Practical Diabetes

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lgorithms for Adjustment of Insulin Dosage by Patients Who Monitor Blood Glucose
JAY S. SKYLER, DENISE L. SKYLER, DEBORAH E. SEIGLER, AND MARY JO O'SULLIVAN

Patient self-monitoring of blood glucose is a useful adjuvant to diabetes therapy that facilitates improved glycemic control when used as part of an intensive diabetes management program that includes careful balancing of food intake, energy expenditure, and insulin dosage. This paper describes an approach by which patient-determined blood glucose measurements may be used to attain and maintain glycemic control. The patient is provided with a set of algorithms by which minor adjustments in a therapeutic routine may be made to achieve the desired control, DIABETES CARE 4-. 3H-318, MARCH- APRIL 1981.
atient self-monitoring of home blood glucose has achieved increased acceptance as a useful technique to monitor diabetic control.1"17 It obviates the vagaries of urine testing and permits documentation of blood glucose levels within the physiologic range, in which glycosuria should not be present. Many physicians and patients have found that self-monitoring of blood glucose facilitates the attainment of improved diabetic control, provided all elements of the treatment plan are intensively applied. For insulin-dependent diabetes mellitus (IDDM), this entails the careful balancing of food intake, serving as an energy source, with energy expenditure in daily activity, and with an insulin dose designed to achieve efficient energy utilization while avoiding the extremes of either hyperglycemia or hypoglycemia. To maintain balance of the three components of therapy —food intake, activity, and insulin dosage—it is necessary for the patient to respond to alterations in one component by a modification of at least one other component. Since this involves all food intake and all daily activity, the patient must be able to make alterations in his/her treatment regimen whenever appropriate. Measurement of blood glucose by the patient not only permits monitoring of the balance between food, activity, and insulin; it also provides the patient a tool by which he/she may measure the impact of various alterations in the treatment regimen. This article outlines our approach to instructing patients with IDDM in making modifications in their management program, particularly in their insulin dosages. It is an extension of our previously described approach to insulin dosage alterations in patients monitoring balance by urine glucose and ketone determinations and clinical cues.18 The algorithms described herein have been refined from previous versions based on our experience with patients using these regimens. Nevertheless, each may require adaptation to meet the needs of individual patients.
DEFINITIONS

Once balance has been achieved, it should be possible to maintain that balance by keeping food intake, energy expenditure, and insulin dosage relatively constant from day to day. This assumes the absence of intercurrent illness or psychological stress. In such circumstances, the insulin dosage that the patient requires to maintain glycemic control is the basal insulin dose. The basal insulin dose should control the usual postprandial blood glucose excursions in a patient with a stable food and activity pattern. The basal insulin dose may vary during specific times of the week (e.g., with increased activity on weekends), month (e.g., with menses), or year (e.g., summer versus winter); it may also change as the patient's food intake or activity pattern changes. In the attainment of refinements in control, and in response to unexplainable fluctuations in control, it is necessary to make minor changes in the treatment regimen. This is easily accomplished by altering the basal insulin dose. These modifications in the basal insulin dose are termed adjustments. They presuppose that the patient follows a stable food and activity pattern, is in good health, and is free from unusual stress. In contrast to adjustments made in the basal insulin dosage, supplemental insulin ("supplements") is additional insulin used in circumstances in which the food or activity pattern is not stable or when there is intercurrent illness or

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Such anticipatory supplements are administered before expected hyperglycemia (e. SKYLER AND ASSOCIATES other stress. outlining those cues requiring intervention and indicating the appropriate response to such cues. Each insulin component may be altered individually in conjunction with nutritional intake and energy expenditure during the relevant time period. supplements are temporary insulin doses. For labile patients.. additional insulin used to prevent hyperglycemia. 3. 