LFAC Education Bulletin No. 21 October 2020
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Adjusting Insulin Doses
Basic rules and unexpected circumstances (food insecurity, sick days, physical activity, Ramadan)

Dear Colleagues,

Sadly, the COVID-19 pandemic has caused immense personal and economic hardship around the world. We have heard of food shortages and lack of access to insulin in some countries, and LFAC is helping as much as it can. In these extreme circumstances, your guidance and reinforcement of the principals of insulin dose self-adjustment to patients and their families may help prevent acute complications such as severe hypoglycaemia or diabetic ketoacidosis.

Here we provide some fundamental principles of insulin dose adjustment and guidance on how to adjust insulin doses on different regimens and for special circumstances such as food insecurity, illness, physical activity and Ramadan.

Many countries have adapted quickly to providing education and reviews remotely including over the phone, WhatsApp, email, video, websites and via real-time Apps, and the following key points could be delivered through such platforms.

Depending on the literacy level of your patients and families, the following information may need to be put in more simplified language before sending it to families. We are planning to develop some plain language patient/family handouts on insulin dose adjustment and will be seeking your input.

General principles of insulin dose adjustments

Insulin dose requirements
Starting doses can be calculated according to body weight (see table below) and then adjusted to individual needs. The “correct” dose of insulin is that which achieves the best attainable glycaemic control for an individual child or young adult without causing obvious hypoglycaemia problems, and resulting in normal growth and development.
Starting total daily insulin done (TDD) - general guide
*doses are very individual and two children of the same age often need different amounts; always start on the lower side and go up later as needed
 
Target Blood Glucose Level (BGL)
To be able to adjust insulin doses it is essential to have a clear picture of how the blood glucose changes throughout the day and what the best possible (target) BGL is for each individual child or young adult. Insulin dose adjustment needs to be based on blood glucose patterns rather than an individual BGL. Having this information is the basis for deciding how much, what type, and when insulin should be given and adjusted. Keeping a BGL log for a week or two with ideally 4-6 checks per day is recommended but two checks per day can give much useful information if checked at different times of the day – see example log book below.
 
*Targets may need to be adjusted for age (generally the younger the child, the higher the targets), type of insulin available, hypoglycaemia awareness, food availability, co-morbidities and other unusual circumstances (e.g. illness, school excursion, camps).
Example Blood Glucose Level Log to establish a Pattern if only 2 test strips are available per day (you could use this log book here):

Essential knowledge before self-adjusting insulin doses
The young adults or parents need to:
  1. Understand how their insulin(s) works – the onset, peak and duration of action, to ensure the right type of insulin and the right dosages are used.
  2. Have an insight and understanding of their ‘usual’ daily blood glucose pattern (this can be done by keeping a daily BGL log – see example log above).
  3. Understand their target (best possible) BGLs.
  4. Understand external factors causing a change in insulin demand (food intake/availability, physical activity, illness, stress, menstrual cycle, certain medication).
