and to serve as a study guide. The Registered Nurse will need to read several of the references as well as the information in the procedures. Or.ca/vc/cont_ed_programs_courses/healthsciences/advanceddiabetes. Write the policy as it applies to the organization.

The Director signs the competency sheet and the Transfer of Medical Function is authorized for all physicians in the Region. The exam can be obtained from Primary Health Services Branch. The successful delegation of a medical function requires a good working relationship between the Registered Nurse and the physician(s) who participates. 2009 Page 9 SIAST Advanced Diabetes Education Certificate does not mean the Registered Nurse is able to adjust insulin. Saskatchewan Health and is issued by the Branch and written in a supervised situation. Each organization will need to decide on the best implementation method to meet the needs of the Registered Nurse. The supervising physician may be an endocrinologist. marked and the results are sent to the candidate. The completed exam is returned to the Branch. Through this practice supervision. A physician with an interest in diabetes management is asked to provide the supervision for the Registered Nurse. Therefore. If you are unsure about an area talk with Registered Nurses who are already practicing with a delegated medical function for IDA and/or your local physicians. Sign and Implement the Transfer of Function. c. The requirements of The Transfer of Medical Function must be completed. Ideally the 3 cases will represent a diversity of client situations which are likely to be encountered in practice. A sample signature form for Transfer of Medical Function is provided in the policy template. Write and successfully pass the provincial exam. The Registered Nurse and physician(s) need to feel confident that clients with diabetes will receive optimal diabetes management. Attend a provincial workshop on IDA when it is available. Successful candidates will receive written documentation to use as part of their Transfer process. Complete physician-supervised cases. Complete the practice cases. The answers are found at the end of module. • The Diabetes Program may not have a Medical Director. Physicians have the choice to “opt out” of the Transfer of Medical Function and may state that they do not wish to have the Registered Nurse provide the IDA service for their clients. the physician will be able to ensure the Registered Nurse demonstrates the required competencies.Saskatchewan Insulin Adjustment Module March. the provincial template suggests that the Registered Nurse be supervised by a physician with a minimum of 3 client cases before obtaining the Transfer of Function. an internist or a family physician with an interest in diabetes management and a willingness to provide the supervision. Implement a process for the Registered Nurse to demonstrate competency in IDA There are two steps to demonstrate competency as part of the provincial template: 1. Examples of implementation include: • The Diabetes Program has a Medical Director who provides the case supervision for the Registered Nurse. d. In each situation below. the physician and the person with diabetes. A pass mark is 80%. This . the policy template was adapted to reflect the method chosen. 2.

The Registered Nurse then approaches individual physicians or physician group practices. 2009 Page 10 physician signs the competency sheet to complete the Transfer of Function. Ideally. the signing physician will be familiar with the practice of the Registered Nurse in IDA.Saskatchewan Insulin Adjustment Module March. Establish a policy for annual demonstration of competency. • A physician could provide practice supervision similar to the initial competency assessment. • A physician could complete a chart audit of 3-5 recent cases where the Registered Nurse was adjusting insulin. explains the policy and procedures and requests their signatures for participation in the IDA service. The competency performance checklist should be signed annually to ensure continuing competency. . There are several options to ensure continuing competency: • A physician who is very familiar with the Registered Nurse’s practice can complete the performance checklist based on ongoing and regular review over the year.

sk.ca CSchmaltz.kornder@sasaktoonhealthregion.ca EMAIL Karen.kthr@shin.Saskatchewan Insulin Adjustment Module March. NAME Karen Butler Betty Deschamps Bev Kernohan Nola Kornder Carlene Schmaltz Judi Whiting HEALTH REGION Regina Qu’Appelle Kelsey Trail Heartland Saskatoon Kelsey Trail Saskatoon TELEPHONE 766-3777 873-3760 948-3323 655-2147 862-7251 655-7406 bev. who have experience with the Transfer of Medical Function and are willing to talk with others who are in the process of developing this delegation model.kernohan@hrha. 2009 Page 11 RESOURCE PERSONNEL The following are Registered Nurses and/or Managers.ca For more information about the provincial template or to apply for the IDA exam.whiting@saskatoonhealthregion.ca nola.gov. contact: Leanne Neufeld Primary Health Services Branch Saskatchewan Health 3475 Albert Street Regina SK S4S 6X6 Ph: 787-0886 Fax: 787-0890 email: lneufeld@health.sk.Butler@rqhealth.sk.ca .ca judi.

POLICIES Adjustment of insulin dosages may be done by a Registered Nurse who demonstrates competency and completes all the requirements for the Transfer of Function. education and recommendations for IDA. Insulin doses will be adjusted for the purposes of optimizing blood glucose control. the Registered Nurse must have at least 2000 hours of work time in diabetes education or hold national certification as a diabetes educator (CDE). but applies only to the basic process. • Demonstrates current clinical and pharmacokinetic knowledge relevant to IDA. appropriate Registered Nurses may obtain an ADVANCED Transfer of Function. To be prepared to write the provincial exam. Experience To obtain the Transfer of Function. PERSONNEL A Registered Nurse who meets the criteria and demonstrates competency in IDA is eligible to obtain the Transfer of Medical Function. These are detailed in Appendix E. See Appendix E for a detailed overview of RN competencies for a Transfer of Function.Saskatchewan Insulin Adjustment Module March. promoting self-care management and/or enhancing safety and quality of life. Extensive experience in educating clients in diabetes self-care and demonstrated competence for adjusting insulin dosages are prerequisites. With additional training and experience. • Understands various insulin schedules and principles for IDA for conventional and intensive therapy. obtain the Transfer of Function and implement it. may make changes to insulin doses and assist clients to make their own changes. In addition. Registered Nurses need to master several competencies. • Communicates with the patient/client and other team members toward the goal of appropriate IDA. • Assesses blood glucose and appropriately interprets information to make changes to insulin doses(s) or other components of the diabetes treatment plan. . This policy defines both basic and advanced Transfer of Function. a Registered Nurse must have a minimum of two years of practice in the profession. 2009 Page 12 POLICY FOR TRANSFER OF MEDICAL FUNCTION FOR BASIC INSULIN DOSE ADJUSTMENT (IDA) PURPOSE A Registered Nurse. • Assesses and addresses diabetes self-care learning needs and readiness to learn IDA. The major competency areas are: • Works within professional and organization standards for Insulin Dose Adjustment (IDA) by Registered Nurses. who has demonstrated competence to adjust insulin doses. • Understands meal planning principles and carbohydrate counting in relation to insulin and uses these in assessment. Transfer of Function may be granted for Nurses to provide BASIC insulin dose adjustment.

Conditions – Registered Nurses and Physicians This procedure will only be considered for specific clients referred by a Physician who is willing to be available to provide ongoing advice and support to the Registered Nurse. 2009 Page 13 Basic Transfer of Medical Function 7 The basic delegation of medical function will apply to IDA for adults. Both parties must mutually agree to this. 8 When a medical function has been delegated and accepted by Nursing. The Registered Nurse and Physician signatures mean the Transfer applies to all the appropriate clients as designated in the Health Region Policy . 2009) Maintenance of Transfer of Function Maintenance of the Transfer will be completed annually by the Registered Nurse. timing) and any subsequent adjustments to insulin type and/or timing. See Policy Appendix for skills covered in Advanced Transfer. The Transfer of Medical Function is applied only with clients whom the Registered Nurse assesses. with either type 1 or type 2 diabetes. A Registered Nurse and Physician(s) who wish to use this Transfer of Medical Function will sign an agreement to indicate their mutual willingness to participate in all the responsibilities of the delegation of the medical function.Saskatchewan Insulin Adjustment Module March. Pharmacists etc. for example. teaches and reviews directly. type of insulin. • The Registered Nurse. • The Registered Nurse and Physician will collaborate on a regular basis to ensure that the client is receiving optimal insulin doses. The delegation of this medical function does not include the Registered Nurse doing IDA for other health care providers such as Home Care Nurses. The Registered Nurse will continuously assess a client’s metabolic status and refer a client to their physician in all situations that are beyond their scope of practice. There will be appropriate resources to facilitate client learning. Dietitians. the Registered Nurse is responsible and accountable for competent performance. and/or situations where 7 Advanced Transfer of Function is not covered by this policy. 8 A sample form is provided in the Policy Appendix B. • IDA for tests and procedures (to be added June. Physician-Registered Nurse Collaboration • The Physician retains responsibility for the insulin schedule that is ultimately selected – initial dose (amount. Neither a Physician nor a Registered Nurse will be obliged to participate in this particular delegation of a medical function unless there is mutual agreement. for: • routine situations when the person with diabetes is in the community setting and well • any insulin schedule including intensive therapy/multiple injections • management of insulin for exercise. Physician and client will collaborate to establish the appropriateness for both Registered Nurse involvement and client participation in IDA. Insulin doses will be changed according to the IDA guidelines. Health Regions have the option of defining ‘basic’ to suit their needs. moving an insulin dose from supper to bedtime or switching from a pre-mixed to short and intermediate-acting insulins.

duration). assessment and plan including any changes in insulin dose. If the client is seen for periodic follow-up or returns to the Diabetes Education Program. • Has had a consultation with a Dietitian and has a suitable nutrition strategy to support IDA. • Able and willing to contact the Registered Nurse on a regular basis for assistance and further education regarding IDA. 9 If the client’s visits are frequent and close together. Precautions There is a potential for hypoglycemia or hyperglycemia when adjusting insulin doses. Conditions – Clients The policy applies to clients who are living independently in the community and do not reside in an acute care setting or long term care facility. If the client does not demonstrate the potential for. clients will meet the following conditions: • Able and willing to frequently monitor blood glucose. barriers and resources. a summary letter will be written monthly and sent to the client’s physician. the Registered Nurse may continue to guide the client who requires ongoing interventions to maintain blood glucose control with agreed periodic contact with the physician of record. Documentation and Reporting A detailed note will be written for each client’s outpatient visit. To receive education about IDA and/or support in actually making the adjustments. • Confirmation that the client is aware of the symptoms of hypoglycemia and demonstrates an understanding of the appropriate treatment and prevention of hypoglycemia. the attending Physician will resume responsibility for the client’s insulin dosage. It is understood by all parties that the Registered Nurse will only be available to support clients in IDA during regular working hours [insert Region schedule]. record and report the results. as a minimum. • Demonstrate an interest in improving control and having regular follow-up. • Client has the knowledge and skill level to either follow a diet which is consistent in carbohydrate intake or can accurately determine his carbohydrate intake of foods. • Confirmation that the client is aware of insulin action (onset. 2009 Page 14 the clients’ metabolic control is deteriorating despite adjustments made to the insulin or other components of the treatment plan. • Provision of self-education materials appropriate to the individual needs of the client. or interest in safe self-adjustment of insulin. peak. 9 See sample form in Appendix D . • Confirmation of the accuracy of the client’s self blood glucose monitoring results by means of an annual laboratory to meter comparison and periodic observation of the client’s technique. Client Assessment The process of teaching clients to adjust insulin will include the following: • Initial assessment of the client’s learning needs. style. • Not acutely or severely ill (examples: immediately post-op. A copy of the note will be sent to the client’s physician. end stage renal disease).Saskatchewan Insulin Adjustment Module March. This will contain relevant data.

the Registered Nurse is supervised by local Physician(s) for a minimum of 3 appropriate client cases Physician(s) signs documentation of Registered Nurse’s competency for IDA according to the Health Region’s policy and Transfer is completed Health Region’s policy determines procedure for implementation within Region with some/all physicians Procedures for Adjusting Insulin Doses A Registered Nurse practicing a delegated medical function to adjust insulin doses will follow the procedures outlined in the Saskatchewan Insulin Dose Adjustment Module. 2009 Page 15 PROCEDURES Transfer of Medical Function The following diagram outlines the process to achieve a Transfer of Medical Function. Saskatchewan Health After successful completion of the exam. Health Region reviews provincial guidelines/template + revises as needed Region Medical Advisory Committee approves Transfer Registered Nurse who meets criteria Reviews policy + procedures Attends provincial course 10 (if available) AND/OR Completes self study program Writes exam and submits to Primary Health Services Branch. changes will be documented in the Module. If the procedures are amended by the Health Region.Saskatchewan Insulin Adjustment Module March. 10 Registered Nurses are encouraged to invite a physician to attend with them .

2009 Page 16 POLICY APPENDIX APPENDIX A . Insulin pumps c. Gestational diabetes f.Saskatchewan Insulin Adjustment Module March. Sick day management d. Children with diabetes b. Pregnancy in women with pre-existing diabetes (Type 1 or Type 2) e.Advanced Certification Advanced certification is NOT included in this provincial template. Special circumstances (travel. . Advanced certification may include some or all of the following specialty areas of IDA. shift work) APPENDIX B . Inclusion of these areas in an individual Registered Nurse’s certification will depend on the experience of the Registered Nurse with the IDA specialty and the frequency that s/he will perform the dose adjustments.SAMPLE PHYSICIAN/REGISTERED NURSE SIGNATURE SHEET The following is a SAMPLE sheet which may be used within a Health Region for the Registered Nurse and Physician(s) to sign once the Registered Nurse has successfully demonstrated the competencies for IDA. The advanced certification areas include: a.

We have read the Health Region policy for insulin dose adjustment and agree to the conditions outlined in the policy. . 2009 Page 17 _____________ HEALTH REGION PHYSICIAN/REGISTERED NURSE SIGNATURE SHEET TRANSFER OF FUNCTION INSULIN DOSE ADJUSTMENT ____________________ has achieved competency to adjust insulin for clients with [Name of Registered Nurse] diabetes according to policy _______.SAMPLE COMPETENCY PERFORMANCE CHECKLIST On the following page is a sample sheet to be used within a Health Region for the Registered Nurse and Physician(s) to sign for annual Transfer of Function of the Registered Nurse for IDA.Saskatchewan Insulin Adjustment Module March. Signed: _________________________ Physician Signed: _________________________ Diabetes Nurse Educator Date: ___________________ APPENDIX C .

unexplained hypoglycemia or change in routine which would necessitate an insulin reduction 4 Insulin to carbohydrate ratios are created according to guidelines 5 Insulin correction factors or insulin grids are created according to guidelines 4 Physician is consulted for non-standard situations and/or failure of IDA to improve control.Saskatchewan Insulin Adjustment Module March. 3 Insulin decrease is based on a pattern of blood glucose readings below target. diet. 2009 Page 18 COMPETENCY PERFORMANCE CHECKLIST Registered Nurse: __________________________ PERFORMANCE CRITERIA OBSERVED NOT OBSERVED COMMENTS 1 Identifies variables in diabetes management which may be appropriate alternatives to IDA eg. injection sites 2 Insulin increase is based on a pattern of blood glucose readings above target. ___ Acceptable competency ___ Competency NOT acceptable Physician Signature: __________________________ Date: _________________________ . exercise. 6 Documentation is completed according to established standards.

If a physician is unable to provide consultation for IDA as required (see consultation list below) and / or if a physician or alternate RN is not available to do IDA in the RN’s absence. the following has been adapted from the BC IDA document. for example BID to MDI Change to different regimen (e. dehydration or other serious problems Recurring / persistent vomiting or diarrhea Disordered eating pattern Significant error in dose or timing of insulin administered by person or caregiver Situations requiring prolonged fasting (eg for religious or medical purposes) Change in brand or type of insulin Change in frequency of injections. with permission. conventional therapy to basal-bolus with MDI or pump) For clients with additional complex medical or endocrine conditions which may influence insulin requirements or client safety In all situations that are beyond the RN’s scope of practice and/or competency level .g. intra or post operatively) During labor & delivery During inpatient hospitalization. IDA is beyond the scope of nursing practice in the following situations: Insulin initiation. from tools in development by the British Columbia Registered Nurses Insulin Dose Adjustment Working Group in preparation for Insulin Dose Adjustment (IDA) by Registered Nurses in BC. there still may be quandaries about the extent of the scope of practice. Total daily dose exceeds what is generally expected for age / body type Client shows signs/symptoms of DKA.Saskatchewan Insulin Adjustment Module March. In any situation which exceeds the RN’s level of competency. Physicians are responsible for insulin orders and IDA for inpatients. To provide clarification. Intravenous (IV) insulin During Diabetic Ketoacidosis (DKA) Surgery (pre. Physician Consultation Required: Physician must be consulted and notified regarding IDA in the following situations: Insulin doses dropping with no apparent cause Recurrent or severe hypoglycemia with no apparent cause Glycemic control is not improving or is deteriorating despite adjustments made to insulin or other components of the treatment plan. 2009 Page 19 APPENDIX D – DETAILED COMPETENCIES FOR SELF ASSESSMENT The following resources have been adapted. What is beyond the scope of practice of the Registered Nurse? Once an RN has obtained a basic Transfer of Function for Insulin Dose Adjustment (IDA) in Saskatchewan. A physician order is required for initiation of insulin doses in all insulin–naïve people with diabetes.