312 DIABETES CARE. Rapidly absorbed simple sugars (causing rapid increments in blood glucose) should be omitted from regular meal planning. weekend versus weekday. additional insulin used to overcome unusual hyperglycemia that is administered in response to unanticipated blood glucose elevations and during periods of acute loss of control (e.INSULIN DOSAGE ADJUSTMENT ALGORITHMS/JAY S. (4) Blood glucose must be regularly measured by the patient to monitor therapy. Then.. perhaps during the night). This division of the day into four separate time periods provides both for maximum flexibility and maximum ease of understanding for patient self-regulation. The meal plan is best derived from a careful dietary history. Unusual exercise requires appropriate compensatory changes in food intake and/or insulin dosage.g. This may be accomplished in groups. L. before an unusually large meal at a dinner party).g. FIG. Algorithms for altering this regimen are outlined in Table I. with intercurrent illness). but would be similar to those in Table 1. Schematic representation of idealized periods of insulin effect for a split-and-mixed insulin regimen in which the evening intermediate-acting insulin is delayed until bedtime. Figures 1-4 depict four multiple component insulin regimens that we have found useful. The other type is anticipatory supplements. When a relatively stable pattern emerges. or during a period of stabilization in any patient. supper. bedtime. Each time period may be monitored by blood glucose determinations 1 or 2 h after the consumption of the meal that initiates the time period. we recommend that fasting blood glucose be determined daily with measurement of one to three other samples most days. Figure 5 depicts an example of a flow sheet on which a patient can record the results of these blood glucose measurements.g. along with insulin dosage and other relevant information. (3) Insulin must be used in a multiple component regimen. REG. 30 min before meal. morning REG afternoon NPH evening REG light NPH IB IS + H S FIG. VOL. We have found it useful to categorize insulin supplements into two types. bedtime snack. and supper. In all of these regimens. and measurement of a complete profile (seven or more determinations) at least once weekly.. lunch. This results in peak insulin action coinciding with fasting blood glucose. Timing of meals should be such to avoid hypoglycemia.org/ by guest on January 25. and NPH. To aid patients in the use of insulin dose adjustments and supplemental insulin doses. psychological counseling of the patient and family may be necessary or desirable to lessen stresses that interfere with glycemic control. INTENSIVE CONVENTIONAL THERAPY •-. These include the following: (1) An activity plan should be relatively constant if food and insulin are to be kept constant. I. and may be conducted by a knowlmorning REG afternoon REG evening REG night NPH |B |B L fS HS |B {L fS f HS |B FIG. Algorithms for altering this regimen are outlined in Table I. Different activity plans (e. regular or short-acting insulin effect. each component of insulin is assumed to have major action during one particular time pemorning REG afternoon NPH evening REG night NPH riod of the day. By definition. time of insulin injection. (2) Food intake (basic meal plan) should be relatively consistent from day to day in terms of calories and proportions of nutrients. we recommend seven or more blood glucose determinations daily (preprandial. 2. 4 NO. Deviations from the basic meal plan require appropriate anticipatory or compensatory changes in insulin dosage and/or activity routine. so that one component of insulin coincides with each period of the day and each meal. S. Symbols used in Figures 1-4 are: B. summer versus winter) may require different food intake and/or insulin dosage. 2014 . In addition to standard diabetic education. which is measured and which should be the glucose nadir. The first of these types is compensatory supplements. Intermediate' acting insulin is given at bedtime to assure duration of action through the night. with "pre-lunch regular" being substituted for "morning NPH" throughout. The attainment of improved diabetic control requires that all elements of the treatment plan be intensively applied. the frequency of monitoring may be reduced. 2. and at the close of that time period (preprandial the next meal). lunch. and so that peak effect coincides with fasting blood glucose. postprandial. breakfast. HS. MARCH-APRIL 1981 Downloaded from http://care. intermediate-acting insulin effect. Schematic representation of idealized periods of insulin effect for a multiple dosage regimen providing four insulin injections daily. (5) Intensive education and motivation of the patient is necessary to attain improved glycemic control.diabetesjournals. Additional blood glucoses may be desirable surrounding extra food consumption or unusual activity. Schematic representation of idealized periods of insulin effect for a "split-and-mixed" insulin regimen. Algorithms for this regimen are not shown. Arrow. Shortacting insulin is given before breakfast. then. we provide them with a predetermined plan of algorithms.

In the interim.6 U/kg/day in pregnant patients during the first 20 wk of gestation. insulin dosages. Example of a flow sheet for patient recording of blood and/or urine glucose results.19"20 INITIATION OF INTENSIVE CONVENTIONAL THERAPY T he first priority in initiating an intensive conventional regimen of diabetes management is to assure that the patient's routine activity program is relatively constant and to develop a basic meal plan appropriate for usual activity. lunch. and give short-acting insulin before breakfast.7 U/kg/day in patients with established diabetes previously treated with 0. the dose is reduced by at least 2025% at the time of beginning an intensive conventional program with a multiple component insulin regimen. SKYLER AND ASSOCIATES •i a «s HS i FIG. and (4) 0.org/ by guest on January 25.9 U/kg/day. requirements may be less. before altering the basal insulin dose. 6.I0-. Although the figure depicts the ultralente being mixed with the morning regular insulin. relatively peakless ultralente insulin. In starting use of insulin in an intensive conventional therapy program. and onehalf is given as intermediate-acting insulin either mixed with short-acting insulin before supper (as in Figure 1) or as a separate dose