  5. Know how much carbohydrate is in the food they eat and ideally know how to ‘carb count’ (for more details see Reference No 1 - page 254-267).
  6. Know how to recognise and treat a hypo; and always carry hypo treatment! (see LFAC/ISPAD, Hypoglycaemia Wallchart)3.
  7. Understand and are competent in making insulin dose self-adjustments (could be assessed through problem solving scenarios or role plays) – see Basic Rules below
  8. Are aware of external factors that can affect BGLs (troubleshooting):                    
    1. Proper insulin storage
    2. Check if recently opened new insulin vial
    3. Rotating injection sites; aware to look for signs of lipohypertrophy (lumps at injection site)!
    4. If there is a change in the caregiver he/she needs to be trained to ensure the right doses are given correctly        
  9. Know how and when it is necessary to contact their diabetes health care team or seek urgent medical attention.
Basic Rules for Insulin Dose Self-Adjustments – adapted from Ragnar Hanas book1
  1. Never stop the long or intermediate acting insulin dose even if you are too sick to eat or if there is no food available! You will need to reduce the dose(s) - for more details see special circumstances below.
            Life-threatening Diabetic Ketoacidosis (DKA) can occur within 24 hours if no insulin is given!
  2. Assess external factors (see rule No 8 above) and DO NOT adjust doses until external factors have been corrected!
  3. If you have a hypoglycaemic episode, begin by decreasing the ‘responsible’ dose(s) to avoid further episodes and wait before attempting to make long-term adjustments. A high blood glucose level could be the result of a rebound/overtreatment of a hypoglycaemic episode.
  4. Symptoms of hypoglycaemia should appear at a normal level, i.e. at 3.5 - 4.0 mmol/L (65 - 70 mg/dL). If they first appear when your blood glucose has fallen below 3.5 mmol/L (65 mg/dL), you should take great care to avoid all low blood glucose levels for the next 1-2 weeks. This will help improve the situation. Insulin doses may need to be reduced to achieve this.
  5. Try to keep the carbohydrate content of the meals and amount of physical activity as consistent as possible when adjusting insulin doses.
  6. Don’t change more than one dose at a time (either morning/day/evening dose), otherwise it is easy to end up in a vicious cycle where you don’t know what has caused what. 
  7. Don’t make large changes in doses all at once (start with an increase or decrease of 10%)
  8. Wait a couple of days between insulin changes and check BGLs 4 - 6 times per day or at least before breakfast and before the evening meal, so that you can see clearly what the outcome is. There is always a depot of insulin in your body and it will take a couple of days before this has reached equilibrium. Intermediate and long-acting insulins (i.e. basal insulins) should not be changed more often than every 2 or 3 days.
  9. If you don’t understand why your blood glucose readings turned out the way they did, try keeping to the same doses for another day or two. You will often see the pattern better then.
  10. For children/young adults who do not check BGLs2              
    1. Base adjustment on clinical symptoms (more thirsty, frequent urination/bedwetting, lethargy/tiredness) and urine glucose checks if available. Attend clinic for blood glucose and urine ketone checks.
    2. Increase Morning and/or Evening dose by 10% if all of these are indicative of hyperglycemia
    3. Check in with clinic frequently (if necessary every 2 days) after any change to see if they are improving
    4. Be aware of hypo/hyperglycemia symptoms
Adjusting insulin doses for different insulin regimens and special circumstances