Competencies for IDA include knowledge and application competencies. RNs must develop and maintain both types of competencies in order to perform IDA as part of their nursing practice. COMPETENCY FRAMEWORK The purpose of the following competency framework and experience record is to help guide and support Registered Nurses in their scope of practice for IDA. 11 This framework and experience record provides a template that can be customized to: • suit the needs and policies of practice settings / organizations • assist RNs and organizations with assessing. Space is included for making notes relevant to each competency. including observation of a competent practitioner (RN or Physician). The competencies and indicators can also serve as a guide for self study.ca/downloads/433-scope. learning needs and potential for learning IDA. safe self-adjustment of insulin. professional development.Saskatchewan Insulin Adjustment Module March. Knowledge competencies can be acquired through self study. overarching competencies required for IDA.crnbc.pdf cited 26 march 2009 . Each main competency is accompanied by indicators which will enable an individual or organization to observe and track competency. Competencies in this framework are organized according to the main. developing and/or tracking RN competencies for IDA. supervised/joint practice. when the client does not demonstrate the potential for. and may assist individuals preparing to write the IDA competency exam. the RN will formulate a plan for ongoing reassessment of the client's insulin dosage. 2009 Page 20 Note: Client education regarding IDA is an important component of nursing practice. 11 The original framework was developed by British Columbia Registered Nurses Insulin Dose Adjustment Working Group for use within British Columbia’s Health Regions where RNs are authorized under the Health Professions Act (2005) and CRNBC to perform insulin dose adjustment with limits and conditions. However. which includes but is not limited to the reading material and learning activities and/or attending relevant workshops. or interest in. in collaboration with the physician. http://www. Application competencies require clinical experience. and independent practice.

clear and timely clinical notes of insulin dose adjustments and related patient education or advice Learning Activities and Experiences completed in this competency area. YES: _____ Date: __________ Signature of RN: ___________________________________ Date: __________ Signature of Mentor(s) ____________________________________ Date: __________ Signature of Mentor(s) ____________________________________ . 2009 Page 21 Competency PROFESSIONAL STANDARDS Works within professional and organization standards for IDA by RNs Joint Practice Joint Practice Independent Observe or Complete SelfStudy Competency Indicator Notes Date/Initial Date/Initial Date/Initial Date/Initial Accepts responsibility for performing IDA and understands the professional and legal implications of doing so Identifies and works within the scope of practice for Registered Nurses as defined by the SRNA and the employing health agency / organization Identifies limits of own knowledge and skill and works within them Demonstrates initiative to advance and maintain knowledge and skills needed for safe IDA Performs IDA often enough to maintain confidence and competence Records accurate.Saskatchewan Insulin Adjustment Module March.

g. hypoglycemia. diagnosis etc.Saskatchewan Insulin Adjustment Module March. distinguishing characteristics. in rare cases allergy) Describes basic physiologic insulin requirements in type 1 and type 2 diabetes in adults as well as usual starting doses based on age. peak. pregnancy. lipohypertrophy. by lipohypertrophy. duration and how these may be altered (e. YES: _____ Date: __________ Signature of RN: ___________________________________ Date: __________ Signature of Mentor(s) ___________________________________ Date: __________ Signature of Mentor(s) ___________________________________ . renal impairment etc) Identifies drugs that may inhibit or potentiate the action of insulin Identifies potential side effects of insulin therapy and how to avoid/minimize and manage them (e. Learning Activities and Experiences completed in this competency area. Identifies non-pharmacological and pharmacological approaches to treating different types of diabetes Describes the pharmacokinetics and action time of all insulins available in Canada including onset. 2009 Page 22 Competency CLINICAL AND PHARMACOKINETIC KNOWLEDGE Demonstrates current clinical and pharmacokinetic knowledge relevant to IDA Joint Practice Joint Practice Independent Observe or Complete SelfStudy Competency Indicator Notes Date/Initial Date/Initial Date/Initial Date/Initial Describes the major types of diabetes including basic pathophysiology.g. weight. and rationale for different treatment plans according to type of diabetes. weight gain. age.

according to the client’s situation Calculates. 2009 Page 23 Competency MEAL PLANNING. activity. CARBOHYDRATE COUNTING AND INSULIN DOSES Understands meal planning principles and carbohydrate counting in relation to insulin and uses these in assessment. and recommendations for IDA Joint Practice Joint Practice Independent Observe or Complete SelfStudy Date/Initial Competency Indicator Notes Date/Initial Date/Initial Date/Initial Describes glycemic responses to different food groups / types Describes the purposes of consistent CHO use and or CHO counting and identifies potential advantages/disadvantages of each. YES: _____ Date: __________ Signature of RN: ___________________________________ Date: __________ Signature of Mentor(s) ___________________________________ Date: __________ Signature of Mentor(s) ___________________________________ . uses. and / or IDA that can be made to improve blood glucose excursions associated with food Identifies dietary and/or IDA for physical activity Identifies effect of alcohol consumption on blood glucose values and provides education and advice to minimize risk/and prevent hypoglycemia Works collaboratively with dietitians and makes appropriate client referrals for nutrition education and support Learning Activities and Experiences completed in this competency area. correction doses/or insulin scales Identifies dietary. education. and evaluates insulin sensitivity factor. uses and evaluates insulin: carbohydrate ratios Calculates.Saskatchewan Insulin Adjustment Module March.

nutritional intake/meal plan. why and how to assess for nocturnal hypoglycemia and potential rebound hyperglycemia Analyzes relationship between blood glucose levels. and any other factors which may be influencing blood glucose • ensures client’s meter accuracy Identifies patterns of hyperglycemia or hypoglycemia. activity. insulin.Saskatchewan Insulin Adjustment Module March. 2009 Page 24 Competency ASSESSMENT & INTERPRETATION: BLOOD GLUCOSE Assesses blood glucose and appropriately interprets information to make changes to insulin dose(s) or other components of diabetes treatment plan Joint Practice Joint Practice Independent Observe or Complete SelfStudy Date/Initial Competency Indicator Notes Date/Initial Date/Initial Date/Initial Identifies age appropriate blood glucose goals and rationale for these Identifies situations in which standard blood glucose goals may need to be modified Perform a comprehensive assessment of the client’s blood glucose: • reviews recorded blood glucose values • obtains pertinent information regarding diet. or changes in routines which require adjustment of insulin and/ or other components of treatment plan Identifies when. and activity levels and identifies appropriate adjustments/course of action Interprets assessment data and plans appropriate intervention based on data Communicates assessment findings to relevant team members as appropriate Learning Activities and Experiences completed in this competency area. YES: _____ Date: __________ Signature of RN: ___________________________________ Date: __________ Signature of Mentor(s) ___________________________________ Date: __________ Signature of Mentor(s) ___________________________________ . insulin or other medications.

2009 Page 25 INSULIN SCHEDULES AND DOSE ADJUSTMENTS Understands various insulin schedules and principles for IDA for conventional or intensive therapy Joint Practice Joint Practice Independent Observe or Complete SelfStudy Date/Initial Competency Indicator Notes Date/Initial Date/Initial Date/Initial Uses established principles and guidelines for IDA based on patterns Identifies situations when an insulin scale or correction dose needs to be used and/ or adjusted Uses pattern management principles to establish. using sound educational theories and principles. as appropriate. correction doses and/or insulin scales for MDI Calculates and uses insulin to carbohydrate ratios Integrates pattern management principles with correction and supplemental doses for intensive therapy with MDI Applies principles of basal-bolus therapy to optimize blood glucose control and/or quality of life (e. Learning Activities and Experiences completed in this competency area. increased flexibility) with: MDI Completes comprehensive assessment of learning needs & provides timely. client centered education for IDA Provides client/family education. YES: _____ Date: __________ Signature of RN: ___________________________________ Date: __________ Signature of Mentor(s) ___________________________________ Date: __________ Signature of Mentor(s) ___________________________________ .Saskatchewan Insulin Adjustment Module March.g. adjust and evaluate baseline doses for different insulin schedules Identifies when a change in the time of insulin administration would be appropriate and consults with MD as required by organization’s policy Applies exercise guidelines appropriate to the patient/client insulin schedule Applies guidelines appropriate to the client for short term IDA for a test or procedure Describes principles and concepts of basal-bolus insulin therapy Uses pattern management to evaluate and adjust basal doses for MDI Calculates and applies insulin sensitivity factors.

YES: _____ Date: __________ Signature of RN: ___________________________________ Date: __________ Signature of Mentor(s) ___________________________________ Date: __________ Signature of Mentor(s) ___________________________________ . ability and readiness to learn principles / guidelines for: basic IDA according to blood glucose patterns intensive therapy with MDI Identifies specific learning needs and formulates learning plan with patient/ client to address basic IDA Evaluates learning and plans follow-up as appropriate to patient/family needs and circumstances. Learning Activities and Experiences completed in this competency area. 2009 Page 26 Competency DIABETES SELF-CARE LEARNING NEEDS Assesses and addresses diabetes self-care learning needs and readiness to learn insulin dose adjustment Joint Practice Joint Practice Independent Observe or Complete SelfStudy Date/Initial Competency Indicator Notes Date/Initial Date/Initial Date/Initial Assesses knowledge.Saskatchewan Insulin Adjustment Module March.

what insulin(s) to change. and expected outcomes) Confirms patient’s understanding of instruction or advice provided Builds relationships with patients/clients to promote self-care and learning and does not encourage ongoing dependence on health professionals for IDA Negotiates learning plan to assist patients/ clients in developing knowledge. YES: _____ Date: __________ Signature of RN: ___________________________________ Date: __________ Signature of Mentor(s) ___________________________________ Date: __________ Signature of Mentor(s) ___________________________________ .g. emotions and concerns Assesses learning needs and provides clear. 2009 Page 27 Competency COMMUNICATION Communicates with the patient/client and other team members towards the goal of appropriate insulin adjustment Joint Practice Joint Practice Independent Observe or Complete SelfStudy Date/Initial Competency Indicator Notes Date/Initial Date/Initial Date/Initial Involves client in reviewing and interpreting blood glucose values to make informed decisions about adjustments to the treatment plan Deals sensitively with patients’ questions.Saskatchewan Insulin Adjustment Module March. skills and confidence for self-adjusting insulin doses Notifies and/or consults with other team members as appropriate Records relevant data on the appropriate records Learning Activities and Experiences completed in this competency area. relevant instructions to the patient about insulin and IDA (e. specific doses.

Eli Lilly. follow-up] Educator’s Signature: _________________________________________ 12 Adapted with permission from a Heartland Health Region resource . Sanofi-Aventis Pre-breakfast Pre-noon Pre-supper Bedtime Other Write out full name(s) of insulin. changes. client concerns] Plan: [recommended insulin changes. other plans.SAMPLE PROGRESS REPORT 12 ______ Health Region Progress Report Date: ___________________ Client: _______________________________ PHN: ________________________________ Date of Birth: _______________________ Physician: ____________________________ Clinic Location: ______________________ Present Insulin Doses: Brand: ______________________ NovoNordisk. 2009 Page 28 APPENDIX E . do not use abbreviations Issues with insulin measurement/injection: ___ none Hypoglycemia: Physical Activity: Nutrition: Usual Pattern of Blood Glucose Readings: Target ac meals: ______ Target post meals: ______ Fast PC brk Lunch PC Lunch Supper PC Supper HS Other times: Assessment: [client progress.Saskatchewan Insulin Adjustment Module March.

permit changing of the time of day insulin is given. Also. Make sure you are aware of your Region’s policies and procedures. It is always an option for a Health Region to adjust the template to their own needs and. I am finding that some physicians expect me to take sole and ongoing responsibility for insulin dose management for their patients. I have a Transfer of Function for Insulin Adjustment. This competency is considered ‘advanced’ because a basic premise of the transfer is management of the ‘well’ adult. for example. can I change the time of day the insulin is given without contacting a physician? What if I am making this change for client safety? ANSWER If your Health Region uses the template developed for the Saskatchewan module. related to client safety. Bev Kernohan. If this is an ongoing concern. Each Health Region has a procedure for changing policies and in particular those which involved a delegated medical function. for example. How do others handle this? ANSWER The intent of the Transfer process is to work collaboratively with physicians and teach people with diabetes and their families to be as independent as possible in diabetes selfmanagement.Commonly Asked Questions and Answers 1. 2009 Page 29 APPENDIX F . This could be a general statement or have limitation. most educators work days. you may need to • Have a discussion with the physician about your scope of practice and workload management • Involve your supervisor in supporting and explaining the intent of the delegated medical function • Use the process of the annual renewal of the delegated function to educate physicians. after she renews her Transfer of Function. Annually. With a Transfer of Function to adjust insulin. . Bev has given permission for others to use or adapt her letter. any change in insulin timing must be done by physician order. 2. Heartland Health Region has found this helpful. Why is sick day management not included in the basic competencies? How can I help my clients with sick day management? ANSWER Not having a Transfer does not preclude an educator from teaching someone how to adjust insulin during illness. she sends a letter to all the physicians in the Health Region. This letter is reproduced at the end of the Question/Answer section. 3.Saskatchewan Insulin Adjustment Module March. MondayFriday and would not necessarily be available to take on responsibility for ongoing insulin adjustments during an inter-current illness.

How should I handle this? Can I make insulin dose recommendations? ANSWER The template for the Transfer of Function policy. You may also wish to document the conversation and indicate not only your suggestions but also the advice to seek a physician order. Usually I do not know the patient or have not made a recent assessment. indicating that the calling professional will need to get a physician order to give the recommendation to the patient. then have a written policy to this effect in your Health Region/organization.Saskatchewan Insulin Adjustment Module March. as written. your nursing department and your medical colleagues feel you can give advice to other professionals. 2009 Page 30 4. It is not intended to cover situations where the RN is not involved with the patient and unable to do his/her own assessment. Reinforce your scope of practice. Possible options to handle this scenario would be • Indicate the terms or conditions of your policy with the delegated medical function and what you can and cannot do • Make general suggestions. Pharmacist) sometimes call me and ask me to make insulin dose adjustments for their patients. • If you. in the provincial module is clear that the Transfer only applies to clients actually being seen by the RN. Now that I have a Transfer of Function other professionals (Home Care Nurse. .

This Transfer will allow me to adjust the insulin dose only. Continued on next page … 13 Developed by Bev Kernohan. Heartland Regional Health Authority. ___________. You are not obliged to participate in this medical transfer of function for insulin adjustment unless you agree to. This letter is to confirm whether you do or do not wish to have this transfer applied to the insulin-using patients in your practice. as a Registered Nurse. If I am not presently involved with the diabetes management of your clients. Used and adapted with permission. timing and any subsequent adjustments to insulin type/or timing. March. BSN. CDE This year I have applied with the Senior Medical Manager.initial dose: amount. 2009 . this permission will only be applicable if I become involved with their management in the next year. 2009 Page 31 SAMPLE ANNUAL LETTER TO FAMILY PHYSICIANS 13 Dr ____________ Insert Date Medical Transfer of Function for insulin adjustment. I am firmly committed to this process and I will continue to communicate any changes in doses of insulin back to the physician. I. which through the referral process. and have attained an annual renewal of the Medical Transfer of Function for insulin adjustments with patients who have Type 1 and 2 diabetes. it will not allow me to give the Home Care Nurses an order to change the insulin. As a physician you retain the responsibility for the insulin regimen that is ultimately selected . I become involved in their diabetes management.Saskatchewan Insulin Adjustment Module March. If I am working with a client who is also a client of Home Care and they are pre-filling the syringes. they still require a written order from a physician. Dr. I am sending this letter to all physicians practicing in Heartland Health Region as per request from Management. I will send to the physician my recommendations and he/she will make the final decision and implement the necessary insulin changes. by the Diabetes Nurse Educator Bev Kernohan RN. will refer all clients to their physician in all situations that are beyond the scope of my practice and/or in situations where the client’s metabolic control is deteriorating despite adjustments made to the insulin or other components of the treatment plan. type of insulin. I will continue to instruct the client to have regular contact with their physician for ongoing management of their diabetes. I will continue to see patients referred to me for education purposes even if you opt not to participate in this transfer of medical function. I have practiced with this Medical Transfer in Heartland Health Region for the past __ years. For the clients under Home Care.