at bedtime (as in Figure 2). (6) Glycosylated hemoglobin should be measured every 4 — 8 wk to document the control attained. For established patients previously treated with greater than 0. Sugar and acetone may be recorded preprandially if blood glucose determination is not done. For the multiple component regimens depicted in Figures 1-4. In all circumstances.e. Alnr + | 1 ! w 1 I t •t I ADJUSTMENTS OF INSULIN DOSE Iftailin I FIG. 4 NO. and any supplemental insulin used.. edgeable diabetes unit staff. For the regimen shown in Figure 3. both to reduce the total volume of injection and to provide smoother action. we have empirically found the following initial distributions of insulin to be generally useful. one-quarter of the total daily dose is given in each of the four injections: short-acting insulin before breakfast. we initially use 40% of the total daily dose as long-acting ultralente insulin. and any hypoglycemic episodes. If the prerequisites have been met. at each time interval. unless it obviously is inadequate. Prerequisites. Adjustments for hyperglycemia.7-0. and intermediate-acting insulin at bedtime.diabetesjournals. 2. it is generally safe to use the following total daily doses: (1) 0. Adjustments of the basal insulin dose assume the absence of intercurrent illness or other stress. When glycemic control is outside of the target range selected for the patient. given in equal amounts (20% of the total daily dose before each meal). Each patient will then alter the various components individually to attain the desired control.5-1. increases in basal insulin dose (i. and supper. Moreover. This is accomplished by use of the algorithms described in this paper. particularly during the period of initial stabilization. an appropriate insulin regimen can be developed. the patient should be assured that alterations in food intake or activity regimen cannot explain the blood glucose findings. dosage requirement may increase markedly. Once activity and food intake are stable and relatively consistent. the patient's previous insulin regimen may be continued. or later. adjustments are made in the basal insulin dose. (3) 0. Satisfactory blood glucose monitoring techniques should be assured and verified before beginning patient-initiated alterations in insulin dosage.0 HINE AND BLOOD GLUCOSE TESTS BREAKFAST INSULIU Until Suppei EXPLANATIONS Bed I Ounrt AM B e Ti™ | K «»™' U per kg weight per day. as outlined below. The morning prebreakfast dose is divided as one-third short-acting insulin and twothirds intermediate-acting insulin. Insulin is initially distributed among the various components of a multiple component regimen arbitrarily. our preference is to provide half of the total ultralente dosage mixed with the pre-supper regular insulin. in the absence of intercurrent infection or other periods of instability. alterations in daily routine. For the regimen shown in Figure 4. During periods of intercurrent illness. lunch. Algorithms for altering this regimen are outlined in Table 2.9 U/kg/day. intermediate-acting dosage (I). In most well-controlled IDDM patients within 20% of their ideal body weight. The patient may begin blood glucose monitoring simultaneous with initiation of review of the activity and food plans. 2014 .7 U/kg/day. upward adjustments) may be made for hyperglycemia as evidenced by blood glucose levels in excess of the target range (Tables 1 DIABETES CARE. Schematic representation of idealized periods of insulin effect for a multiple dosage regimen providing preprandial short-acting insulin and basal insulin as long-acting. we initially use approximately twothirds of the total daily dose in the morning and one-third of the total daily dose in the evening. For established patients previously treated with less than 0. insulin dose requirements on a multiple component regimen will approximate 0. the application of intensive conventional therapy will require frequent contact between the patient and diabetes unit staff. and supper.4 U/kg/day during the "honeymoon" period. For the regimens shown in Figures 1 and 2. VOL. 4. their previous dose is used. (2) 0.INSULIN DOSAGE ADJUSTMENT ALGORITHMS/JAY S. These distributions are empirically derived from the average distribution requirements of other patients.5 U/kg/day in newly diagnosed patients. During the period of relative remission ("honeymoon" period). MARCH-APRIL 1981 313 Downloaded from http://care. Insulin columns include room for recording short-acting dosage (S). One-half of the evening dose is given as short-acting insulin before supper. 5.

The evening short-acting regular insulin has major action between supper and bedtime. hypoglycemia. consult your doctor or clinician.diabetesjournals. but less than 105 mg/dl before bedtime snack. If blood glucose 2 h after lunch is consistently greater than 150 mg/dl AND blood glucose before supper is less than 105 mg/dl. dose changes should not exceed 1 U in any increment. glycemic control may gradually be attained. our algorithms preclude the patient making an adjustment on the basis of postprandial excess if the blood glucose value before the next meal is already in the "ideal" range. if blood glucose on arising OR before supper is greater than 140 mg/dl. If blood glucose on arising OR before supper is greater than 200 mg/dl. (Protamine zinc insulin cannot be used in the regimen shown in Figure 4 because it often has a nocturnal peak. This helps obviate adjustments being made for random variations in blood glucose. should be approximately 1 U of insulin for every 30-40 mg/dl that glucose differs from the target level up to a maximum of 4 U in one increment. consult your doctor or clinician. During initial stabilization. and its effect is reflected in the blood glucose test results on arising the next morning. If fasting blood glucose on arising is less than 60 mg/dl. for patients greater than 40 kg in weight. We advise patients to increase only one insulin component at a time. particularly if there are marked excursions in glycemia. VOL. Record the supplement in the supplement column so that you do not accidentally change the basal dose of regular insulin. The magnitude of dose increment. 