There are various insulins and regimens available, none of which are perfect but good glycaemic control can be achieved with any insulin1. For more details on insulin action profiles see Pocketbook for the Management of Diabetes in Childhood and Adolescence in under-resources countries, 2nd Edition, IDF, 2017, page 23.

Adjusting insulin doses on a basal-bolus regimen

Basal-bolus refers to a regimen of intermediate or long-acting insulin given once or twice daily morning and/or evenings which provides essential background insulin (basal insulin) and a short or rapid-acting insulin administered before meals (bolus or meal insulin). The bolus insulin dose should be based on the amount of carbohydrate food eaten with the meal.
If using Analog insulins (e.g. Glargine and Aspart/Lispro) start with
  1. Adjusting the evening/bedtime basal insulin (e.g. Glargine) dose to obtain in-target overnight (5 - 8mmol/L / 90 - 145mg/dL) and pre-breakfast BGLs (4 - 7mmol/L / 70 - 126mg/dL)
  2. If taking basal insulin twice daily adjust the morning dose (e.g. Glargine) to obtain in-target daytime BGLs (4 - 10mmol/L / 70 - 180mg/dL)
    • Adjust doses by 5-10% every 3-4 days until numbers are in target.
  3. Adjust the bolus (meal) insulin dose (e.g. Aspart/Lispro) according to the following steps:
    1. Always first check BGL!
    2. Assess the total carbohydrate content of the meal to be eaten (this determines the amount of bolus insulin needed– work out insulin to carbohydrate ratio and correction factor if you have been taught (for more details see reference No 1, page 151).
    3. What am I going to do after the meal? Physical activity, normal work or school, relaxation? Lower the doses if you are going to be more active than usual (discuss this with your diabetes health professional).
    4. What happened last time I was in the same situation? Check your logbook!
    5. Change doses of less than 3 units by 0.5 units at the time, 3-10 units by 1 unit and those more than 10 units by 2 units at a time if guessing carbohydrate amounts.
    6. If you use carbohydrate counting, a change of the ratio by 1 gram is usually sufficient if the ratio is below 10 (i.e. 1 unit of bolus insulin per less than 10 grams of carbohydrate); 2 grams if it is between 10 and 20 and 3-5 grams if it is above 201.
    7. Check blood glucose 2-3 hours after each main meal (if sufficient test strips are available) – it should be back to ± 2 mmol/L / 40 mg/dL of the before meal BGL (for more details see Reference No 1 - page 107-115). It is important not to eat or drink anything other than water between the meal and checking the BGL!
If using Human insulins (e.g. Humulin NPH and Humulin R) start with
  1. Review whether there is any insulin-to-food mismatch and understand the onset and duration of insulin action and the need to eat snacks to prevent hypoglycaemia. Humulin R takes 30-60 minutes to start working and peaks at 2-3 hours while NPH sets on after 1-2 hours and peaks at 4-6 hours. Therefore, Humulin R should be injected 30-60 minutes before a meal and a morning snack should be consumed after about 3 hours when insulin R and NPH overlap. If NPH is injected at bedtime it is crucial to consume a snack containing carbohydrate and protein at that time to avoid overnight hypoglycaemia e.g. slice of bread with nut-butter, cheese and crackers, glass of milk. In other words, 3 meals and a morning and bedtime snack that are rigidly scheduled are important to achieve in-target glycaemic control.
  2. Adjusting the evening/bedtime intermediate acting insulin (e.g. Humulin NPH) dose to obtain in-target overnight (aim for 5 - 8mmol/L / 90 - 145mg/dL) and pre-breakfast BGLs (aim for 4 - 7mmol/L / 70 - 126mg/dL)
  3. If taking intermediate acting insulin twice daily adjust the morning dose (e.g. Humulin NPH) to obtain in-target daytime BGLs (aim for 4 - 10mmol/L /70 - 180mg/dL)
  4. Then adjust the short acting (meal) insulin dose (e.g. Humulin R) according to the following steps:
    1. Always first check BGL!
    2. Assess the total carbohydrate content of the meal to be eaten (this determines the amount of meal/bolus insulin needed– work out insulin to carbohydrate ratio and correction factor if you have been taught (for more details see reference No 1, page 151).
    3. What am I going to do after the meal? Physical activity, normal work or school, relaxation? Lower the doses if you are going to be more active than usual (discuss this with your diabetes health professional).
    4. If you use carbohydrate counting, a change of the ratio by 1 g is usually sufficient if the ratio is below 10; 2 g if it is between 10 and 20 and 3-5 g if it is above 20 g1.
    5. Check blood glucose before lunch and the evening meal (if sufficient test strips are available) – Aim for BGLs of 4 – 10 mmol/L / 70 - 180 mg/dL. Due to the overlap of the short and intermediate insulin the risk of hypoglycaemia is highest before and around lunchtime.
 Adjusting basal-bolus doses during food insecurity
  •  Always give some intermediate/long acting insulin (e.g. Humulin NPH/Glargine) even if there is no food! It may be necessary to reduce the intermediate/long acting evening insulin doses by 20-50% before going to bed if no dinner is available and the morning dose by 20-50% if no breakfast is available.
  • Give short/rapid acting insulin only when you have some carbohydrate food to eat.
  • Check BGLs as often as possible, at least before bedtime and overnight (2-3am). Increase your target BGL to 7 - 13.9 mmol/L / 126 - 250 mg/dL
  • If BGLs drop too low (less than 4 mmol/L / 70mg/dL) or you experience hypoglycaemia symptoms, follow the usual hypo treatment or if no food available, sip on sugary water, suck on a sugar cane or lolly or any other type of rapid sugar (15g) that is locally available. Recheck BGLs in 15 min and every 2-3 hours thereafter if possible.
Adjusting insulin doses on a twice daily regimen of intermediate and short acting insulin