Saskatchewan Insulin Adjustment Module March. Name of Physician __________________________________________________ PRINT NAME AND SIGNATURE Date_______________________ Retain a copy and fax or send a copy back to Bev Kernohan by May 12th. . phone 948-6041 if you require info. I give permission to Bev Kernohan to adjust the dosage of insulin of patients in my practice. Name of Physician __________________________________________________ PRINT NAME AND SIGNATURE Date_______________________ I do not give permission to Bev Kernohan to adjust the dosage of insulin of patients in my practice.. Sask. Biggar. S0K-0M0 fax 948-2011. 2008 Box 130. 2009 Page 32 Please indicate below whether you wish to have patients in your practice participate in this transfer of medical function for insulin adjustment.

muscle. fat. the breakdown of fat and protein to form glucose and by products. the alpha cells are stimulated to secrete glucagon which stimulates certain metabolic processes (glycogenolysis in the liver primarily) which modulate the blood glucose and keep it in the normal range. These hormones and glucagon are termed 'counter-regulatory' in that they all have 'anti-insulin' action in raising blood glucose values. Hormonal Regulation of Blood Glucose in the Individual without Diabetes Blood glucose levels are constantly monitored by the alpha and beta cells of the Islet of Langerhans in the endocrine pancreas.Saskatchewan Insulin Adjustment Module March. Stimulated Lipogenesis Gluconeogenesis Glycogenolysis Stimulated Inhibited Inhibited . Glycogen is stored in the liver and muscles. cortisol. • Name the potential metabolic effects of hyperinsulinemia. Average daily insulin secretion by the non-diabetic pancreas is about 30 units. liver. lipogenesis. • Define key metabolic processes and whether insulin facilitates or inhibits the process. the breakdown of glycogen into glucose. • Describe how obesity in the non-diabetic may alter normal insulin secretion. • Describe briefly insulin's effect on cellular glucose uptake in the following organs/tissues: brain. the beta cells secrete insulin which stimulates certain metabolic processes (glycogenesis. glycerol and fatty acids. and growth hormone. If glucose levels are dropping. Other hormones stimulated by dropping blood glucose values are epinephrine. 2009 Page 33 LEARNING ABOUT AND PROCEDURES FOR INSULIN DOSE ADJUSTMENT Endogenous Insulin Learning Objectives Upon completion of this section you will be able to: • Describe the hormonal regulation of blood glucose in the non-diabetic individual. the formation of fat from its substrates. cellular glucose uptake) which modulate the blood glucose and keep it in the normal range. • Describe the metabolic effects of an absolute lack of insulin. Metabolic Process Glycogenesis Definition Stimulated or Inhibited by Insulin the formation of glycogen from glucose. Insulin secretion is also stimulated by ingestion of protein because insulin is required for protein synthesis. If glucose levels are rising.

abnormal timing of post-prandial insulin secretion. often resulting in: a. Metabolic syndrome is characterized by several abnormalities including: abdominal obesity. Insulin facilitates glucose uptake by muscle cells. obese non-diabetic individuals have been shown to have a decreased number of insulin receptors and decreased sensitivity of receptors to insulin. hypertension. page S11 . higher circulating insulin levels than a normal weight non-diabetic individual. How Obesity Alters Normal Insulin Secretion in the Non-diabetic Person Obese individuals may have abnormal insulin secretion. Excessive lipogenesis often resulting in increased adipocyte deposition of lipid. Insulin facilitates glucose uptake by liver cells. gluconeogenesis. dyslipidemia. Inhibition of lipolysis and glycogenolysis Hypoglycemia may develop postprandial as a result of the above processes. Potential Metabolic Effects Of Hyperinsulinemia • • • Glycogenesis often resulting in a glycogen saturated liver. 2009 Page 34 Insulin’s Effect On Cellular Glucose Uptake • • • • Insulin is not required for glucose uptake by brain cells. These metabolic changes eventually lead to either type 1 or type 2 diabetes. Metabolic Effects Of Lack Of Insulin An absolute insulin deficiency will cause: • decreased glucose uptake by liver. lipolysis. Eventually there will be pancreatic ‘burnout’ and insulin levels will drop. there is often a broader underlying disorder known as metabolic syndrome. Nearly exclusive cellular utilization of fatty acids for energy production results in accumulation of ketone bodies in the blood causing ketoacidosis. resulting in a resistance to the action of insulin. • excessive glycogenolysis. 14 14 2008 Clinical Practice Guidelines. In addition. • inhibited glycogenesis and lipogenesis resulting in hyperglycemia and hyperosmolar diuresis. b. insulin resistance and dysglycemia. fat cells. Insulin facilitates glucose uptake by fat cells. muscle.Saskatchewan Insulin Adjustment Module March. With type 2 diabetes.

5 h 2-3 h 2h Duration 3-5 h 3. • Describe the potential adverse effects of subcutaneous insulin use. • Describe other medications which affect insulin action • Describe insulin requirements in type 1 and type 2 diabetes. Insulin Approved for Use in Canada The following table indicates the insulin types currently available in Canada. manufacturers. 40/60. and duration of action. . TYPES OF INSULIN Insulin type (trade name) Prandial (bolus) insulins Rapid-acting analogues (clear) • Insulin aspart (NovoRapid) • Insulin lispro (Humalog) • Insulin glulisine (Apidra) Short-acting insulins (clear) • Humulin-R • Novolin ge Toronto Inhaled insulin Onset 10-15 min 10-15 min 10-15 min 30 min 10-20 min Peak 1-1. 50/50 Premixed insulin analogues (cloudy) • Biphasic insulin aspart (NovoMix 30) • Insulin lispro/lispro protamine (Humalog Mix 25 and Mix 50) See notes on next page. • Describe the action time of the various insulins available in Canada including onset.5-3. peak. 2009 Page 35 Exogenous Insulin Learning Objectives Upon completion of this section you will be able to: • List the sources.75 h 3-5 h 6.Saskatchewan Insulin Adjustment Module March. page S47.5 h 6h Basal Insulins Intermediate-acting (cloudy) • Humulin N • Novolin ge NPH Long-acting basal insulin analogues (clear) • Insulin detemir (Levemir) • Insulin glargine (Lantus) 1-3 h 5-8 h Up to 18 h Up to 24 h 90 min Not applicable (glargine 24 h. It is referenced to the 2008 Clinical Practice Guidelines 15 and may need periodic updating by users of this module. A single vial or cartridge contains a fixed ratio of insulin (% of rapid acting-acting or short-acting insulin to % of intermediate-acting insulin) 15 2008 Clinical Practice Guidelines. detemir 16-24 h) Premixed Insulins Premixed regular insulin – NPH (cloudy) • Humulin 30/70 • Novolin ge 30/70. and trade names of commercially available insulins in Canada.5 h 1-2 h 1-1.

* Insulin glulisine (Apidra) Released January 2009 – not covered by Saskatchewan Drug Plan * Inhaled insulin has been approved for use in Canada. Its use is not covered in this module. weight gain.ca/about-diabetes/literature/consumer-guide cited 23 Dec 2008 Potential Adverse Effects Of Subcutaneous Insulin Use Adverse effects of exogenous insulin use may include hypoglycemia. but is not yet commercially available. lipoatrophy. Using the above table. Hypoglycemia will be discussed further in the next section. peak and duration for insulins commonly used in your practice. They thereby block the early warning signs of hypoglycemia that are mediated by the sympathetic nervous system. lipohypertrophy (if rotation of sites is not observed). See the following website and review the current devices for insulin measurement and injection [resource is updated annually] http://www. and in rare cases localized insulin allergy (presence of IgE antibodies).diabetes. Drugs That May Inhibit Or Potentiate Insulin Action Inhibit Thiazide diuretics Glucagon Prednisone Thyroid Hormone Potentiate Propranolol Alcohol MAO inhibitors Salicylates (1. They are also dangerous because they block the sympathetic nervous system response to epinephrine secreted during a hypoglycemic episode.5-6 g/day) Non-selective beta blocking agents such as propranolol (Inderal®) potentiate the action of insulin by reducing glycogenolysis from the liver. Use of Beta Blocking Drugs . 2009 Page 36 NOTES: CPGs recommend reference to the most current edition of the Compendium of Pharmaceuticals and Specialties (CPS: Canadian Pharmacists Association. Canada and product monographs for detailed information. draw sample diagrams to use with clients to illustrate the onset.Saskatchewan Insulin Adjustment Module March. 2. Learning Activity 1. insulin resistance (presence of IgG antibodies). Ontario. Ottawa.

7 units/kg of body weight per day. • 16 Franz. Review the above medications and be familiar with the effects for insulin users. General guidelines suggest: 16 • For type 1 diabetes. editor.5 to 0. MJ. when weight is within 20% of normal. 4th edition: Diabetes Management Therapies. p. These requirements will be lower during the “honeymoon” phase (0. usual insulin requirements are 0.Saskatchewan Insulin Adjustment Module March. Insulin Requirements Insulin requirements will vary with each individual. 2009 Page 37 Learning Activity 1.2-0. For type 2 diabetes the insulin requirement will be individualized depending on the degree of insulin deficiency and insulin resistance. The next section provides information on the options for insulin regimens and the use of insulin with oral anti-hyperglycemic agents. At the high end insulin requirements may be hundreds of units per day. 103 . (2001) A Core Curriculum for Diabetes Education. American Association of Diabetes Educators. At the low end requirements may be only 5-10 unit/day.6 u/kg).

2009 Page 38 PRACTICAL ASPECTS OF INSULIN MANAGEMENT Learning Objectives Upon completion of this chapter you will be able to: • Describe the causes of fasting hyperglycemia • Describe the indications for insulin use in type 2 diabetes • Describe and implement the procedures listed below Procedures • • • • • Variables influencing glycemic control to assess before IDA is performed Use of insulin with oral anti-hyperglycemic agents in type 2 diabetes Therapeutic approaches useful in prevention and treatment of hypoglycemia in those prone to asymptomatic hypoglycemia Important points to consider when switching a client from short-acting to rapidacting insulin Important points to consider when switching a client from intermediate-acting insulin to a long-acting basal insulin analogue Variables Influencing Glycemic Control [PROCEDURE] Variables influencing glycemic control which should be assessed before initiating insulin or changing a dose include: .alcohol use . extra doses ∗ timing of dose .monitoring technique .concurrent illness/infection .injection site problems ∗ variable absorption ∗ lipodystrophies .Saskatchewan Insulin Adjustment Module March.insulin administration problems ∗ inaccurate dose ∗ missed doses.unusual stresses .diet: carbohydrate content.length of time between carbohydrate intake and blood glucose monitoring .activity .menstrual cycle .abnormal glucose counter-regulation .pregnancy .weight changes .insulin antibodies .concurrent medications . timing and delayed gastric emptying .

Discuss your table with other diabetes practitioners and your physician leader to gain local consensus on current practice. 2. • There is marked hyperglycemia (A1C > 9%). Use the current version of the Compendium of Pharmaceuticals and Specialties (CPS) and create of a table of oral antihyperglycemic agents and the recommendations for their use with insulin. LEARNING ACTIVITY 1. page S53 .Saskatchewan Insulin Adjustment Module March. See the pink-edged pages to find specific diabetes medications. 17 2008 CPG. • Current agents are not successful in achieving glycemic targets. This may require medication adjustment and/or additional medications to attain target A1C in 6-12 months. antihyperglycemic agents need to be initiated concomitantly with lifestyle management and consideration needs to be given to initiating combination therapy with 2 oral AHAs or initiating insulin. safety issues and important points for client education when combining insulin with an OAA. 2009 Page 39 Using A Combination of Insulin and Oral Antihyperglycemic Agents [AHA] The 2008 CPGs recommend the timely addition of anti-hyperglycemic agents (either orally or with insulin) if 17 : • Glycemic targets are not achieved within 2-3 months of lifestyle management. Read the CPG pages S53 to S58.

Yale J-F. Can J Diabetes. Available at http://www. In practice. severity.2:128-140.ca/Files/Diabetes%20and%20Driving%20Guidelines-June%202003--FINAL. McSherry J. identify with the client: • his/her earliest perception/sensation that blood glucose may be dropping and the usual blood glucose at that time • the history of hypoglycemia. Canadian Diabetes Association’s Clinical Practice Guidelines for Diabetes and Private and Commercial Driving. the target range for blood glucose control should be higher. 27.pdf cited 24 Dec 2008. 2003. 2009 Page 40 Useful Therapeutic Approaches Useful In the Prevention And Treatment Of Hypoglycemia [PROCEDURE] Learning Activity Read the following resources: • 2008 Clinical Practice Guidelines section on hypoglycemia and read the related guidelines on driving and diabetes • Begg IS. usual treatment and usual prevention strategies • if he/she has hypoglycemia unawareness 18 and how this has been and will be managed 18 See Jones et al (2009) for more information about hypoglycemia unawareness . instead of 47 ac meals. this should result in downward adjustment of the appropriate insulin dose if results are less than 6. Rowe RC.g. family members should be instructed in the administration of Glucagon wear diabetes identification teachers. and what action to take if possible. The following measures are important in the prevention and treatment of hypoglycemia particularly in those prone to asymptomatic or severe hypoglycemia: • • • • • • • • • • frequent home blood glucose monitoring (four times daily) appropriate self-adjustment of insulin dose consistent carbohydrate intake or carbohydrate counting with appropriate insulin:carbohydrate ratio appropriate timing of meals and snacks preparation for increase in physical activity and management during and post activity if needed. including the frequency. its signs. for severe hypoglycemia.Saskatchewan Insulin Adjustment Module March. e. family.diabetes. RL. 6-10. Houlden. co-workers. friends should be informed of potential hypoglycemia.

Recent studies have pointed out that although the Somogyi effect causes some degree of excessive post-prandial hyperglycemia the following morning. the magnitude of the Somogyi effect may be over-estimated. poor sleep. A bedtime dose of intermediate-acting insulin would likely reach its peak during the dawn and counteract the hyperglycemic effects of this phenomenon. it will confirm the Somogyi phenomenon. The Somogyi Phenomenon Waning Insulin Joslin’s Diabetes Deskbook (2003) notes the waning effect of the insulin dose given the previous evening can also be a factor in fasting hyperglycemia. Signs during the waking hours may be hyperglycemia following an insulin reaction despite appropriate dietary treatment of the hypoglycemic episode. Dawn Phenomenon The “Dawn Phenomenon” refers to the increased production of glucose by the liver and decreased sensitivity to the action of insulin that occurs between 0400 and 0800 hours in people with and without diabetes. To rule out or confirm Somogyi phenomenon at night.m. Additional blood glucose testing between meals is required to demonstrate this problem. If it is normal or high. also known as rebound hyperglycemia. Somogyi is ruled out. In addition. Therefore higher levels of insulin are required to maintain euglycemia during these hours. and perspiration. The duration of action of the overnight insulin is insufficient and leads to a gradual rise in blood glucose level from bedtime to morning. Daytime Somogyi phenomenon can be confirmed by questioning the client on precisely how they treated the hypoglycemic episode that precedes hyperglycemia. intermediate insulin dose. undocumented hypoglycemia during the day results in a rebound hyperglycemia. It may be difficult to differentiate this from the Dawn Phenomenon discussed below. Over-treatment of hypoglycemia is much more common than daytime Somogyi. These surges are normal physiological events that are not a result of counter-regulatory responses to hypoglycemia. tossing and turning. The etiology is believed to be increased production of counter-regulatory hormones in response to hypoglycemia. Difficulty may arise if asymptomatic. fasting hyperglycemia unresponsive to increases in the appropriate insulin dose is suspicious of Somogyi phenomenon. has been defined as hyperglycemia (not caused by excessive dietary intake) following a hypoglycemic episode.Saskatchewan Insulin Adjustment Module March. 2009 Page 41 Causes Of Fasting Hyperglycemia There are three potential causes for fasting hyperglycemia: The Somogyi phenomenon. it does not cause “extreme hyperglycemia and instability”. headache or nausea upon wakening in the morning especially if the client reports nocturnal symptoms such as nightmares. Not all clients demonstrate this phenomenon. In other words. Nocturnal surges of growth hormone cause the transient insulin resistance. Signs suspicious of this phenomenon are fasting hyperglycemia. the client should test their blood glucose 6-8 hours after the p. If this reading is low. .

. inject immediately to prevent blunting of the rapid insulin action after mixing. • Monitor blood glucose regularly. Reminders for Using a Rapid-Acting Insulin Analogue • When mixing insulins. as compared to short-acting insulin. It is particularly suitable for people on MDI. • Do not mix any insulin with a long-acting basal insulin analogue • Inject rapid-acting insulin within 15 minutes of a meal.c. assuming the usual dose is effective and safe • Your client. Intermediate before breakfast and bedtime • Rapid analogue before meals. monitoring 7 to 8 times per day for about one week (a. though. Initially. i. meal and 2 hours p. • The dosage of intermediate insulin or long acting basal insulin analogue may have to be increased and/or divided into two injections per day to provide adequate basal coverage. use only with the same brand of insulin. • Examples of use of a rapid-acting insulin analogue: • Rapid analogue before meals. it tends to have an overlap in coverage with the intermediate-acting insulin. those new to insulin as well as those already using insulin. children and adults. Intermediate at bedtime • Rapid analogue before meals. 2009 Page 42 Considerations When Switching From Short-Acting Insulin To a Rapid Acting Insulin Analogue [PROCEDURE] Rapid-acting insulin analogues closely duplicate the action of the body’s endogenous insulin in response to food ingestion. It is beneficial for type 1 or 2. When transferring to a rapid-acting insulin analogue: • The same dose may be used as short-acting insulin. TID or QID regimens or pumps. Long-acting basal insulin analogue in the evening Be sure to discuss regimen changes with the client’s physician.) may be required to determine the correct doses. benefit people with diabetes by providing: • • • “inject and eat” convenience improved post-prandial glucose control less risk of hypoglycemia between meals and overnight Rapid-acting insulin analogues are suited to people who want improved glycemic control and more flexibility in their schedule.Saskatchewan Insulin Adjustment Module March. Since short-acting insulin has a longer action. The rapid onset and short duration. do not mix a NovoNordisk brand insulin with an Eli Lilly brand insulin. may feel more secure taking about 10 to 20% less initially until the effect can be gauged.e.c. A rapid-acting insulin analogue has a shorter duration which can result in rising blood glucose prior to the next meal. for example. • If the rapid analogue is mixed with intermediate-acting insulin.