2. take an extra 2 . It may be desirable to alter other components of the regimen (i. OR if you have a hypoglycemic reaction between breakfast and lunch. For patients weighing less than 40 kg in weight. consult your doctor or clinician. OR if you have a hypoglycemic reaction between lunch and supper. increase your evening regular insulin by 1 — 2 U. Undetected hypoglycemia is most likely with nocturnal hypoglycemia. If blood glucose 2 h after lunch is greater than 150 mg/dl. If blood glucose 2 h after breakfast is greater than 150 mg/dl OR if blood glucose before lunch is greater than 130 mg/dl for 2 days in a row. starting with the prebreakfast short-acting insulin. Caution must be exerted to avoid inadvertently increasing insulin dosage in response to rebound hyperglycemia that follows hypoglycemia (Somogyi reactions). If blood glucose after supper OR at bedtime is less than 60 mg/dl. reduce your morning NPH insulin by 1 — 2 U. reduce your evening regular insulin by 1-2 U. and hence untreated. 4 NO. In addition. Blood sugars Ideal Fasting Before meals After meals (1 h) After meals (2 h) 60-90 mg/dl 60-105 mg/dl 140 mg/dl or less 120 mg/dl or less Acceptable 60-130 mg/dl 60-130 mg/dl 180 mg/dl or less 150 mg/dl or less your morning NPH insulin by 1-2 U. we ask that the patient consult his/her physician or clinician. change timing of injection) rather than adjusting the insulin dose. increase and 2). If blood glucose 2 h after supper is greater than 150 mg/dl. If blood glucose after breakfast OR before lunch is less than 60 mg/dl.) 314 DIABETES CARE. If blood sugar 2 h after breakfast is greater than 150 mg/dl. although that may still be the action chosen. Hyperglycemia (high blood sugar) not explained by unusual diet/exercise/ insulin If fasting blood glucose on arising is greater than 130 mg/dl for 2 days in a row.INSULIN DOSAGE ADJUSTMENT ALGORITHMS/JAY S. In that case. One advantage of evening intermediate-acting insulin being administered at bedtime (as in Figures 2 and 3) rather than before supper (as in Figure 1) is that peak action then coincides with fasting blood glucose. 2014 . but less than 105 mg/dl before lunch.21"22 Rebound hyperglycemia most often occurs if there is unrecognized. If blood glucose 2 h after supper is greater than 150 mg/dl.4 U of regular insulin as a supplement at that time. take an extra 1-2 U of regular insulin as a supplement at that time. and its effect is reflected in the blood glucose test results after breakfast and before lunch. this should be the component controlling fasting blood glucose. our algorithms provide that hyperglycemia be evident for at least 2 days before an incremental adjustment is made. After fasting hyperglycemia is corrected. In this manner. OR if you have a hypoglycemic reaction between supper and bedtime. The morning intermediate-acting NPH insulin has major action between lunch and supper. The evening or bedtime intermediate-acting NPH insulin has major action overnight. increase your evening NPH insulin by 1 — 2 U. rather than occurring in the middle of the night while the patient sleeps. Adjustments may be made if either there is excess postprandial glycemia or if the blood glucose has not returned to the "acceptable" range before the next meal. OR if blood glucose at bedtime is greater than 130 mg/dl for 2 days in a row. the patient can sequentially adjust the other insulin components. The essentially peakless ultralente insulin also is unlikely to induce nocturnal hypoglycemia.e. which is measured. reduce your evening NPH insulin by 1-2 U. increase your morning regular insulin by 1-2 U. The patient should wait 2—3 days between dose increments. Supplements In addition. If blood glucose after lunch OR before supper is less than 60 mg/dl. OR if blood glucose before supper is greater than 130 mg/dl for 2 days in a row. OR if there is evidence of hypoglycemic reactions occurring overnight.. and its effect is reflected in the blood glucose test results after lunch and before supper. SKYLER AND ASSOCIATES TABLE 1 Algorithms for adjusting insulin doses using a "split-and-mixed" insulin dosage regimen and patient monitoring of blood glucose Assumptions The morning short-acting regular insulin has major action between breakfast and lunch. MARCH-APRIL 1981 Downloaded from http://care. reduce your morning regular insulin by 1 — 2 U. Hypoglycemia (low blood sugar) not explained by unusual diet/exercise/ insulin Prevent insulin reactions by eating meals and snacks on time. However.org/ by guest on January 25. and its effect is reflected in the blood glucose test results after supper and at bedtime.