4 hours after rapid analogue may not result in hypoglycemia. the vial can be kept unrefrigerated up to 28 days away from direct heat and light as long as the temperature is not greater than 30ºC. People with gastroparesis should use a rapid-acting analogue with caution. the usual education related to insulin use should be provided. • In addition. Insulin may need to be administered after the meal to match with the rise in blood glucose. insulin requirement may be lower due to decreased insulin metabolism. Use in lactation has not been established. Frequent blood glucose monitoring is required. Levemir has a duration of 16-24 hours. Extra blood glucose monitoring is needed to determine the timing of injection with the rise of blood glucose after food is absorbed. Indications for Use • Can be used with either type 1 or type 2 diabetes where a basal insulin is required Precautions for Use • Do not mix with any other insulin • As with all insulins. If refrigeration is impossible. • Use in pregnancy should be cautious and only if clearly needed. If a person must exercise in that timeframe. there may be mild discomfort at the injection site. 2ºC to 8ºC. recommend a reduction in the rapid analogue dose by 50%.Saskatchewan Insulin Adjustment Module March. Exercise 2 . possibly resulting in hypoglycemia. • As the insulin is acidic. It should not be allowed to freeze. Discard after 28 days if unrefrigerated. . • Long-acting insulin should be stored in a refrigerator. 2009 Page 43 Precautions • • • A rapid-acting insulin analogue is not recommended in conjunction with acarbose (Prandase) as acarbose slows the digestion of carbohydrate. long acting insulin analogues may cause hypoglycemia • For persons with renal or hepatic dysfunction. Switching To a Long-Acting Basal Insulin Analogue 19 [PROCEDURE] Two brands of long-acting basal insulin analogues are available in Saskatchewan: Lantus (insulin glargine) and Levemir (insulin detemir). Lantus has a duration of up to 24 hours. Either one can be used as a basal insulin. Client Education with Long-Acting Basal Insulin Analogue • Advise the client not to mix with any other insulin or dilute the long-acting insulin analogue. the recommended starting dose is 10 units once daily with subsequent adjustment according to client needs. Advise your client to avoid strenuous exercise within 2 hours after taking a rapid-acting insulin analogue. • Long-acting insulin analogues are clear insulins and should not be used if cloudy. Both are clear insulins. Dosage and Administration • For “insulin naïve” clients with type 2 diabetes already treated with oral anti-hyperglycemic agents. 19 See details about each insulin’s properties in the current version of CPS.

. 2009 • Page 44 Change over to a long-acting insulin analogue from intermediate acting insulin: o in clinical studies when the transfer was from once daily NPH human insulin or ultralente. o in studies where the transfer was from twice daily NPH to once daily long-acting insulin analogue at bedtime. the initial dose was reduced by a minimum of 20% of the previous total daily dose of intermediate or long-acting insulin.Saskatchewan Insulin Adjustment Module March. the initial dose was not changed.

Insulin Regimens Insulin regimens must be planned to meet the metabolic requirements of the individual while being able to control the blood glucose level throughout the 24-hour day. Level 1A. multiple daily injections (prandial [bolus] and basal insulin) or the use of CSII is the treatment of choice. Bolus insulin is the insulin used to cover glucose rise as a result of food intake. To achieve glycemic targets in adults with type 1 diabetes. Therefore. Grade A. The 2008 CPG recommend a basal/bolus regimen with: • Rapid-acting insulin analogues (aspart or lispro). p. Recommendation 1. newly diagnosed type I individuals may benefit from two to four injections of insulin per day aimed at keeping pre-prandial glucoses less than 7 mmol/L. 23 20 21 2008 Clinical Practice Guidelines. in combination with adequate basal insulin. 2008 Clinical Practice Guidelines. including nocturnal hypoglycemia. 21 • A long-acting insulin analogue (detemir. S49. Recommendation 2. Pattern management c. This level of blood glucose control appears to slow the auto-immune destruction of beta cells thus leaving well controlled individuals with greater beta cell reserve one year following diagnosis than individuals with higher blood glucoses levels. Type 1 The DCCT has shown that individuals with Type 1 diabetes will benefit from metabolic control as close to normal glucose levels as possible. Commencing insulin and stabilizing the glucose levels calls for different approaches depending on individual requirements and the “intensity” of therapy. S49. 20 Basal insulin is the amount of insulin required to counteract hormonal and other variables potentially causing hyperglycemia between meals and overnight. 2009 Page 45 Insulin Regimens And Adjustments Learning Objectives Upon completion of this section you will be able to: • Describe the insulin regimens • Describe carbohydrate counting • Describe and implement the procedures listed below Procedures • • Definition and implementation of IDA: a. Variable insulin doses: i) correction factor for low/high glucose readings ii) use of insulin:carbohydrate ratios Principles of IDA for exercise or increased physical activity. should be considered over regular insulin to improve A1C while minimizing the occurrence of hypoglycemia and to achieve postprandial glucose targets. glargine) may be considered as an alternative to NPH as the basal insulin 22 to reduce the risk of hypoglycemia. Typically this can range from 40-60% of the total daily requirement for insulin. Level 2.Saskatchewan Insulin Adjustment Module March. Initiating an Insulin Regimen and Establishing Client Goals b. p. Grade B. . considering the client’s lifestyle and routines.

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A total daily dose of 0.5 - 1.0 units/Kg of body weight is usually required. The total daily dose is distributed according to the type of insulin regimen initiated 24 . • • It is the physician’s responsibility to determine the initial dose and regimen. If the RN practicing under a delegated medical function feels that regimen changes should be made, i.e. number of injections or type of insulin she/he must do so in collaboration with the physician.

Insulin action times must be taken into account when deciding which insulin to adjust for a particular blood glucose problem at one time of day. Caution must be observed once euglycemia is attained. As glucose toxicity is overcome for those newly diagnosed with type 1 diabetes, beta cell function improves and may synergistically work with injected insulin to cause hypoglycemia ie. the honeymoon period has begun. Be prepared to reduce the injected dosage quickly in these individuals as indicated by blood glucose results. Requirements may be <0.5 units/kg body weight/day 25 .

Type 2
The individual with type 2 diabetes may benefit from several types of insulin regimens.
• • •

bedtime intermediate-acting or long-acting basal insulin analogue and daytime oral AHA 26 a.c. breakfast and supper rapid or short/intermediate mixture including pre-mixed insulins t.i.d. insulin pre-meal (short or rapid acting) and intermediate or long-acting at breakfast and/or supper. The second injection of intermediate or long-acting may also be given at bedtime (q.i.d insulin)

If adding h.s. intermediate or long-acting basal insulin analogue to daytime oral AHA, increase the dosage regularly (every 3-4 days) until the fasting glucose reaches the target range25. Because of insulin resistance, the dosage requirement may vary widely between clients, but it will not benefit the client to stop increasing the dose short of the glycemic target. When using daytime insulin for the type 2 individual, consider insulin action times in deciding which insulin to increase or whether to add another type of insulin to improve glucose control at a particular problem time of day. Again because of insulin resistance, very high daily total doses (100 - 200 units) may be required to achieve the glycemic target range. A hindrance to stabilizing clients on insulin therapy is that insulin action times may vary from individual to individual. Use insulin action times as a guideline to adjust your client’s insulin but be prepared to recognize how the insulin is working in your client.

2008 Clinical Practice Guidelines, p. S49. Recommendation 4, Grade B, Level 2. See 2008 CPG p S 40 for levels of evidence. 24 See the above reference for examples of insulin distribution with different regimens. Also see the chapter on intensifying insulin therapy in The Essentials for examples of calculating insulin doses. 25 2008 Clinical Practice Guidelines, p. S150. 26 See 2008 Clinical Practice Guidelines p S197-198 for guidelines for insulin initiation in people with type 2 diabetes
22 23

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To use insulin to carbohydrate ratios for IDA, the Registered Nurse must be familiar with carbohydrate counting. Ideally the client will be referred to a Registered Dietitian to learn about carbohydrate counting. Both the Dietitian and Registered Nurse can support the client in the learning process and provide reinforcement in preparation for IDA by the client. There are several criteria to consider when suggesting a client use carbohydrate counting and subsequently an insulin to carbohydrate ratio to adjust insulin: • the person’s motivation to learn a new skill. • ability to perform simple math skills. • the person’s willingness and ability to use resources (nutrient information, food labels and tools (measuring cups, weigh scales) ) to accurately determine carbohydrate content of meals and snacks. For those who have been frustrated by fluctuating blood glucose levels, it may be helpful for them to use nutritional scales 27 . • accurate and detailed food records will enhance the process and help assess the client’s ability to carbohydrate count and support client skill development.

Carbohydrate Counting

A. Read the following resources:

Learning Activities

1. Ensure you are familiar with the CDA resource, Beyond the Basics and basic carbohydrate counting resources. You can review the background information at http://www.diabetes.ca/for-professionals/resources/nutrition/ . 2. If you are a DES member you can view a presentation on basic carbohydrate counting and complete the exercises at http://www.diabetes.ca/for-professionals/members-only/ You must sign in using your DES membership number. 3. Learn how to read “Nutrition Facts” labels, see http://www.diabetes.ca/aboutdiabetes/nutrition/healthy-eating/ and through this site you can access other resources. Take the virtual grocery store tour. 4. Obtain a resource for carbohydrate values of common foods such as: a. Nutrient Value of Some Common Foods (2002). Health Canada. http://www.publications.gc.ca/pub?id=316070&sl=0 Available free b. Holzmeister L. The Diabetes Carbohydrate and Fat Gram Guide, 3rd edition. American Diabetes Association. www.diabetes.org c. Netzer, CT. The Complete Book of Food Counts, 8th edition. 2008;New York:Dell Publishing. ~ $10 in paperback. d. Borushek, Allan. The CalorieKing Calorie, Fat and Carbohydrate Counter, 2009. ~ $11 in paperback e. For fast foods, treats etc see http://www.bcchildrens.ca/Services/SpecializedPediatrics/EndocrinologyDiabetes Unit/ForFamilies/default.htm go to diabetes/nutrition handouts f. USDA on line nutrient data base http://www.nal.usda.gov/fnic/foodcomp/search/ f. http://www.elook.org/nutrition/search.php
ALL REFERENCES cited 30 december 2008

27

The Essentials, Chapter 10.

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B. Practical Applications 1. Complete the exercises with a resource from selection above. 2. Keep a food record for three days, being as specific as you can with amounts and calculate your carbohydrate intake for each meal. Consult with a dietitian colleague to get some feedback or answers to your questions.

Insulin Dose Adjustments (IDA) [PROCEDURE] Initiating an Insulin Regimen and Establishing Client Goals
A written (in-person or by fax), verbal or telephone order is required from the attending physician prior to the initiation of insulin therapy, specifying the type, dose and time of insulin. This order will be discussed with the Registered Nurse and client prior to the initiation of insulin therapy. Verbal/telephone orders must be signed according to Health Region policy. See an

example of this form on page 45.

Physician’s orders will be documented in the client’s chart Subsequent alteration in the type of insulin or significant changes in the time at which insulin is to be given will be discussed with the Registered Nurse, the physician and the client. Target Blood Glucose Levels – the following can serve as standard reference points

Recommended targets for glycemic control
A1C (%) FPG/preprandial PG (mmol/L) 2-hour postprandial PG (mmol/L)

Target for most patients

≤ 7.0

4.0 – 7.0

(5.0 to 8.0 if A1C targets not being met)

5.0 – 10.0

2008 Clinical Practice Guidelines, page S30. NOTE: treatment goals and strategies must be tailored to the individual with consideration given to individual risk factors.

Individualized Goals: Individualized goals for blood glucose control will be specified in the client’s chart and will be determined collaboratively with the physician, the Registered Nurse, the client, significant others and other health care providers. Factors which may be considered in setting goals include the age of the client (eg. seniors) and other health problems.

• Start Humalog 3 units at breakfast ( an ↑ of 1 unit) and 6 units (same dose) at supper. 2009. and 24 units q p.Saskatchewan Insulin Adjustment Module March. I would like to: Date Signature 28 Developed by Kelsey Trail Health Region Diabetes and Heart Health Centre. Try and be fairly consistent with the time of this Humulin N insulin. I will continue to send progress notes following visits with any insulin adjustments. . Please sign below and return to me if you wish to initiate this change or wish to make different recommendations so that I will have a signed record for my files. XXX was encouraged to call if he had any questions or concerns. 2009 Page 49 Diabetes & Heart Health Centre 28 Diabetes Educators xxx.m.m. Take this insulin immediately before eating XXX is to monitor his blood sugar QID ac and pc on at least 5 days prior to his next appointment on Feb 11. Recommendation: • Stop Humalog Mix 25 • Start Humulin N 10 units at breakfast (an ↑ of 4 units) and 10 units at HS (a ↓ of 8 units and moved from supper to HS). RN. His present dose is Humalog Mix 25 8 units q a. BScN. RD xx. □ □ Yes. CDE xxx-xxxx Ext xxx xxx-xxxx Ext xx FAX Date: XXXXXXXXXXX To: Fax: XXXXXXXXXX XXXXXXXXXX Date: To: From: FAX BACK Attention: XXX Fax: (306) xxx-xxxx From: XXX @ xxx-xxxx Please Complete & Return ASAP! Diabetes Medication/Insulin Review Client: XXXXXXXXXXXX PHN: XXX XXX XXX DOB: XX XXX XXXX Background information: XXXX blood sugar levels are continuing to increase and due to his Humalog Mix 25 we are unable to “fine tune” his insulin dose to maximize his blood sugar control. please go ahead with the above recommendations: No. Used with permission.

a high level of functional dependency and/or limited life expectancy the goal should less stringent. Remember night time hypoglycemia may be reported as nightmares. Wait at least 3-4 test days between each IDA to have sufficient data to determine a pattern. Consider that when one insulin is increased. another may need to be decreased. The goal should be to avoid severe or unrecognized hypoglycemia. Increase insulin when there is a pattern of repeating high glucose results. 2009 Page 50 Some special situations which may require individualization of goals include: • elderly or ill clients The same glycemic targets apply to otherwise healthy elderly individuals as to younger people. The target blood glucose levels for therapy for these clients should be adjusted upward. Patterns are consistent trends in blood glucose that occur at the same time of day for three to four days in a row. This method presupposes that the person has a consistent pattern of meals. carbohydrate intake and activities. In persons with multiple co-morbidities. DO NOT increase insulin on the basis of sporadic or single high readings. tossing and turning or perspiration. Try to avoid symptoms of hyperglycemia and prevent hypoglycemia 29 Women planning a pregnancy must strive for tighter glucose control (A1C < 7% (<6% if safely achievable 30 ) to decrease the risk of congenital abnormalities and further problems in pregnancy. Adjust first to eliminate low blood glucose readings. Use a combination of pre-prandial and post-prandial blood glucose levels to guide adjustments. S181 2008 Clinical Practice Guidelines. Remember there may be several possible reasons for fasting hyperglycemia. S170 . poor sleep. • • • • 29 30 2008 Clinical Practice Guidelines. has no concurrent illness and is free from unusual stress. p. p. Basic Principles of Insulin Dose Adjustment • • Make IDA to usual insulin dose based on blood glucose patterns. Pattern Management Modifications are made in the base (usual) insulin dose based on blood glucose patterns.Saskatchewan Insulin Adjustment Module March. • • Hypoglycemia unawareness (failure to sense hypoglycemia) may place clients at risk of life threatening hypoglycemia. Adjust only one insulin dose at a time (unless this will cause a low blood glucose level at a later time).

In some literature this is also referred to as the insulin sensitivity factor.Saskatchewan Insulin Adjustment Module March. • • Provide the client with guidelines for when to notify the Registered Nurse or physician. insulin grid or scale.adjustment of the insulin dose in advance of carbohydrate intake based on carbohydrate content of the meal or snack. a correction factor guides a person to make adjustments to the usual dose of short or rapid-acting insulin according to pre-meal blood glucose levels. 31 In resources and the literature many terms are used in place of “correction factor”. including nocturnal hypoglycemia and possible rebound hyperglycemia. adjust by 1 . For those who count carbohydrate.adjustment of the insulin dose to correct for a high or low blood glucose level. For those who eat consistent carbohydrate only. . • Provide guidelines to monitor ketones (in those who are high risk) during periods of hyperglycemia or illness. Ensure the client is aware of the need to contact the physician when one of the following occurs: Hyperglycemia with ketones (moderate or large) and/or illness Experiences recurrent hypoglycemia with no apparent cause or severe hypoglycemia requiring assistance to treat Is unable to eat or drink (for any reason) Is vomiting or has persistent nausea Blood glucose levels continue to fluctuate with no apparent cause Hyperglycemia is not responding to increases in insulin dose Variable Insulin Dose Adjustments Two types of IDA may be used: a. These include: insulin sensitivity factor. b. 2009 • Page 51 IDA in most circumstances will be by 10% increments. For example: o Usual dose of less than 10 units.2 units and so on Assessment of Blood Glucose Patterns • Assess frequency and timing of any hypoglycemia. Correction Factor . Use of Correction Factors 31 Short or rapid-acting insulins may be given according to a correction factor to compensate for a pre-meal blood glucose above or below target. • Ensure clients are familiar with strategies to prevent and treat hypoglycemia. algorithm. adjust by 1 unit o Usual dose of 10-20 units. the pre-meal dose of short or rapid-acting insulin is determined by use of both the correction factor for glucose levels above or below the target AND the amount of carbohydrate to be consumed at the meal. Insulin to Carbohydrate Ratio .