and 4:00 a. increase your pre-supper regular insulin by 1-2 U.g.m. and its effect is reflected in the blood glucose test: results after breakfast and before lunch. reduce your prelunch regular insulin by 1-2 U.24 When hypoglycemia is documented. This may be done over several nights and may include staggering the timing of these measurements (e.m.g. one night. the condition should be treated by consumption of rapidly absorbed simple sugar (approximately 10 g). Supplements In addition. reduce your ultralente insulin by 1-2 U. 3:00 a. and hypothermia. sugar cubes wrapped in foil). thus obviating apparent rebound from occurring as a consequence of cessation of insulin effect. These regimens also assure sustained insulin availability through the night. Other clues are bad dreams or nightmares. If blood glucose after supper OR at bedtime is less than 60 mg/dl. consult your doctor or clinician. reduce your morning regular insulin by 1-2 U. soaked bed sheets). Rebound hyperglycemia after nocturnal hypoglycemia may be suspected by morning ketonuria (ketosis also may occur as a consequence of the counterregulatory surge that follows untreated hypoglycemia) with blood glucose less than 250 mg/dl. we recommend that patients try to verify hypoglycemia by determining their blood glucose.g. Blood sugars Ideal Fasting Before meals After meals (1 h) After meals (2 h) 60-90 mg/dl 60-105 mg/dl 140 mg/dl or less 120 mg/dl or less Acceptable 60-130 mg/dl 60-130 mg/dl 180 mg/dl or less 150 mg/dl or less If blood glucose 2 h after lunch is consistently greater than 150 mg/dl AND blood glucose before supper is less than 105 mg/dl. It also helps patients previously uncontrolled to adapt to lower ambient levels of glycemia without imposing additional calories for symptoms triggered by counterregulatory hormone release occurring without true hypoglycemia. If blood glucose after lunch OR before supper is less than 60 mg/dl.m. It is surprising how rare the rebound phenomenon becomes when an intensive conventional therapy program is used as outlined herein. the next night. The pre-lunch regular insulin has major action between lunch and supper. consult your doctor or clinician. and its effect is reflected in the blood glucose test results after supper and at bedtime. evidence of nocturnal sweating (e.. OR if you have a hypoglycemic reaction between lunch and supper. and its effect is primarily reflected in the fasting blood glucose. In response to hypo- glycemic symptoms. 2. If meal time is more than 1 h away. take an extra 1-2 U of regular insulin as a supplement at that time. If blood glucose 2 h after supper is greater than 150 mg/dl. OR if you have a hypoglycemic reaction between supper and bedtime. This obviates attributing to hypoglycemia symptoms occurring for some other reason (e. 2014 . If hyperglycemia was indeed a consequence of insulin deficiency. It is generally safer to assume rebound and reduce insulin dosage. anxiety). abdominal pain or headache. Record the supplement in the supplement column so that you do not accidentally change the basal dose of regular insulin. OR if blood glucose at bedtime is greater than 130 mg/dl for 2 days in a row. if one of the regimens shown in Figures 2—4 is selected. presumably because the magnitude of glycemic excur- sions is lessened. increase your pre-lunch regular insulin by 1-2 U. Patients should always have available with them an acceptable source of sugar for this purpose (e. SKYLER AND ASSOCIATES TABLE 2 Algorithms for adjusting insulin doses using an ultralente/3-dose regular insulin regimen and patient monitoring of blood glucose Assumptions The ultralente insulin provides a background basal dosage of insulin. Hypoglycemia (low blood sugar) not explained by unusual diet/exercise/ insulin Prevent insulin reactions by eating meals and snacks on time. OR if you have a hypoglycemic reaction between breakfast and lunch. consult your doctor or clinician. but less than 105 mg/dl before lunch..org/ by guest on January 25. the patient should awaken and obtain blood glucose determinations during the night. or if blood glucose determination cannot be obtained and hypoglycemic symptoms occur. OR if there is evidence of hypoglycemic reactions occurring overnight. but less than 105 mg/dl before bedtime snack. If blood glucose after breakfast OR before lunch is less than 60 mg/dl. 2:00 a..INSULIN DOSAGE ADJUSTMENT ALGORITHMS/JAY S.diabetesjournals. VOL. The morning regular insulin has major action between breakfast and lunch. 4 NO. If blood glucose 2 h after supper is greater than 150 mg/dl.23 A djustments for hypoglycemia. take an extra 2—4 U of regular insulin as a supplement at that time.. reduce your presupper regular insulin by 1-2 U. the overnight insulin component should be decreased. if blood glucose on arising OR before supper is greater than 140 mg/dl. When nocturnal hypoglycemia is suspected. increase your ultralente insulin by 1-2 U. When rebound hyperglycemia is suspected after nocturnal hypoglycemia. If fasting blood glucose on arising is less than 60 mg/dl. it will be exacerbated and insulin can be adjusted later. the third night). If blood glucose 2 h after breakfast is greater than 150 mg/dl OR if blood glucose before lunch is greater than 130 mg/dl for 2 days in a row. The pre-supper regular insulin has major action between supper and bedtime. increase your morning regular insulin by 1-2 U. and its effect is reflected in the blood glucose test results after lunch and before supper. morning grumpiness. If blood sugar 2 h after breakfast is greater than 150 mg/dl. If blood glucose 2 h after lunch is greater than 150 mg/dl. additional slowly DIABETES CARE. MARCH-APRIL 1981 315 Downloaded from http://care. Hyperglycemia (high blood sugar) not explained by unusual diet/exercise/ insulin If fasting blood glucose on arising is greater than 130 mg/dl for 2 days in a row. OR if blood glucose before supper is greater than 130 mg/dl for 2 days in a row. If blood glucose on arising OR before supper is greater than 200 mg/dl.g.

In anticipation of that eventuality. After taking two or three supplements. During intercurrent illness. If urine ketones are large and blood glucose is 300 or more.g. however. call the doctor or nurse immediately. during. Anticipatory insulin supplements. Supplemental insulin doses always consist of short-acting insulin. the patient should verify that blood glucose is elevated and calculate the appropriate dosage for the supplement. Compensatory insulin supplements. since other medical action may be necessary or become necessary. add U of regular insulin every 3 . The frequency of supplements need only be preprandially if hyperglycemia does not exceed 250 mg/dl. doubled. the patient should decrease the relevant insulin component by 1-2 U the next day. patients also need to be aware of the food exchange equivalents of soft foods and liquids that may be desirable if nausea supervenes during illness.g. Anticipatory 316 DIABETES CARE. our algorithms provide for dosage decrements when preprandial blood glucose determinations are below our target range and are not otherwise explainable. 0. contact the doctor or nurse to let them know you're having a problem. Supplements (or decrements) are temporary changes in insulin and thus should be recorded in the patient's record separate from the basal insulin dose to avoid confusion with same (Figure 5). Check urines for ketones at the time of each blood glucose measurement. In patients greater than 40 kg in weight. To prevent progressive deterioration of control our algorithms provide for the use of supplemental insulin if the preprandial blood glucose before breakfast or supper exceeds HO mg/dl. although extreme caution should be exercised before giving bedtime supplements in the absence of intercurrent illness. double amount of insulin to be taken.5-1. For blood glucose 200-250 mg/dl before meals or at bedtime. 2. larger and more frequent supplements may be needed (Table 3). Supplements may be repeated as often as every 3-4 h. supplements are proportionately reduced (e. the magnitude of the supplements should be increased.g. Initially.150 mg/dl before meals. SUPPLEMENTAL INSULIN DOSES TABLE 3 Algorithms for compensatory insulin supplements during illness During illness. For patients less than 40 kg in weight. This helps preclude unintentional incorporation of supplements into the basal dose as a result of misinterpretation of the recorded dosage. delayed meal or unusual activity.. VOL. and the outcome monitored by blood glucose determinations before and after the meal for which the anticipatory supplement is taken. add U of regular insulin every 3-4 h.g. For blood glucose 150-200 mg/dl before meals or at bedtime. There is great individual variation in the quantity of anticipatory supplements. e. For blood glucose of 350-400 mg/dl. we also recommend that patients notify their physician if more than two supplements are needed. When ill. that most hypoglycemia episodes are readily explainable by known alterations in food/activity/insulin balance. if hyperglycemia exceeds 250 mg/dl. this may be 10-15 g carbohydrate every 30-45 min during activity. For blood glucose of 250-300 mg/dl. as outlined by the algorithms (Tables 1 and 2). During illness. however. add U of regular insulin. e. For blood glucose of 300-350 mg/dl.. 2014 .diabetesjournals. In addition to symptomatic hypoglycemia. Such a circumstance may be the consumption of an unusually large meal (e. They should appreciate the need to continue taking their basal insulin dose throughout illness. A reasonable starting dose for an anticipatory insulin supplement is 5% of the total daily insulin dosage for a "typical" large meal. before administration of each supplement. add U of regular insulin. Blood glucose should be monitored frequently—before. add U of regular insulin every 3-4 h. They may be given several times each day if necessary. MARCH-APRIL 1981 Downloaded from http://care. The amount will clearly be determined by "trial and error" with a dose selected for a particular amount of excess food. 4 NO. we routinely provide patients with anti-nauseants and with anti-emetic suppositories for use during intercurrent illness. Our initial supplements during illness are. we use approximately 1-2 U of insulin for every 30-50 mg/dl that glucose exceeds the target range. with intercurrent illness). COMPENSATIONS FOR UNUSUAL EXERCISE During activity that is not part of the patient's usual daily routine. compensatory insulin supplements are used to overcome unusual hyperglycemia and are administered in response to unanticipated blood glucose elevations and during periods of acute loss of control (e. If the hypoglycemic episode is not explainable by there having been an alteration in food intake or activity.. take extra regular insulin according to the following schedule: For blood glucose 120. If glycemia is deteriorating despite the use of supplemental insulin. and after exercise—to determine the effectiveness of this intervention. we suggest that compensation be made as extra food to provide an energy source for the increased energy expended. at a dinner party) where there is not expected to be a compensatory increase in activity. SKYLER AND ASSOCIATES absorbed food (complex carbohydrate and/or protein) should be consumed..org/ by guest on January 25.g. It should be noted. add U of regular insulin. as necessary. and are administered before expected hyperglycemia outside the target range. Moreover. Supplemental insulin may be used either to compensate for unusual hyperglycemia or in anticipation of same. be sure to drink plenty of fluids—more than you think you need. approximately 1-2 U of insulin for every 30-50 mg/dl that glucose exceeds 120 mg/dl (for patients greater than 40 kg in weight).. Anticipatory supplements are used to prevent hyperglycemia. In all circumstances. If you are unable to keep food down or are vomiting.INSULIN DOSAGE ADJUSTMENT ALGORITHMS/JAY S. As indicated earlier. not only between patients but also in a given patient depending on the amount of excess food consumption.0 U for every 30-50 mg/dl that glucose exceeds the target range).4 h. again.