The 2 hour pc reading is also useful when making initial IDA. Methods to Develop Correction Factors The basic principles to remember when developing a correction factor are: 1. Use of this insulin at bedtime should be discussed with the physician. Consider the individual’s target range for glucose control and willingness to supplement for values out of the target range. Use of rapid or short-acting insulin at bedtime is not usually recommended because of the risk of nocturnal hypoglycemia. Consider how sensitive your client is to rapid or short-acting insulin when developing the correction factor. the blood glucose returns to target range (ideally 4-7 mmol/L) prior to the next meal/snack ie: in 4 to 6 hours. the blood glucose returns to target range as with short-acting insulin. If your client has not seen a dietitian in some time and you suspect inconsistency in carbohydrate intake or difficulties with counting carbohydrate. • Using rapid-acting insulin. err on the hyperglycemic side initially). 3. Teach your client to adjust the appropriate basal dose of insulin or the insulin to carbohydrate ratio if they have to correct regularly. a conservative dose of short or rapid-acting insulin can be used for an excessively elevated blood glucose reading at bedtime. 2. 2009 Page 52 Correction factors must be designed on an individual basis taking into consideration the person’s: • target blood glucose range • sensitivity to insulin • total daily dose of insulin • insulin type – short or rapid acting insulin IDA to the base insulin dose should not be made if the person has a concurrent illness or is experiencing stress. Use of rapid or shortacting at bedtime may be indicated if glucose levels are high and ketones are present or if the individual routinely has a large bedtime snack. and revise if necessary. refer the client to a dietitian. evaluate for effectiveness. Construct the factor conservatively (that is.Saskatchewan Insulin Adjustment Module March. A correction factor is effective when: • Using short-acting insulin. Any change to a pre-existing correction factor should be sent to the attending physician using a progress note or fax information sheet. . However.

Quebec. DES members section www.diabetes.08. Note.5 If the correction factor is working. 32 Sources: Building Competency in Diabetes Education: Advancing Practice.ca 33 See practice cases for exercises to develop correction factors. 1. EXAMPLE: TDD = 48 units 100/48 = 2.2 9.6 15. EXAMPLE: In the example below. Use a pre-set standard of 1 to 3 units for 2. the post-meal glucose will be at about the same level or slightly lower than the pre-meal glucose.5 11. Seminar presented at the 2004 CDA Professional Conference.Saskatchewan Insulin Adjustment Module March. The next step would be an increase in the pre-meal correction factor to 2 units for every 2 mmol/L above the target. a correction factor of 1 unit has been used for every 2 mmol/L above the target glucose.2 to 2. This assumes a consistent carbohydrate intake and that the usual dose provides the correct ratio of insulin to carbohydrate. it may be appropriate to use the rule of 85 for those who are insulin resistant no matter which type of insulin is being used.8 13. p2-41 to 2-43 and Lightfoot. C and Pytka ES (2004) Making Carbs Count: Advanced Carbohydrate Counting for Intensive Diabetes Management. rounded to 2 mmol/L This means 1 unit of rapid-acting insulin will drop the blood glucose by 2 mmol/L. . PRE-MEAL GLUCOSE 10.8 mmol/L desired change in the blood glucose level. The resulting number represents the drop in blood glucose for each unit of insulin. Start conservatively using 1 unit and increase based on feedback from the blood glucose readings.3 (using rapid-acting insulin and a consistent carbohydrate intake) TWO HOURS POST-MEAL 14. The Rule Method Divide either 100 (for rapid-acting insulin) or 85 (for short-acting insulin) by the person’s TDD (total daily dose). 2009 Page 53 There are two methods which can be used to develop a correction factor 32.33 . Pay attention to the next pre-meal blood glucose as it can be difficult to achieve target post-meal glucose without making the next pre-meal glucose too low. 2. Available on CDA website. Quebec City.

Saskatchewan Insulin Adjustment Module March.0 4.1-7.9 mmol/L Target blood glucose level = 7 mmol/L Correction factor = 2 [one unit of insulin lower glucose by 2 mmol.0 7.0 >15. Calculation for each blood glucose reading To use this method the individual • does a pre-meal blood glucose test • subtracts the target blood glucose from the result • divides by the correction factor EXAMPLE: Current blood glucose level pre-noon = 11.0 9.1-11. Clients who find math a challenge will likely prefer the second method.0 13.1-13. 2.1-9. Written grid or scale for insulin IDAs Using this method the educator will create a grid for the client to use based on the correction factor. The grid indicates the number of units to be added to or subtracted from the base dose. the client can use it in two ways. 2009 Page 54 Using the Correction Factor Once a correction factor has been determined. 1.] (11.1-15.1 Morning -1 6 +1 +2 +3 +4 +5 Noon -1 10 +1 +2 +3 +4 +5 Supper -1 12 +1 +2 +3 +4 +5 Intermediate or Long-Acting Insulin Lantus 22 units at bedtime TARGET RANGE Usual doses .4 units. EXAMPLE: The TDD is 50 units. 100/50 = 2 [rule method] 1 unit will decrease blood glucose by 2 mmol/L Dose of rapid or short-acting insulin BLOOD GLUCOSE < 4.0 11.9 – 7)/2 = 2. rounded to 2 units This amount of insulin will be added to the usual dose or the amount of insulin being taken for the carbohydrate to be eaten at the meal.

Divide the number of grams of carbohydrate taken at a meal by the number of units of insulin given at the meal. There are three methods to determine the insulin to carbohydrate ratio: 1. For example. greater flexibility and variability of carbohydrate intake will be possible. . An insulin resistant person may require 5 gms of CHO per unit of insulin as compared to a thin or fit person or a child needing 20 gms of CHO per unit. b. This method can be used when the amount of insulin taken provides adequate control based on changes in pre versus post-meal blood glucose of no more than 3 mmol/L at 1 hour pc . hypoglycemia if the anticipated rise in blood glucose does not occur. and 11 respectively.Saskatchewan Insulin Adjustment Module March. Experimenting to get the right ratio requires some time and effort involving frequent blood glucose monitoring and documentation of food intake. Clients should be reminded that a compensatory correction can be safely made at the next meal time. Remember carbohydrate to insulin ratios vary from person to person and may differ from meal to meal. In this situation the values in the morning column would read: 5. some individuals are more insulin resistant at breakfast than at supper. 9. Two more rows can be added to the grid for clients who are carbohydrate counting: • A line for the usual carbohydrate at the meal • A line for the insulin to carbohydrate ratio Insulin to Carbohydrate Ratio If a person is planning to eat a variable amount of carbohydrate at meals he can “anticipate” the resulting variability in blood glucose and minimize it by decreasing or increasing the premeal dose of short or rapid-acting insulin. it is suggested that carbohydrate content at meals and snacks remain consistent when first establishing insulin to carbohydrate ratios. 2009 Page 55 For some clients it is necessary to write in the actual dose rather than the amount to be added to the usual dose. decreased risk for disordered eating. reflects more normal eating practices where people gauge how much food they are hungry for. greater flexibility and quality of life b. 10. rather than a set amount they have to eat. weight gain if a person frequently increases insulin to allow for extra food. 7. NOTE: Initially. The result will yield: 1 unit of insulin per xx grams of carbohydrate. The disadvantages of this method are: a. 8. c. The advantages of using the method are: a. 6 (usual dose). Once a baseline is established. Pattern Management.

0 Therefore. • the amount of carbohydrate average/day is determined.Saskatchewan Insulin Adjustment Module March. 3. EXAMPLE TDD = 63 units 500/63 = 7. IDA may be needed based on actual results. • the carbohydrate/day is divided by the total pre-meal or bolus insulin. Rule of 500 In this method 500 is divided by the TDD This method will yield the same insulin to carbohydrate ratio for all meals. 1 unit of insulin would be taken for every 8 grams of carbohydrate. 1 unit of insulin would be taken for every 5 grams of carbohydrate. 2. .4 Therefore. observations of “what works” and use of method #1.9 Therefore. 1 unit of insulin would be taken for every 9 grams of carbohydrate. EXAMPLE: Total pre-meal or bolus insulin/day = 28 units Average grams of carbohydrate eaten/day = 140 grams 140/28 = 5. 2009 Page 56 EXAMPLE Meal time carbohydrate = 66 grams Meal time insulin = 7 units 66/7 = 9. Averages of Pre-meal insulin and carbohydrate intake In this method: • the bolus or pre-meal insulin doses are added for the full day.

The client should have a source of short-acting glucose available during exercise. b. Depletion of glycogen stores may occur with moderate to intense exercise and may result in hypoglycemia many hours after exercise. g.Saskatchewan Insulin Adjustment Module March. People with type 1 diabetes who have a urine ketone level > 8. Canadian Diabetes Association: Toronto. 34 35 2008 Clinical Practice Guidelines. page S48 Rabasa-Lohoret R. 36 Jones H. (2009). f. IDA may also be needed to the basal insulin dose(s).0 Insulin Dose Adjustment for Exercise or Increased Physical Activity IDA for exercise or physical activity depends heavily on your client’s response to insulin. Exercise at consistent times of the day will facilitate more reliable IDA. inject in the abdomen rather the leg before running.1 Guidelines for IDA for exercise are: a. 36 i. for example.24(4):625-630. Bourque J et al. For some this can be as long as 24 hours. Insulin injection into an exercising limb may speed insulin absorption and action. Diabetes Educator Section. Building Competency in Diabetes Education: The Essentials. Adequate hydration is also important. Anticipatory IDA for exercise without compensatory carbohydrate intake may be recommended as follows 35 . particularly if this has happened during the evening. The bedtime basal insulin may need to be decreased by 10-30% followed prolonged endurance exercise. editor. Blood glucose monitoring should be employed initially before. See accompanying table. 1. Insulin should be injected into a non-exercised part of the body prior to exercise. Compensatory food intake may be used to prevent hypoglycemia without IDA or as an adjunct. Diabetes Care 2001. d. . Guidelines for Premeal Insulin Dose Reduction for Postprandial Exercise of Different Intensities and Durations in Type 1 Diabetic Subjects Treated Intensively with Basal-Bolus Insulin Regimens (Ultralente-Lispro). e. Physical activity may enhance the effect of exogenous insulin by increasing glucose uptake by muscle cells and intracellular glucose metabolism.0 mmol/L or blood ketone level > 3. Metabolic deterioration will occur with exercise. c. These are guidelines and will need to be evaluated with each individual. If possible. during and after new exercise routines to determine its effect on glycemic levels for the individual. Following prolonged exercise. It is important to note that recognition of hypoglycemia may be delayed during vigorous exercise due to the masking of early warning signs.0 mmol/L 34 should not exercise. subsequent meal doses of rapid or short-acting insulin may need to be reduced by 20-50%. blood glucose monitoring is required to ensure safe and effective IDA. the intended activity and its timing in relation to food and insulin. Thus. Ontario. The temporal effect on blood glucose levels will vary depending on the person and intensity and duration of activity. 2009 Page 57 1.

may reduce by 10-30% * Prolonged activity may have a delayed glucose lowering effect. Source: The Essentials. Exercise Time Insulin Type Intensity of Exercise ↓ Mild Moderate Strenuous Prolonged > 3 hours* Immediately post-meal Pre-meal Bolus Morning or Afternoon Morning Basal Very early in morning Previous evening basal Post Prolonged activity* Meal or Basal 20-50% 50% Up to 80% 30-50% Adjust with exercise intensity Trained athletes may require up to 80% reduction No more than 50% reduction Adjust with exercise intensity Post activity pre-meal doses. 2009. . Chapter 10.These are only initial conservative recommendations to be evaluated by blood glucose monitoring and revised as necessary. may reduce by 20-50% Bedtime basal insulin.

you may need to eat extra food depending on your blood glucose results before you start exercising – always test! The following table tells you how much food to eat. However.Extra Food For Extra Exercise 37 Adult Guidelines – must be adjusted for pediatric clients You may have already taken less insulin. Swimming. . 15 grams of carbohydrate Food intake should not be increased. Do not exercise until diabetes control improves. Small amounts at frequent intervals are preferable for prolonged activity 6 – 10 mmol/L 11 – 17 mmol/L [no ketones] Moderate urine ketones >8 mmol/L or blood ketones >3 mmol/L are present 45 grams of carbohydrate before exercise. Racquetball. House Cleaning. Cycling. Bowling) Moderate for one hour (Tennis. Sexual Intercourse. these are only guidelines. CDA (2005). Strenuous for one hour (Hockey. Revised and updated based on Clinical Practice Guidelines and Beyond the Basics. Football. 37 Original from Learning to Live With Diabetes Nova Scotia Diabetes Centre. 30 grams of carbohydrate 15 grams of carbohydrate Do not exercise until diabetes control improves. Remember. Golfing) Blood Glucose Levels Less than 6 mmol/L Carbohydrate Amount 15 grams Less than 6 mmol/L 6 – 10 mmol/L 11 – 17 mmol/L Moderate urine ketones >8 mmol/L or blood ketones >3 mmol/L are present Less than 6 mmol/L 30 grams of carbohydrate before exercise. Table 2 Exercise Light for one hour (Walking. An additional 10–15 grams of carbohydrate is required for each additional hour. An additional 10-15 grams of carbohydrate is required for each additional hour. Competitive Sports) NB.

Potential barriers to the learning process may preclude the client being able to effectively adjust their own insulin dosages. unable to analyze abstract data. Examples of resources are in the reference section. 2.Saskatchewan Insulin Adjustment Module March. make the appropriate change in diet. review consistency of carbohydrate intake at meals and snacks and/or accuracy of carbohydrate counting b. and ability to perceive early warning signs of hypoglycemia. 4. relationship of SMBG results to specific insulin action. and to self-adjust medication when indicated. 3. The 2008 Clinical Practice Guidelines should be used for target ranges for blood glucose control and IDA subject to individual needs. Before making insulin adjustments. unable to take action to make necessary IDA due to insecurity or unwillingness to take over perceived medical function. 2009 Page 60 Teaching Procedure For Self-Adjustment Of Insulin Learning Objectives • Upon completion of this chapter you will be able to: Teach clients to self-adjust their insulin taking into consideration their age. c. General guidelines that can be provided to clients for self-adjustment include: a. target blood glucose range. concurrent medical conditions. Principles 1. interpretation of results. etc.g. Consider usual meal times and insulin injection times. Principles for IDA teaching must take into account the individual client’s response to their insulin. Review the time actions the client’s own insulins and present these in relation to his or her own lifestyle. unable to understand necessary concepts. unable to afford SMBG b. These could include but are not limited to: a. Assessment of the client on insulin should include their willingness and ability to learn SMBG. . Look for patterns of high/low blood glucose results at specific times of the day. • If the patterns are unexplainable adjust the appropriate insulin by a factor of 10%. insulin action times.g. etc. General guidelines based on the usual or ‘mean’ response pattern are useful for group instruction and for individuals until specific variation in insulin response is determined. etc. 5. d. activity. long-term complications of diabetes. These guidelines are subject to individual variation related to factors such as the client’s age. Self-adjustment of insulin can be taught in a group setting or on an individual basis. e. concurrent medical conditions and lifestyle. e. • If the patterns are explainable. identification of blood glucose trends.

can be very serious if your diabetes is in poor control. during. Decrease the insulin that will be working at the time you plan to exercise. The extra insulin with the correction factor must be included in your evaluation of patterns of hypo/hyperglycemia. Compensate for high or low blood glucoses if your Registered Nurse or doctor has provided you with a correction factor for rapid or short-acting insulin. 38 7. excessive hyperglycemia. less frequent monitoring is required. during and after exercise. Dehydration. Once a satisfactory pattern of glycemic response to exercise and insulin/food adjustment is obtained. such as glucose tablets. Also see Additional Resources at the end of Module 39 . c. In such cases. Exercise is not recommended if urine ketones are > 8 mmol/L or blood ketones >3 mmol/L. If self-adjustments do not improve the identified problem consult your Registered Nurse or doctor. d. Other information to give clients for exercise: • • • When you exercise. Principles for IDA for exercise include: Monitoring of blood glucose is essential in determining the need for insulin and/or food compensation for exercise. or hypoglycemia. always carry some form of sugar. juice. lifesavers or hard candy. e.Saskatchewan Insulin Adjustment Module March. Monitor blood glucose before and 2 hours after meals while making IDA and evaluate the result of specific IDA over the following three to four days. consult your Registered Nurse or doctor. 38 The Registered Nurse receiving such a request will communicate with the physician to coordinate care relative to the illness and need for additional rapid or short-acting insulin. Sick Day Management. Insulin or food adjustments for exercise are best evaluated by SMBG before. 6. a. d. f. and after exercise. Never drink alcohol around the time you exercise as it can result in low blood sugar. pregnancy. Contact your doctor in the event of illness for further specific IDA guidelines. especially in hot weather. Refer to information in the Learning/Procedure module which can be modified as a client handout. Insulin adjustment for acute illness is not part of the basic Transfer of Medical Function. Only make IDA every 3 to 4 days. b. The additional insulin must take into account the presence or absence of ketones. Use the guide from your Registered Nurse or doctor when making changes 39 . Revise IDA as required to optimize blood glucose control. 2009 Page 61 c. Prevent dehydration by drinking water before. travel. except in unusual circumstances such as illness.

birthday. your blood sugars will be high that day. e. Blood glucose monitoring to evaluate effectiveness is recommended. special meal. .Saskatchewan Insulin Adjustment Module March. can prevent hyperglycemia post meal or later in the day.g. 8. 2009 Page 62 • If you reduce your insulin and are unable to exercise. Taking extra rapid or short-acting insulin in anticipation of a special meal/food. etc.