In addition. CONCLUSIONS A lgorithms should be individualized appropriate for the circumstances of any given patient. eliminate 1 fruit or Vi bread from snack. increase your morning regular insulin by 1-2 U. and its effect is reflected in the blood glucose test results on arising the next morning. VOL. Hypoglycemia (low blood sugar) not explained by unusual diet/exercise/ insulin Prevent insulin reactions by eating meals and snacks on time. pregnancy is one circumstance in which meticulous glycemic control is both desirable to lessen fetal morbidity and mortality. increase your evening regular insulin by 1-2 U. Ideal and target blood sugars Fasting 60-90 mg/dl Before meals 60-105 mg/dl After meals (1 h) 140 mg/dl or less After meals (2 h) 120 mg/dl or less Hyperglycemia (high blood sugar) not explained by unusual diet/exercise/ insulin If fasting blood glucose on arising is greater than 90 mg/dl for 2 days in a row.10 Such control is attainable with this type of intensive conventional therapy. monitored by patient determination of blood glucose on a continuing regu- TABLE 4 Algorithms for adjusting insulin doses using a "split-and-mixed" insulin dosage regimen and patient monitoring of blood glucose during pregnancy Assumptions The morning short-acting regular insulin has major action between breakfast and lunch. resulting in sustained food requirement after cessation of activity to replete those glycogen stores. OR if you have a hypoglycemic reaction between supper and bedtime. and its effect is reflected in the blood glucose test results after supper and at bedtime.org/ by guest on January 25. The evening or bedtime intermediate-acting NPH insulin has major action overnight. in this case. The evening short-acting regular insulin has major action between supper and bedtime. OR if you have a hypoglycemic reaction between lunch and supper. Finally. MARCH-APRIL 1981 317 Downloaded from http://care. if blood glucose on arising OR before supper is greater than 140 mg/dl. our algorithms are modified so The disciplined application of an intensive conventional program of diabetes management permits many patients with IDDM to attain excellent glycemic control. If blood glucose 2 h after supper is greater than 120 mg/dl. too. If blood glucose after lunch OR before supper is less than 60 mg/dl. dose increments may be made at only 2-day intervals.9"12 During pregnancy. reduce your morning NPH by 1-2 U. Record any acetone in the urine. consult your doctor or clinician.25 ADAPTING ALGORITHMS FOR SPECIAL CIRCUMSTANCES that ideal and target blood glucose levels are identical. DIABETES CARE. reduce your evening regular insulin by 1 — 2 U. take an extra 1-2 U of regular insulin as a supplement at that time. If fasting blood glucose on arising is less than 60 mg/dl. drink a glass of milk or eat if it is snack or meal time. energy expenditure. which outlines the algorithms used for the regimens depicted in Figures 1 and 2. 2014 . If blood glucose after supper OR at bedtime is less than 60 mg/dl.INSULIN DOSAGE ADJUSTMENT ALGORITHMS/JAY S. If blood glucose 2 h after breakfast is greater than 120 mg/dl AND if blood glucose before lunch is greater than 105 mg/dl for 2 days in a row. AND if blood glucose before supper is greater than 105 mg/dl for 2 days in a row. If blood sugar is very low (45 mg/dl or less) have a fruit and a milk or if it is meal or snack time. SKYLER AND ASSOCIATES decrements in insulin dosage should be considered in addition to the dietary supplements. If blood glucose on arising OR before supper is greater than 200 mg/dl. test your blood and if the blood sugar is between 45 and 60 mg/dl. If blood glucose after breakfast OR before lunch is less than 60 mg/dl. and represents a modification of Table 1 for pregnancy. and insulin dosage. 12 h after daytime jogging). and its effect is reflected in the blood glucose test results after lunch and before supper. Supplements In addition. consult your doctor or clinician. OR if there is evidence of hypoglycemic reactions occurring overnight. If blood glucose 2 h after supper is greater than 120 mg/dl.. This is illustrated in Table 4. reduce your morning regular insulin by 1-2 U. Record the supplement in the supplement column so that you do not accidentally change the basal dose of regular insulin.diabetesjournals. Some patients find hypoglycemia occurs well after exercise (e. but less than 105 mg/dl before bedtime snack. increase your morning NPH insulin by 1-2 U. the reduction in insulin component should match the period of anticipated hypoglycemia. If blood sugar 2 h after breakfast is greater than 120 mg/dl. increase your evening NPH insulin by 1-2 U. If blood glucose 2 h after lunch is greater than 120 mg/dl. but less than 105 mg/dl before lunch. fasting urinary ketones are carefully monitored to avoid starvation ketosis. OR if you have a hypoglycemic reaction between breakfast and lunch. 4 NO. eat immediately. consult your doctor or clinician. patients should recognize that moderately intensive exercise may deplete glycogen stores. AND if blood glucose at bedtime is greater than 105 mg/dl for 2 days in a row. Special rules If a blood sugar is greater than 140 mg/dl 2 h after any meal. If you feel a reaction coming on. If blood glucose 2 h after lunch is consistently greater than 120 mg/dl AND blood glucose before supper is less than 105 mg/dl. During pregnancy. reduce your evening NPH insulin by 1-2 U. the criteria for implementing a dosage change are lowered.g. Moreover. since euglycemia is highly desirable and progressive increased dosage requirements can be expected. and its effect is reflected in the blood glucose test results after breakfast and before lunch. 2. The achievement of such control requires careful balancing of food intake. take an extra 2-4 U of regular insulin as a supplement at that time. For example. The morning intermediate-acting NPH insulin has major action between lunch and supper.