Saskatchewan Insulin Adjustment Module March.8 Post Breakfast 9. Her last A1C reading was 7.hs snack – 30 grams What variables would you consider in client assessment? What insulin dose adjustments would you consider? .9 4.lunch.8 Post Noon 7. 2009 Page 63 PRACTICE CASES The following cases are to be completed after reviewing the Learning and Procedure Module.0 9. CASE #1 Sarah is 60 years old with type 2 diabetes.0 6.60 grams .5 5.6 8. there will be discussion of the cases at the workshop.2 7.pm snack – 15 grams .7 Bedtime 6.2%. Also consider what questions you might ask a client in each of these situations. the diabetes educator can review the cases with a qualified physician and/or an experienced diabetes educator colleague. Review each of the following cases and provide an answer with rationale. If there is a provincial workshop. Her eating and activity patterns were recently assessed and are relatively consistent from day to day.9 Post Supper 8. Or.breakfast – 50 grams .8 8.1 6. She has been using insulin for about one year and has had diabetes for 8 years.8 7.2 9.1 5.6 8.3 Eating pattern as assessed by a dietitian: Carbohydrate distribution . Answers are provided at the end of this section for each case.Supper – 65 grams .6 7. INSULIN DOSE: N 15 units at bedtime Date June June June June 10 13 16 20 Before Breakfast 7. She weighs 165 lbs (75 kg).

0 5.2 6.7 Bedtime 8.2 5.Saskatchewan Insulin Adjustment Module March. 2009 Page 64 CASE #2 This continues the story with Sarah from Case #1.0 5.7 6.8 5.8 Before Lunch 5.3 Other What variables would you consider in client assessment? What insulin dose adjustments would you consider? .0 9.0 4. She has increased her bedtime N to 22 units and her fasting blood glucose levels are consistently below 7 mmol/L. INSULIN DOSE: N 22 units at bedtime Date Jan Jan Jan Jan 10 13 16 20 Before Breakfast 6. The following pattern has emerged in her blood glucose levels over the past four weeks.5 9. now 6 months later.5 5.9 Before Supper 4.3 6.2 9.

She is not physically active in the evening as she does not want to drive in the evening and has other interests to keep her occupied. You have requested a physician order for pre-supper rapid-acting insulin. You know that Sarah usually eats about 65 grams of carbohydrate at supper and works hard to be consistent with this amount. What would you recommend and what would be your rationale for this recommendation? What follow-up plan would you make with Sarah for ongoing IDA to the presupper rapid-acting insulin? . The physician agrees and asks you for your suggestion for an amount of insulin.Saskatchewan Insulin Adjustment Module March. 2009 Page 65 CASE #3 Continuing with Sarah from cases 1 and 2. you have reviewed the variables suggested in the answer for Case 2 and found she will not be able to decrease the evening glucose level through changes in eating or activity.

1 5. 2009 Page 66 CASE #4 John is 50 years old.9 Bedtime 6.6 Before Supper 4.8 12.1 Before Lunch 4. His BMI is 24.2 Other Low during the night His doctor would like to switch him to an extended long-acting insulin analogue (Lantus) and asks you to recommend a dose. State the dose you would recommend and your reasons.2 7. What advice will you give John in terms of what he might expect to see in his glucose readings when he makes the switch? . He has been on insulin for 10 years and has had diabetes for 12 years.Saskatchewan Insulin Adjustment Module March. John says he prefers taking the long-acting insulin at bedtime.8 5.0 16.8 8.4 6.9 7. works as an accountant. INSULIN DOSES: • Breakfast • Noon • Supper • Humalog 7 units 0 Humalog 10 units Humulin N 28 units Humulin N 8 units • Breakfast Bedtime The following values represent typical log book entries Date Oct 24 Oct 25 Oct 26 Before Breakfast 2.

His noon carbohydrate varies from 60-80 grams. He has omitted his afternoon snack to help compensate. 2009 Page 67 CASE #5 This case continues with John from Case #4. they were usually below the target of 7. What advice would you give about the amount of H to use at noon? Explain your recommendation.Saskatchewan Insulin Adjustment Module March. He is now using Lantus 32 units at bedtime. . However. no longer has night-time or fasting hypoglycemia and his fasting glucose levels are usually between 5-6 mmol/L. but the glucose readings at supper remain elevated. Prior to the insulin change. his pre-supper blood glucose levels are slowly rising. now they are usually 8-9 mmol/L and occasionally higher.

Create a grid for John’s breakfast insulin dose.6 one morning. Use the “rule method” to calculate the correction factor. but adjusts his insulin accordingly. His usual doses of insulin in a day are Breakfast Humalog 7 units Noon Humalog 8 units Supper Humalog 10 units Bedtime Lantus 32 units He occasionally changes his carbohydrate intake. 2009 Page 68 CASE #6 John from Cases 4 and 5 has followed your advice and it has worked out well. write down the calculation he would use if his fasting blood glucose reading is 12. If John does not want to carry around a grid. He does not snack between meals.Saskatchewan Insulin Adjustment Module March. Usually he cannot explain them and he finds this frustrating. What would be different in this calculation if John was using a short-acting insulin rather than a rapid-acting insulin? . He now says he would like to be able to “fix” the high blood glucose levels which he gets from time to time.

He has gone back to his meal plan and followed it fairly faithfully.Saskatchewan Insulin Adjustment Module March.2 Before Supper 16.3 cm).5% INSULIN DOSES • a. height is 71 inches (180. In the past two months Mike says that whatever he tries. His A1C one month ago was 10.m.2 15. His weight is 165 lbs (75 kg).4 11.5 Other What insulin changes would you recommend to this gentleman? .9 14.9 12.9 17.7 Bedtime 12. 2009 Page 69 CASE #7 Mike is 39 years old with type 2 diabetes. This is confirmed by a visit to the dietitian.8 Before Lunch 8. he can’t get his blood glucose levels under control. Humulin N 30 units • supper Humulin N18 units Date Monday Tues Wed Before Breakfast 10.1 12.3 10.6 13. He walks in the evening 2-3 days per week.

She has had high fasting readings for a few weeks.Saskatchewan Insulin Adjustment Module March. She has been on insulin for the past 15 years. In the last week she has been increasing her pre-supper N. but the high readings continue in the morning. She also has been having restless sleeps and morning headaches. 2009 Page 70 CASE #8 Milly Smith has had diabetes for 22 years. INSULIN DOSES: • • pre-breakfast: Humulin R 6 units and Humulin N 24 units pre-supper: Humulin R 3 units and Humulin N12 units Does Milly need any insulin adjustment? .

). He hates insulin injections. It has been 1 year since initiation of insulin therapy.Saskatchewan Insulin Adjustment Module March. He has a 6 year history of type 2 diabetes. decreased sleep INSULIN DOSE: • single injection NPH 80 units before breakfast What changes would you consider? . He tests regularly and has regular contact with the dietitian who confirms that he has a consistent carbohydrate intake. 2009 Page 71 CASE # 9 Fred is a 58 year old lean male (70 kg. He has several complaints when he comes to see you: • morning hyperglycemia • mid-afternoon hypoglycemia • nocturia.

9 11.1 Bedtime 8.7 Before Lunch 11. above his healthy weight and would like to lose some weight.7 4.1 Before Supper 7.8 16. He has no complaints and feels well.7 11.1 11. He is on no specific diet and can recall no dietitian contact.4 4.4 2. He is 4 kg. 2009 Page 72 CASE # 10 Joe is a 36 year old sedentary Assistant Manager in a meat packing plant and has had diabetes since age 24.7 16.1 6.7 16.7 15.Saskatchewan Insulin Adjustment Module March. but he says that he eats “regular” meals and quantities. His sister with diabetes is developing retinopathy and he is anxious to learn more about his diabetes and improve his control.9 8.1 16.9 6.2 6.7 11.8 9.4 6.7 Other What would you discuss with him and what possible recommendations might you make regarding his insulin dose? . Glucose patterns on a three day per week before meal and bedtime snack testing routine are as follows: Date Before Breakfast 4. He is taking • Humulin R10 units and Humulin N 35 units each morning • Humulin N 25 units at supper.7 16.8 7.

2009 Page 73 Joe has decided to do carbohydrate counting and has made some dietary changes to reduce his weight.Saskatchewan Insulin Adjustment Module March. Review his food records on the following page and calculate the total carbohydrate intake for each meal. ¾ cup ½ banana. small # grams of carbs TOTAL CHO PER MEAL/SNACK Snack Time: BG Supper Time: BG: . orange or banana. As a reference use Beyond the Basics (2005). CASE # 11 MEAL Basal Insulin Breakfast Time: 0615 hrs BG: 4. whole wheat 2 tsp. 1 cup 1 slice bread. whole grain 2 slices cheese or ½ cup salmon 2 tsp margarine lettuce and tomato slice Apple.4 Two hour BG: Activity Snack Time: BG Lunch Time: 1200 hrs BG: FOOD EATEN 2 toast. jam (regular) 6 ounces unsweetened orange juice At work – sitting Orange Sandwich: 2 slices of bread. skim w artificial sweetener. whole grain yogurt. medium 1 cup skim milk Oatmeal granola bar Meat or fish about 3 ounces 1 cup potatoes Broccoli .

2 tsp. skim w artificial sweetener. orange or banana 1 cup chocolate milk # grams of carbs INSULIN TAKEN 0 Rapid 12 units Rapid 10 units Snack Time: BG 12. He is now using Lantus at 10 pm as his basal insulin • • For each meal calculate the insulin to carbohydrate ratio using the food record below [see bottom] and then fill in the insulin to be taken at the meal.7 Lantus 32 units Insulin:carbohydrate Insulin:carbohydrate Insulin:carbohydrate Insulin:carbohydrate ratio ratio ratio ratio is is is is ___ ___ ___ ___ units units units units for for for for ___ ___ ___ ___ grams grams grams grams of of of of carbohydrate carbohydrate carbohydrate carbohydrate or or or or ____units (breakfast) ____ units (lunch) ____ units (supper) ____ units (bedtime) .8 Meat or fish about 3 ounces 1 cup potato salad corn.3 Supper Time: BG: 10.6 Basal Insulin Bedtime Time: 10 p. Comment on the appropriateness of the calculated ratio.8 Activity Snack Time: BG Lunch Time: 1200 hrs BG: 5.m. 2009 Page 74 CASE #12 Joe is now comfortable with carbohydrate counting and has started using some pre-meal rapidacting insulin based on the amount of carbohydrate he eats. MEAL Basal Insulin Breakfast Time: 0615 hrs BG: 4. BG: 6. jam (regular) ½ grapefruit At work – sitting 1 cup carrot & celery sticks 2 tbsp low fat dip Sandwich: 2 slices of bread 2 slices cheese or ½ cup salmon 2 tsp margarine lettuce and tomato Apple.Saskatchewan Insulin Adjustment Module March. ¾ cup ½ banana.4 Two hour BG: 9.3 FOOD EATEN 2 toast. Assume the single bg values given here represent the usual pattern of bg results. 1 cup 1 slice bread yogurt. small 1 apple Rapid 10 units 2 hour BG: 13.

7 Lantus 38 units . small # grams of carbs INSULIN TAKEN Meal Bolus: Correction: TOTAL Taken: 2 hour BG: Basal Insulin Bedtime Time: 10 p. Assume his • target glucose level is 7 • insulin:CHO ratio for supper is 1:10 • TDD is usually ~ 70 units/day What is his correction factor? Write in any correction insulin doses you would recommend using the same chart below. BG: 6. ¾ cup ½ banana. ½ cup 1 slice bread yogurt.Saskatchewan Insulin Adjustment Module March. skim w artificial sweetener. MEAL Supper Time: BG: 10.8 FOOD EATEN Meat or fish about 3 ounces 1 cup rice salad corn.m. He is disappointed with some of his pre-meal glucose levels. 2009 Page 75 CASE #13 Joe is getting very good at counting CHO and deciding how much insulin to take. He asks you what he can do to correct some of the high pre-meal levels.

on Saturdays.9% He plans to take up his old school sport of basketball – two hour practice on Monday from 7-9 p. and weekly game 2:30-4:30 p. a 30 year old salesman is fairly inactive and has type 1 diabetes of ten years duration. He is moderately obese.m. INSULIN DOSES: Breakfast: Noon: Supper: Bedtime: (Novolin) Novorapid 10 units Novorapid 6 units Novorapid 12 units Levemir 26 units 90% of his blood glucose tests are in the 4-8 range and exceptions are usually explained by food and activity variations. What advice does he need to leave him safe for the new exercise pattern? . overweight and slowing increasing. some 8 kg. He typically eats three meals and three snacks.m.Saskatchewan Insulin Adjustment Module March. He would like to drop a few pounds. 2009 Page 76 CASE # 14 Jeff. His last A1C was 6.

60 grams • Snack 0 – 15 grams • Supper .3 7. She has seen a dietitian recently and her carbohydrate intake is usually consistent from day to day.9 Other Carbohydrate intake distribution (as assessed by the dietitian) • Breakfast .30 grams • Lunch .5 9. 16 units. Her weight is ~151 lbs (68.5 kg) and height is 61” (155 cm).30 grams What target glucose level would you set with Karen and her physician? What does the current dose of 28 units of NovoMix 30 represent in terms of types of insulins and how many units of each insulin does this dose represent? What changes.2 11.Saskatchewan Insulin Adjustment Module March. She has had no problems with hypoglycemia recently.0 2.45 grams • HS .1 Before Lunch 7. In the past she has had mild hypoglycemia and 6 months ago she had an unrecognized low blood glucose level. if any. 2009 Page 77 CASE # 15 Karen is 78 years old. 28 units. would you recommend to her current medications? What might you consider if the first issue or problem you identify is resolved? . lives alone and has had type 2 diabetes for 12 years. In addition to diabetes she has had a myocardial infarct 2 years ago. Present Medications • Metformin 1000 mg bid • NovoMix 30. has hypertension (now controlled) and dyslipidemia (now controlled).1 Before Supper 3.4 4. Her neighbor called 911. A daily afternoon snack has been recommended.8 Bedtime 8.0 7. pre-breakfast • NovoMix 30.8 8. pre-supper Recent blood glucose readings: Date Before Breakfast 10.2 6.

3 7.2 6.0 7.1 Before Lunch 7. Use the medication doses from the answer to case #15 here.Saskatchewan Insulin Adjustment Module March.8 8. See the current blood glucose pattern below.4 7.0 7. 2009 Page 78 CASE #16 Karen has taken care of the first problem you identified in Case #15.9 Other What suggestions do you have to help Karen achieve target glucose levels? . All her circumstances remain unchanged. Date Before Breakfast 10.1 Before Supper 7.2 11.8 Bedtime 8.5 9.

Her weight is 176 lbs (80 kg) and her height is 63” (160 cm). INSULIN DOSES: Novolin 30/70 using an insulin pen • 40 units at breakfast • 35 units at supper What changes can you suggest? . Her most recent A1C = 9.4%. She has found blood glucose levels to be increasingly difficult to control and is gaining weight. She has had type 2 diabetes for 10 years and started insulin one year ago. She is already on a maximum dose of metformin.Saskatchewan Insulin Adjustment Module March. 2009 Page 79 CASE # 17 Mary is a 65 old female. Blood glucose readings are 10-12 across the day with little variation.