Kurtz. A. J. A. B. management. M. Lancet 1: 732-35.: In search 15: 91-93. 1962. Diabetologia Am.. R. Mintz.INSULIN DOSAGE ADJUSTMENT ALGORITHMS/JAY S. B. J. 1978. A. J.: Jet injection of insulin dur. by the Division of Children's Medical Services. A. Med.. and Obstetrics 3: 57-186. 1979. and the Diabetes-Endocrinology Unit. B. Univer15 Dupuis. S. Indiana. Jones. Am. E. Diabetes Care 1: 150-57.. G. by the Diabetes Research Institute Foundation. L. Mintz. and Christensen. Florida.. T.. L. 17 Tattersall. Clarke. J. Lasky.. and Gallop. H. J. R. 20 Gonen. Gale. Med. Allison. and Sunder.) 238: 145-55. E.: Self-monitoring of blood glucose by the diaida 33136. C.. S. M. funded by a contract with the Health Program Office. L. Walford. M. Y. H. I. Lasky. A. 1980. 235-39.: Psychological sity of Miami School of Medicine. Med. R.: Home monitoring of blood glucose by diabetic mics/bmc. P. Skyler. P. J. 68: 105-12. Florida. E... Holsinger.: Selfmonitoring of blood glucose in diabetic pregnancy. Peterson... Robertson.. S.: Home blood glucose monitoring. I. McLeod. DiCare 3: 69-76. Skyler. 1978. D. C.: Exacerbation of diabetes by excess insulin action.diabetesjournals. J. patients. H.. and Knight.bovitz. R. Skyler. C . M.: Self sampling for blood sugar. Lancet 2: 279-82. 1980. C.: StimuO'Shea. R. (Suppl.... 1980. 1979. A. Miami. Ellis. and Lowy. K. and Tattersall.abetes 13 Sonksen. and Chez. 23 Gale.. 1978. Burkett.. Elkhart. 318 DIABETES CARE. M. VOL. C. 1980. Practical Cardiology 6: 50-64. Diabetes Care i: 49-63. cose profiles in insulin-dependent diabetic pregnant women. Symonds. H. somatics2/: Hospital and Clinics (D-l). and of the Somogyi effect. Department of Health and Rehabilitative Services. Dupuis. 1959. Tajima. State of Med.. N. Yoroyama. Am. 1980.. Diabetes Care From the Departments of Medicine. J.. 12 Florida.. Diabetes Care 2: 39-45. S. J. 2014 . Br. F.. Science 200: of blood glucose. 1978. and Rubenstein. D. Davison. 4 Walford.: Diabetes mellitus and pregnancy.: Patient self-monitoring of blood REFERENCES glucose and refinements of conventional insulin treatment. 15: 71-74. SKYLER AND ASSOCIATES 9 Peacock.. 19 3 Bunn.: Blood glucose control during pregnancy. R. partment of Health and Rehabilitative Services.. K. I. Allison. L . This article has outlined the details by which we instruct patients to alter their regimen to attain the desired control. H. Ide.. and Peterson.: Insulin induced Ikeda. Gabbay. R.: Feasibility of improved blood glucose control in patients with insulin-dependent diabetes mellitus..: Instructing patients in making alterations in insulin ing self-monitoring of blood glucose. University of Miami 581-91.. Hunter.. Lancet!: 729-32. R. Indianapolis.: Hemoglobin Aj and diaB. L. 1978.. H . 1969. Skyler. 1978. J. D. 25 8 Wahren. J. 1979. Diabetologia diabetes mellitus.. Psychoeffects Address reprint requests to Jay S. R. and Mintz. F. and Tattersall. and Gale. Miami. M.. O'Sullivan. dosage. Nimami. B. A.. S.. C. 1979. Pediatrics. R..: Home blood glucose monitoring as an aid in diabetes Am. M. A. L. M. H.. D.. Hendler. 26: 169-91... E. 18 Lancet/: 1037-40. State of D. A C K N O W L E D G M E N T S : This work was supported by the Univer11 Jovanovic. 1976.. A.: The glycosylSonksen. 2: 1333-36. 5 Skyler. and betes mellitus. of blood glucose self-monitoring in diabetic patients. M. 4 NO. 7 Peterson. 1475 NW 12th Avenue. J. Diabetes Care 2: lation of counterregulatory hormonal responses in diabetic man by a fall in glucose concentration.M. H.. 1980. 14 Symposium on home blood glucose monitoring. S. R. J. P. 2. Flor16 Shuman. N. Judd. P. J. June 1980. E. B. patients must be motivated and work in close conjunction with their health care team..: Pilot study of self measurement of blood glucose using the post-hypoglycemic hyperglycemia as a cause of "brittle" diabetes. Acta Endocrinol. S. K. Bernstein. D. C : Home monitoring ation of hemoglobin: reference to diabetes mellitus. R. 24 DeFronzo. and Field. Skyler. B.: Self monitoring of blood glucose. Indiana. by G. and Tattersall.. P. Jones. DeSkyler. 1978. Y. L . M. S.: Feasibility of maintaining normal glugram. and Abe.. 1979. To accomplish this.: Glucose turnover during exercise in health and in Tattersall.. H. S. A.org/ by guest on January 25. 22 6 Bloom. H. Diabetes 28: 82-88.. S. W. K.. R. 21-27.. and Le2 Danowski. J. A. L. D. H. and by Bio-Dyna.. D . Dawood. 10 Mintz. .. Saxena. the Ames Company. G. J. 70: 177-82. E. Skyler. 47: 891-903. B. Dextrostix-Eyetone system for juvenile onset diabetes.. G. I. Robertson. ^ed.. A. 21 Somogyi. J. M.. G. MARCH-APRIL 1981 Downloaded from http://care. 1981. E. and Saudek. sity of Miami/Southeastern Florida Regional Diabetes Pro. Diabetes Care 1: 27-33. lar basis. Diabetologia 15: 1-8. betic patient. B. and Gynecology. 1980. 1 Keen. Diabetes 29: 125-31. Y. Lasky. M . N. P.

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