1-13 13. Meal plan .0 kg). His carbohydrate intake is consistent at each meal.105 grams • Lunch – 90 grams • Pm snack – 30 grams • Supper – 75 grams • HS . and Humalog at each meal using the following grid: Blood glucose <5 5.s.m.45 grams Stan prefers not to have a mid morning snack.9 9. He has seen a dietitian recently.m. weight 147 lbs (67.1-15 >15 Stan’s • • • present blood glucose pattern is: High fasting blood glucose High blood glucose at 10 p. What changes would you recommend? END .11 11.1 – 7 7. He has had Type 1 diabetes for two years. Insulin regime: N 35 units at h. but likes having one in the afternoon and a more substantial one in the evening. 2009 Page 80 CASE # 18 Stan is a 36 year old lean male. Lows in mid-morning to noon a.1. He usually works long hours at a physically demanding job. 10 11 12 13 14 15 16 Noon 6 7 8 9 10 11 12 Supper 12 13 14 15 16 17 18 He monitors his blood glucose closely and frequently and makes insulin changes based on meal pattern and activity levels.1.Saskatchewan Insulin Adjustment Module March. height 68½” (174 cm).2500 calories with the following carbohydrate intake: • Breakfast .

ANSWER .CASE #2: Assuming there were no issues with her insulin measurement/injection technique or blood glucose monitoring. if any? IDA to consider if improvement in glucose levels at bedtime are not found in eating or activity strategies: addition of rapid acting insulin pre-supper. The Transfer of Function does not cover initiation of a new insulin regimen so the Registered Nurse would need a physician order to make this change.Saskatchewan Insulin Adjustment Module March. you might also review: • Her usual food intake at supper is 65 grams of carbohydrate (from case #1) o Has anything changed recently? o Is the client accurate with her carbohydrate counting? o Is the amount consistent from day to day or variable? • What is her evening activity level? Has this changed in the past month? Has she noticed that physical activity in the evening will improve her bedtime readings? What evening activity is she willing to consider. treatment and prevention of hypoglycemia with the anticipated improvement in control. 2009 Page 81 ANSWERS TO PRACTICE CASES ANSWER – CASE #1 As the case states her eating and activity patterns are consistent from day to day. . Sarah could be taught to make changes every 3-4 test days until she finds her fasting blood glucose readings below 7 mmol/L It would also be important to review the symptoms. you might also consider: • Does she always have the snack at bedtime (30 grams)? • Accuracy of blood glucose monitoring • Accuracy in her use of her insulin measurement and delivery system IDA: increase the bedtime N by 10% or 2 units to reduce fasting glucose.

it is recommended that the total dose of intermediate-acting insulin be reduced by 20% and the Lantus be given as a single dose. but the need for the snack should be reassessed. 4. This change will require a physician’s order. Total dose of N per day = 36 units 20% of this dose = 7. .CASE #3 As Sarah has not taken rapid-acting insulin pre-meal before.m. keep it in for now. John prefers to take this insulin at bedtime.7. 6. He may wish to check another 3 a. the fasting glucose levels are high (>7 mmol/L). increase the dose of rapidacting insulin by 1 unit after 3 test days • If evening glucose levels are too low or she has symptoms of hypoglycemia. to determine whether he needs to start a pre-noon dose of H. The following recommendations are based on the injection occurring at bedtime.2 units Recommended starting dose of Lantus = 29 units Advice to John 1. The follow-up plan with Sarah could include the following: • Record food or grams of CHO eaten at supper for a few days on the new insulin dose • Test 2 hours post supper and at bedtime to assess the new insulin’s effectiveness • If post meal glucose levels are not dropping to 10 or less. First avoid hypoglycemia. If he is presently taking an afternoon snack. 2009 Page 82 ANSWER . He may find his pre-supper glucose readings become elevated as he no longer has intermediate acting insulin in morning. Section D in module). If he has night-time or early morning hypoglycemia symptoms. glucose level before making further increases. Review the treatment and prevention of hypoglycemia with John. you could recommend 2-3 units as the initial dose of rapid-acting insulin pre-supper. Sarah would take 1 unit of insulin for every 23 grams of carbohydrate. If there is no hypoglycemia and after 3-4 days on the starting dose. Ask John to do some 2 hr pc lunch and ac supper results. 5. Wait 3-4 days between each insulin increase. 3. An alternative could be a morning injection of long-acting as Lantus is usually a once a day injection as long as it is given daily at the same time. according to the calculation. Her supper carbohydrate is 65 grams 65 ÷ 23 = 2. He will likely need to start on a pre-noon dose of H. reduce the pre-supper dose of rapid-acting insulin by 1 unit ANSWER . her sensitivity to this insulin is not known. rounded to 23 Therefore. This information will be valuable for the physician to determine what he needs to order. 500 ÷ 22 = 22. At present her TDD is 22 units. To get a “ball park” idea the amount of insulin you could use the Rule of 500 (see Chapter IV. increase Lantus by 3 units. Check a glucose level around 3 am to ensure he is not missing hypoglycemia. 2.CASE #4 When switching from intermediate-acting insulin to Lantus.Saskatchewan Insulin Adjustment Module March. reduce the Lantus by 10% or 3 units.8 Therefore.

advise treatment of hypoglycemia and stabilization of blood glucose level before taking insulin and before deciding on the dose. then it will confirm to John that he is using the correct amount of insulin for CHO eaten. . ANSWER . if he agrees to say about 70 grams.1 – 11.Saskatchewan Insulin Adjustment Module March. TDD = 7 + 10 + 32 = 49 500 ÷ 49 = 10.75 This means 1 unit of insulin will drop his blood glucose approximately 1. If John has a history of severe low glucose levels. Or. make a referral to the dietitian.0 13.75. 2009 Page 83 ANSWER . It will be easier to assess the effectiveness of this recommendation if he agrees to use close to the same amount of carbohydrate for a few days. If the results fall between the target of 7-10.75 mmol/L To create a grid the 1. Advise John to check his 2 hr pc noon meal blood glucose levels.1 – 7. If he seems unsure about carbohydrate counting or needs more information/support. Grid using 1 unit will yield a decrease of approximately 2 mmol/L for morning insulin.0 11. .0 > 15. you could set the target glucose level higher. 100 ÷ 57 = 1. So.1 – 13.1 • Insulin Dose 6 7 8 9 10 11 12 Note: As part of client education.CASE #6 First calculate John’s total daily dose TDD = 7+10+8+32 = 57 units Use the rule of 100 as he is using rapid acting insulin.0 7.0* 4. He has the option to add extra carbohydrate at his noon meal to compensate for the extra calories he has lost with the elimination his afternoon snack.1 – 9. for example.CASE #5 Using the Rule of 500 to determine how many grams CHO for each unit of insulin. for example. 3 mmol steps.1 – 15. then he would use 7 units of H pre-noon. to 8 mmol/L. the grid would be as follows: Blood Glucose Range < 4. Some clients may need less than the lowest amount on the grid. could be rounded to up to 2 mmol/L. hypoglycemia unawareness or is nervous about being “too low” you could use a larger range for the dose changes.0 9.2 Therefore. for every 10 grams CHO he would use 1 unit of insulin.

6/1. 2009 Page 84 If John does not want to use a written grid.6 units per kg and it is all basal insulin with no insulin for his meals. .5 to 1. This is about 0.5 11. rounded to 3 Add 3 units to his base dose of 7 = 10 units Humalog to be taken pre-breakfast OR He could use the rounded correction factor of 2 mmol/L drop for 1 unit of insulin 5.0 4. Discuss with Mike his thoughts on the use of rapid/short-acting insulin with meals. If John was using a short-acting insulin.6 Target glucose = 7 Difference = 12.1 – 8. he may be anxious about using these insulins.5 The grid below for short-acting illustrates blood glucose ranges of 1.CASE #7 Mike is currently using a TDD of 48 units of insulin. he would likely gain greater benefit from starting to use pre-meal insulin.6 Divide the difference by his correction factor: 5. So the calculation would be: 85/57 (total daily dose of insulin) = 1.7 = 5. His BMI is 23 so you would not expect insulin resistance and a higher dose needed related to his weight. Supper to bedtime – general lowering. Noon to supper – pattern remains similar (1 elevation by supper.0 7.5 mmol and insulin dose increments of one unit. As he has only used intermediate insulin. round up to 3 additional units added to the base dose of Humalog. the TDD would be divided into 85 instead of 100.6 . Review • • • • current his current patterns in his blood glucose records.1-11.8.2.Saskatchewan Insulin Adjustment Module March. He could increase his doses of N further.0 > 13.0 10. could also suggest Mike check blood glucose 2 hrs pc when pre-meal blood glucose levels come closer to target.5-10. For extra information to guide IDA.1 Insulin Dose 6 7 8 9 10 11 12 ANSWER .6 ÷ 2 = 2.6-13. The overall picture is too high. The usual expected insulin requirement is about 0. but considering his A1c and his only insulin is basal insulin. Blood Glucose Range < 4. although not to target. Highest pattern is fasting with a bedtime to fasting rise.5 8.0 units/kg. he would proceed as follows: Blood glucose = 12. could explore reason). Breakfast to noon – a decrease by noon although not to target.75 = 3.1 – 7.

He may be more comfortable with decreasing it 10% initially until he gains experience with this move. she may need to move her N from supper to bedtime to prolong the action towards morning without risking hypoglycemia with the higher doses. • • • • ANSWER . Since N at supper is already fairly large. if this was lowered. some rapid or short-acting insulin will be required at supper. • Increased fasting blood glucose level – with an average 5 mmol/l rise overnight. round to 2. RNs need to keep current with EDS requirements of the Saskatchewan Drug Plan. With this move. 1 unit of insulin will decrease the glucose level by 2 mmol/L. correlation between evening activity and night-time symptoms? Also. consider moving the N to bedtime. it may assist with noon and other times of the day as a domino effect occurs. 3 a. Milly and her doctor may also consider use of a long-acting insulin analogue as EDS status is now available in Saskatchewan for Lantus 40 40 See Saskatchewan Exception Drug Status Program for current information: http://formulary.gov. She may need to decrease her dose of N when the timing is changed.drugplan.08. she could reduce her evening N to see if the night-time symptoms disappear. Changing the timing of the insulin requires a physician’s order.Saskatchewan Insulin Adjustment Module March.health. You could begin with a conservative estimate of 1 unit for 20 grams of carbohydrate and adjust as needed.CASE #8 Two things suggest that Milly may be having night-time hypoglycemia: the restlessness during the night and “new” higher fasting readings. Also look at the impact of the potentially lower fasting reading on the daytime insulin doses. In your assessment also consider: • What does Milly eat at bedtime – if she does snack o Is the carbohydrate consistent? o How much carbohydrate does she eat? o Does she use a combination of protein and carbohydrate? o Does she sometimes miss an evening snack? o Do any of these variables correlate with the symptoms or high fasting readings? • Is Milly physically active in the daytime (especially later afternoon) or evenings? Is anything different on the nights when Milly is active in the day/evenings – lower prebedtime readings. If the night-time symptoms disappear and the fastings remain elevated. consider the rule of 100 for rapid or 85 for short: 100/48 = 2. Consider with this move the effect on the breakfast to noon blood glucose level pattern. as Mike is ready. 2009 Page 85 Possible choices to manage patterns– these may need to be done in steps.sk.ca/ cited 26 march 2009 . different fasting glucose levels the following mornings. Ideally it would be useful for Milly to test a few glucose readings at bedtime. His insulin grid will change by 2 unit increments. To determine the correction dose of rapid or short-acting insulin. You will need to determine how much of the short or rapid-acting insulin to start to cover the supper carbohydrate intake. A dietitian will be able to help you determine his usual intake. and fasting to see if there is a trend of lower blood glucose overnight. See what this move does however it is likely that Mike will also need to consider using some meal insulin at other times of the day.m.

• • You may need to gradually add in pre-meal short or rapid-acting insulin If he needs short or rapid-acting insulin later. It is likely that Fred would benefit from spreading out his insulin however this will all depend on Fred’s readiness and will likely need to be done in a series of steps. Some options for him to consider: He currently uses 1. 2009 Page 86 ANSWER .Saskatchewan Insulin Adjustment Module March. it may not last long enough to control glucose levels through the night and early morning. he could use a syringe to measure to keep the number of injections at 2 or 3 per day.CASE #9 Consider as you have your discussion with Fred: • What is Fred willing to do? What are his goals for himself? Is he happy with what is happening? Does he have some ideas on what he could do? • Explore his concerns around insulin injections as the options for improving control involving more injections – what does he currently use – syringes. • The N peaks in the afternoon and could cause mid-afternoon hypoglycemia. All of his insulin is basal insulin and it is also being used to cover his meals. . Lower the morning N by 10% every 3-4 days until unexplained low blood glucose levels are eliminated. pens? Injection sites? Technique? Fears he has? The large single morning injection of one insulin may be causing some/all of Fred’s complaints. This would be responsible for the nocturia and the high fasting glucose levels.1 units/kg per day which is more than usual considering he is lean. Split the morning N dose between morning (2/3 of the NPH dose) and at supper or bedtime (⅓ of the NPH dose). • Even though the dose of N is large. some N will need to be added at supper. It is likely that at the same time. as Fred is ready. Review his usual food intake and activity habits. The first priority is to reduce the frequency of lows in the afternoon by: • increasing the carbohydrate taken in the afternoon • reducing activity • decreasing insulin dose in the morning Assume Fred is happy with his carbohydrate intake and activity pattern.

When he has a meal planning method. Remember he is used to taking insulin twice daily and you may need to approach change gradually. may be to added. Glucose levels for the remainder of the day are usually above target and the blood glucose level does rise from supper to bedtime. . Depending on his response to proposed changes and options. the pattern of the glucose levels can be reviewed again. The N may need to be reduced as the HS blood glucose levels will likely improve.Saskatchewan Insulin Adjustment Module March. He could consider moving his supper N to bedtime or using extended longacting insulin analogue. one choice. Likely the best option for Joe to consider will be pre-meal rapid acting insulin to handle the meal time carbohydrate. one insulin at a time. it would be beneficial for Joe to see a dietitian.#10 The pattern of Joe’s glucose readings shows the supper N lasts until the following morning with fasting glucose reading at or below the recommended target of 4-7 mmol/L. Before he changes his insulin. He can decide whether or not he wants to use an approach of consistent carbohydrate or learn carbohydrate counting. 2009 Page 87 ANSWER CASE . initially. such as adding R to his supper insulin dose.

medium 1 cup skim milk Oatmeal granola bar Meat or fish about 3 ounces 1 cup potatoes Broccoli . jam (regular) 6 ounces unsweetened orange juice At work – sitting Orange Sandwich: 2 slices of bread.5 TOTAL CHO PER MEAL/SNACK 62.4 Two hour BG: Activity Snack Time: BG Lunch Time: 1200 hrs BG: Note answers are included in the table. 1 cup 1 slice bread.Saskatchewan Insulin Adjustment Module March. whole grain 2 slices cheese or ½ cup salmon 2 tsp margarine lettuce and tomato slice Apple.5 .5 15 30 15 60 15 15 28 0g 30g 0g 15g 15g 7. FOOD EATEN 2 toast. whole wheat 2 tsp. 2009 Page 88 ANSWER – CASE #11 MEAL Basal Insulin Breakfast Time: 0615 hrs BG: 4. orange or banana. skim w artificial sweetener.5g 28 Snack Time: BG Supper Time: BG: 67. small # grams of carbs 30 10 22. ¾ cup ½ banana. whole grain yogurt.

2 tsp. orange or banana 1 cup chocolate milk # grams of carbs 30 10 15 55 INSULIN TAKEN 0 Meal Bolus: Correction: 12 TOTAL Taken: 12 15 Meal Bolus: Correction: 10 30 TOTAL Taken: 10 15 30 75 Snack Time: BG 12.m.8 Activity Snack Time: BG Lunch Time: 1200 hrs BG: 5.4 Two hour BG: 9.5 97.7 (supper) 0:15 (bedtime) Answered continued on next page .5 Meal Bolus: Correction: 10 TOTAL Taken: 10 2 hour BG: 13. ¾ cup ½ banana.5 (lunch) 1: 9. skim w artificial sweetener.7 1 apple Lantus 32 units 15 0 Insulin:carbohydrate Insulin:carbohydrate Insulin:carbohydrate Insulin:carbohydrate ratio ratio ratio ratio is is is is 12 10 10 _0 units units units units for for for for 55 75 75 15 grams grams grams grams of of of of carbohydrate carbohydrate carbohydrate carbohydrate or or or or 1:_5 (breakfast) 1:7.6 Meat or fish about 3 ounces 1 cup potatoes corn. BG: 6. jam (regular) ½ grapefruit At work – sitting 1 cup carrot & celery sticks 2 tbsp low fat dip Sandwich: 2 slices of bread 2 slices cheese or ½ cup salmon 2 tsp margarine lettuce and tomato Apple.3 FOOD EATEN 2 toast.6 Basal Insulin Bedtime Time: 10 p.3 Supper Time: BG: 13. 2009 Page 89 ANSWER – CASE #12 MEAL Basal Insulin Breakfast Time: 0615 hrs BG: 4. 1 cup 1 slice bread yogurt. small 0 30 30 15 15 7.Saskatchewan Insulin Adjustment Module March.

ANSWER – CASE #13 His TDD is 70 units. BG: 1 apple Lantus 38 units 15 0 . The ratio may be appropriate if his pre-supper readings were consistently at target. he would calculate the correction by subtracting his target glucose level (7) from his current reading and then dividing by the correction factor. he may need to adjust the insulin:CHO ratio to 1:8 or 1:5.8 FOOD EATEN Meat or fish about 3 ounces 1 cup rice. • If the pc noon and pre-supper readings are at target.4 This means that 1 unit of insulin will lower the blood glucose by 1. 10. he may need some basal insulin fasting. small # grams of carbs 0 45 0 15 15 15 7.5 97.4 = 2.7 additional units – this could be rounded to 3 units.8 – 7 = 3.m. The ratio may need to be lowered to 1:5.8 mmol/L.8 mmol above target 3. The insulin:CHO ratio cannot be accurately assessed at present as his pre-supper is already elevated. • First he needs to lower the pc noon reading.8. skim w artificial sweetener. MEAL Supper Time: BG: 10. 2009 Page 90 The insulin:CHO ratio seems appropriate for breakfast as the pc reading is 9.5 INSULIN TAKEN Meal Bolus: 10 Correction: 3 TOTAL Taken: 13 2 hour BG: Basal Insulin Bedtime Time: 10 p. The rule of 100 applies to use of rapid-acting insulin. The insulin:CHO ratio seems too high for noon as his pc reading is 12. but the pc supper bg remains above target. cooked salad corn. ¾ cup ½ banana. 100 ÷ 70 = 1.3.Saskatchewan Insulin Adjustment Module March. • If pc noon readings are at target and this does not improve the pre-supper reading. ½ cup 1 slice bread yogurt. brown.8 ÷ 1.4 mmol/L For the pre-supper reading of 10.

beginning at pre-noon. Depending on his bedtime glucose reading.m. If Jeff takes his Novorapid at noon. he should also consider reducing his bedtime Levemir. . assuming a pre-supper glucose of 4-7 mmol/L [see suggested reduction in the Saskatchewan Learning/Procedure Manual]. he many also need to reduce his bedtime Levemir. for example. What does the current dose of NovoMix 30 represent in terms of types of insulins and how many units of each insulin does this dose represent? NovoMix 30 insulin represents a mixture of 30% NovoRapid (Aspart) and 70% aspart protamine crystal. If he needs extra carbohydrate pre or mid-game. he should take a fast acting carbohydrate choice. he could drop his pre-supper Novorapid by 50% or 6 units.Saskatchewan Insulin Adjustment Module March. he may need additional carbohydrate at bedtime and he may need to consider also checking a glucose at 3 a. experience with unrecognized hypoglycemia and previous medical history. He could be advised to check his blood glucose levels: • Pre-supper • Pre-practice • Mid point in the practice • Post practice • Bedtime • Following morning As there is the possibility of a carry over effect of the evening physical activity. ANSWER – CASE #15 What target glucose level would you set with Karen and her physician? Due to her age. Saturday afternoon game. 2009 Page 91 ANSWER – CASE # 14 Monday evening practices: The practices will occur during the action time of supper dose of Novorapid. until he learns more about the effects of the practice on his night-time glucose. he will be past the peak action time by game time. Post game he will need to consider reducing his pre-supper NR because of the carry over effect of the exercise. the recommended target pre-meal glucose level could be raised from 4-7 mmol/L to. 6-8 mmol/L or slightly higher depending on your assessment of her ability to manage diabetes and recognize hypoglycemia. Depending on the pre-game level he may need extra CHO then and/or at the mid-point in the game.m. about 20% or 2 units for the first game. 28 units of NovoMix 30 insulin is . 2:30 to 4:30 p. initially by 20% (mid-point in the suggested reduction range of 10-30%). Depending on his experience with post-activity glucose levels. It would be advisable for him to carry extra CHO such as juice and a choice from grains/starches food group. As he wants to lose weight. As the activity is 120 minutes. He would check his glucose level at the same times as he did for practices. He could make a modest reduction in the pre-noon NR. it would be preferable to decrease insulin instead of eating extra food. The aspart protamine crystal has an activity profile similar to NPH. He could begin with a 20% reduction. living alone.

if any.6 units of intermediate-acting insulin 16 units of NovoMix 30 insulin is • 5 units of rapid-acting insulin • 11 units of intermediate-acting insulin • • What changes.6).m.4 units of rapid-acting insulin 19. 2009 Page 92 8.5 units intermediate-acting (previously 19. 20/80) or splitting the insulins into their individual components. Reinforce the consistency of her afternoon snack. Ask Karen to check a couple of glucose levels at ~3 a. consideration may need to be given to using a different pre-mix (for example. If the 3 a.. overall health and symptoms of hypo or hyperglycemia. glucose levels are not too low and the fasting glucose levels remain elevated.5 units rapid (previously 8. target blood glucose levels for her age. ANSWER CASE #16 The only glucose levels which are above target now are the fasting ones. then the pattern of glucose readings can be re-assessed. This would translate to 7. As bedtime glucose levels are “at target” continue with the amount of rapid-acting insulin from the NovoMix30 dose (30% of 16 units = 5 units pre-supper). NOTE: This would require 3 different insulins which may be confusing to the client.Saskatchewan Insulin Adjustment Module March. 10% is about 3 units or a reduction to 25 units. In order to decide the best action you will need to consider the client’s ability and willingness to manage the proposed changes. so a 10% minimum reduction in the morning NovoMix 30 would be recommended. • Ask her to test her blood glucose level at 0300 a few times to ensure hypoglycemia is not being missed. Before making any changes to insulin: • Review the amount and type of food she is eating at bedtime. Assuming there are no issues with either of the above.4) and 17. 2.m. Move the remainder of the dose. (70% of 16 units = 11 units intermediate-acting insulin. Novolin NPH) to bedtime. would you recommend to her current medications? Current glucose pattern shows: • Fasting – above target • Noon – at or close to target • Supper – too low • Bedtime – at target The first consideration is always prevention of hypoglycemia. Change to Levemir or Lantus at HS with short-acting insulin (Novolin Toronto or Humulin R) at breakfast and supper. What might you consider if the first issue or problem you identify is not resolved? In some cases. The long-acting basal insulin analogue would decrease the . increase the bedtime NPH by 10%. If the above change increases the pre-supper readings to target. you could consider the following IDA: 1.

2009 Page 93 risk of nocturnal hypoglycemia but would provide minimal insulin coverage for meals. BUT Karen’s blood glucose levels decrease from breakfast to lunch. Change to Levemir or Lantus at HS (same calculation as above) with rapid-acting insulin (NovoRapid or Humalog) with all meals. You might suggest a dietitian consult if there are food issues to be addressed. Dose calculations would be as follows: • Levemir or Lantus = total intermediate dose for the day – 20% of total dose when moving from a BID to OD dose. the morning dose could be decreased by at 2 units to decrease the risk of mid morning hypoglycemia. her emotions)? • a general food intake review paying attention to recent changes. other variables than lack of insulin may be causing the recent elevation in glucose levels. • ask about recent infections If there are no “clues” to improve glucose control in any of the above. • assess her quality of sleep. You might suggest she log her food for about 3 days. • ask Mary to demonstrate her technique with her insulin pen to ensure accuracy.2 (20% reduction in total intermediate dose) = 24.6 + 11. using food to cope. consider the following with Mary: • she is gaining weight – what might be different (food intake and/or activity level. • This regimen would require 4 injections per day with 2 different insulins. • This regimen would require 3 injections per day with 2 different insulins. the morning dose would be 7 units and the supper dose would be 5 units. • review a typical day to assess activity level and routines and possible changes. Also the benefits of rapid-acting insulin on post-meal blood glucose levels in the pre-mix will be lost. Short-acting insulin could provide insulin coverage for all 3 meals with a total of 3 injections per day and 2 types of insulin. • ask Mary to demonstrate her blood glucose monitoring technique.6 = 25 units at HS • Short-acting insulin dose could be the same as in the premix.93 units/kg body weight and although she may have insulin resistance.2 = 30. cooking methods. especially if she has poor food awareness or if she is depressed. ANSWER CASE # 17 Mary is already using 0. • screen for depression. • Because Karen has a fairly consistent carbohydrate intake from day to day. • ask questions to determine if Mary has any symptoms suggestive of hypoglycemia (even though it’s unlikely). a routine dose of insulin with each meal may be an option rather than counting carbohydrates for each meal.Saskatchewan Insulin Adjustment Module March. NOTE: a physician’s order would be needed to implement any of these changes. Therefore to be cautious. Often it is beneficial to try to improve the fasting blood glucose level first. Initiate rapid-acting insulin with meals at 1 unit per 15 grams of carbohydrates. then consider an insulin dose increase. as a food review can be 50% inaccurate. fat intake. food portions.8 – 6. Before making any IDA. 3. Therefore 19. . Therefore.

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ANSWER CASE #18

The first priority will be to eliminate the lows at noon. If these are not related to food or activity changes, then his pre-breakfast insulin grid could be reduced by 1-2 units. Consider that he may feel he cannot eat any more for breakfast and he does not want to add a mid-morning snack. If this change results in elimination of the lows, and high glucose levels persist at 10 p.m. and fasting, he could look at strategies to reduce his bedtime glucose levels, hoping this would also reduce his fasting glucose. He could check his blood glucose about 2 hours after supper to assist in determining the effectiveness of his pre-supper insulin. If levels are rising > 10 mmol/L (if the pre-supper level is at target), then he can increase his pre-supper insulin grid by 2 units. If the post supper glucose level is < 10 and the rise occurs between that time and 10 p.m. then his basal insulin is likely responsible. His bedtime NPH may not be lasting 24 hours. He could consider two options: • Try moving the NPH injection to supper time – this may still leave the fasting glucose levels high. • Starting a small dose of NPH at breakfast to help later evening basal coverage. Make sure he understands how to use the insulin grid as less insulin may be needed prenoon and/or pre-supper insulin to prevent hypoglycemia. With improved fasting blood glucose levels, he may need a further reduction in his pre-breakfast grid to prevent mid-morning or pre-noon hypoglycemia. He may also need to look at the quantity of his evening snacking. If he needs or wants these calories, he may need a small dose of rapidacting insulin at bedtime. To make this change you would need to consult with his physician.

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REFERENCES
Educators are strongly advised to use a core text or reference when learning about insulin and IDA to supplement the module. Two excellent Canadian resources are highlighted in the references.
___Insulin (2009). In Canadian Pharmaceutical Association, Compendium of Pharmaceuticals and Specialties Ottawa, Ontario. Beaser RS, editor. Joslin’s Diabetes Deskbook: A Guide for Primary Care Providers 2nd edition. 2007;Joslin Diabetes Center:Boston. www.joslin.org Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2008 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes. 2008;32(suppl 1):S1-S201. Chapman TM. Insulin Detemir: a review of its use in the management of type 1 and type 2 diabetes mellitus. Drugs 2004;64(22):2577-2595. Davison KM. Eating Disorders and Diabetes: Current Perspectives. Can J Diabetes. 2003;27;1:6273. Insulin. A Clinical Journal for Health Care Professionals. Free online access. www.InsulinJournal.com cited 25 February 2009 Jones H. editor. (2009). Building Competency in Diabetes Education: Advancing Practice. Diabetes Educator Section, Canadian Diabetes Association: Toronto, Ontario. (in press, March 2009) Jones H. editor. (2004). Building Competency in Diabetes Education: The Essentials. Diabetes Educator Section, Canadian Diabetes Association: Toronto, Ontario NOTE: a new edition will be available in 2010. Perkins BA, Riddell MC. Type 1 Diabetes and Exercise: Using the Insulin Pump to Maximum Advantage. Can J Diab. 2006;30(1):72-79 Riddell MC, Perkins BA. Type 1 Diabetes and Vigorous Exercise: Applications of Exercise Physiology to Patient Management. Can J. Diabetes 2006;30(1):63-71 RxFiles cited 25 February 2009. RxFiles is an academic detailing program to assist physicians,
pharmacists and other health care professionals to get excellent and objective drug data. This reference relates to current insulins in Canada. If the resource has been updated since the module was printed, look at www.rxfiles.ca

Saskatchewan Registered Nurses Association. The Registered Nurse Scope of Practice: Guidelines for Nurses Prescribing and/or Distributing Drugs by Transfer of Functions. 1999. To order: http://www.srna.org/practice/resources.php

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Saskatchewan Registered Nurses Association. The Registered Nurse Scope of Practice: Special Nursing Procedures and Nursing Procedures by Transfer of Medical Functions. 1993. To order: http://www.srna.org/practice/resources.php Sclater A. Diabetes in the Elderly: The Geriatrician’s Perspective. Can J Diabetes. 2003;27(2):172175. Swenson K, Brackenridge B. Lispro Insulin for Improved Glucose Control in Obese Patient with Type 2 Diabetes. Diabetes Spectrum. 1998;11(1):13-15. Tibaldi J. Initiating and Intensifying Insulin Therapy in Type 2 Diabetes Mellitus. Am J. Medicine. 2008;121(6A):S20-29. Tibaldi J. Intensifying Treatment in Poorly Controlled Type 2 Diabetes Mellitus: Case Reports. Am J. Medicine. 2008; 121(6A):S30-34. Thompson DM, Kozak SE, Sheps S. Insulin Adjustment by a diabetes nurse educator improves glucose control in insulin-requiring diabetic patients: a randomized trial. CMAJ. 1999;161(8):959-962. White JR, Davis SN, Cooppan R, Davidson MB, Mulcahy K, Manko GA, Nelinson D. Clarifying the Role of Insulin in Type 2 Diabetes Management. Clinical Diabetes. 2001;21(1):14-21.

Registered Nurses may refer clients for pre-pregnancy support and management during pregnancy to one of the clinics below.aspx?cat=3066&id=3120 cited 26 march 2009 2. Sk. SK S7N 0W8 P 655-1571 F 655-6758 E linda.Boyd@rqhealth. Saskatoon Pregnancy Clinic Linda Bachiu. Medical Office Wing 1440-14th Avenue Regina. Inc.0 DIABETES AND PREGNANCY NOTE: The Saskatchewan template for Transfer of Medical Function does not include management of diabetes during pregnancy. Insulin Dose Adjustment: An Online Education Program for Parents of Children with Diabetes 16 february 2007. Children’s Hospital.Saskatchewan Insulin Adjustment Module March.bachiu@saskatoonhealthregion.com (USA) a patient insulin adjustment workbook which may be helpful in explaining concepts of IDA.com/us/hcp/main. Diabetes Nurse Educator Diabetes Education Centre Royal University Hospital 103 Hospital Drive Saskatoon. http://www. B. Eli Lilly Canada. (2008).bddiabetes.0 CLIENT HANDOUTS ON INSULIN/INSULIN ADJUSTMENT Husband A.ca .htm cited 26 march 2009 BD Diabetes. http://www. The content may assist care providers to develop explanations and client guidelines. it demonstrates useful ways to explain IDA to anyone.bcchildrens.ca Regina Pregnancy Clinic Marion Boyd Metabolic and Diabetes Education Centre 2nd floor. S4P 0W5 P 766-4540 F 766-4178 E Marion.ca/Services/SpecializedPediatrics/EndocrinologyDiabetesUnit/ForF amilies/InsulinDoseAdjustment. 2009 Page 97 ADDITIONAL RESOURCES 1. NOTE: all the examples are in mg% for blood glucose values and it would not be appropriate as a Canadian handout as it may cause confusion. Juggling for Control.C. Although this resource is for pediatrics.

Chair. BSP. review or implementation of the Transfer of Medical Function for Insulin Dose Adjustment. 2001. Five Hills Health Region. Diabetologist. 2001. RN. BSP. reviewer 2005. RN. 2005. 2005. Working Group 2009 and Provincial Diabetes Advisory Body Gideon Dala.2005. RN. Karen Butler. Drug Plan and Extended Benefits Branch. 2009 Working Group Heather Nichol. MD. Saskatoon Health Region. RN. Regina Qu’Appelle Health Region. RN. Saskatoon Health Region Betty Deschamps. Kelsey Trail Health Region.Saskatchewan Insulin Adjustment Module March. 2009 Working Group Karie Witte. development. Saskatoon Health Region. LiveWell Diabetes Program. 2001. Kelsey Trail Health Region. 2009 Working Group Carol Straub. RD. Saskatchewan Health. Saskatoon Health Region. RN. 2001. Program Coordinator. 2009 Working Group Nola Kornder. 2009 Page 98 ACKNOWLEDGEMENTS Saskatchewan Health would like to thank the following individuals who were involved as either committee members or others who were involved in the design. 2005 Working Group . 2005. Saskatchewan Registered Nurses’ Association Carlene Schmaltz. 2005. 2009 Working Group Bev Kernohan. RxFiles Greg Riehl. RN. 2001 and 2005 Working Group Judi Whiting. 2009 Working Group Arlene Kuntz. RN. RD. Nursing Practice Advisor. British Columbia Registered Nurses Insulin Dose Adjustment Working Group Loren Regier. Heartland Health Region.

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