This regimen refers to intermediate acting insulin (e.g. Humulin NPH) and short acting insulin (e.g. Humulin R) usually mixing together in one syringe and given twice daily before breakfast and before the evening meal.  The intermediate acting insulin provides essential background insulin and the short-acting insulin can be adjusted for the amount of carbohydrate food eaten with breakfast and the evening meal.
Start with
  1. Review whether there is any insulin-to-food mismatch and understand the onset and duration of insulin action and the need to eat snacks to prevent hypoglycaemia. Humulin R takes 30-60 minutes to start working and peaks at 2-3 hours while NPH sets on after 1-2 hours and peaks at 4-6 hours. Therefore, Humulin R should be injected 30-60 minutes before a meal and a morning snack should be consumed after about 3 hours when insulin R and NPH overlap. If NPH is injected at bedtime it is crucial to consume a snack containing carbohydrate and protein at that time to avoid overnight hypoglycaemia e.g. slice of bread with nut-butter, cheese and crackers, glass of milk. In other words, 3 meals and a morning and bedtime snack that are rigidly scheduled are important to achieve in-target glycaemic control.
  2. Adjusting the evening/bedtime intermediate acting insulin (e.g. Humulin NPH) dose to obtain in-target overnight (5 - 8mmol/L / 90 - 145mg/dL) and pre-breakfast BGLs (4 - 7mmol/L / 70 - 126mg/dL)
  3. Then adjust the morning intermediate acting insulin dose (e.g. Humulin NPH) to obtain an in-target daytime BGLs (4 - 10mmol/L /70 - 180mg/dL)
  4. Then adjust the short acting breakfast or dinner dose (e.g. Humulin R) according to the following steps:
    1. Always first check BGL!
    2. Assess the total carbohydrate content of the meal to be eaten (this determines the amount of meal insulin needed. Ask your health professional (dietitian) how to calculate the amount of carbohydrate in different foods.
    3. What am I going to do after the meal? Physical activity, normal work or school, relaxation? Lower the doses if you are going to be more active than usual (discuss this with your diabetes health professional)
    4. Check blood glucose before lunch and the evening meal (if sufficient test strips are available) – Aim for BGLs of 5 - 10mmol/L / 90 - 180 mg/dL. Due to the overlap of the short and intermediate insulin the risk of hypoglycaemia is highest around lunchtime therefore it is recommended to have a mid-morning carbohydrate containing snack.
Adjusting twice daily insulin doses during food insecurity
  1. Always give some basal (intermediate acting) insulin (e.g. Humulin NPH) even if there is no food! It may be necessary to reduce the intermediate acting evening insulin doses by 20-50% before going to bed (if no dinner available) and the morning dose by 20-50% if no breakfast is available.
  2. Give short acting insulin only when you have some carbohydrate food to eat.
  3. Check BGLs as often as possible, at least before bedtime and overnight (2-3am). Increase your target BGL, aim for 7 -13.9 mmol/L / 126-250 mg/dL
  4. If BGLs drop too low (less than 4 mmol/L / 70mg/dL) or you experience hypoglycaemia symptoms, follow the usual hypo treatment or if no food available, sip on sugary water, or suck on a sugar cane or lolly or any other type of rapid sugar (15g) that is locally available. Recheck BGLs in 15 min and every 2-3 hours thereafter if possible.
Adjusting twice daily pre-mixed insulin2
  1. Review whether there is any insulin-to-food mismatch and understand the onset and duration of insulin action and the need to eat snacks to prevent hypoglycaemia. Pre-mixed human insulin 30/70 contains 30% short acting and 70% intermediate acting insulin. It takes 30-60 minutes to start working and peaks at 2 hours and 6 hours. Therefore, pre-mixed human insulin should be injected 30-60 minutes before the morning and evening meals. A morning snack should be consumed after about 3 hours when short and intermediate acting insulin overlap. If pre-mixed insulin is injected in the evening, it is crucial to consume a snack containing carbohydrate and protein at bedtime to avoid overnight hypoglycaemia e.g. glass of milk, slice of bread with nut-butter, cheese and crackers. In other words, 3 meals and a morning and bedtime snack that are rigidly scheduled are important to achieve in-target glycaemic control.
  2. Find a Pattern of high/low BGLs over at least 2 days (without unusual physical activity or illness)
    • If BGL are high or low in the MORNING --> adjust evening dose
    • If BGL are high or low in the EVENING --> adjust the morning dose
  3. Adjust one dose (MORNING or EVENING) at one time if BGL between 10 – 16.6 mml/L / 180 - 300 mg/dL
    • ↑ evening dose by 10% if morning/fasting BGL is elevated
    • ↑ morning dose by 10% if evening BGL is elevated
  4. Increase both MORNING and EVENING dose if BGLs are >16.6 mmol/L / 300 mg/dL
    • ↑ both doses by 10%
Adjusting twice daily pre-mixed insulin doses during food insecurity
This insulin regimen increases the risk of Diabetic Ketoacidosis (DKA) or severe hypoglycaemia if there is food insecurity as it is very difficult to adjust pre-mixed insulin doses! Therefore, a switch to an intermediate and short acting insulin regimen is strongly recommended.
If only pre-mixed insulin is available follow these rules:
  • Always give some pre-mixed insulin even if there is no food available and you are not able to check your BGL!
  • Increase your target BGL, aim for 8.3 - 13.9 mmol/L / 150 - 250 mg/dL
  • If you can’t check your BGL during food insecurity, take at least 50% of your usual morning and evening doses
  • Check BGLs as often as possible during the day or at least before bedtime and overnight (2-3am).
  • If BGLs drop too low (less than 4 mmol/L / 70mg/dL) or you experience hypoglycaemia symptoms, follow the usual hypo treatment or if no food available, sip on sugary water, cordial, juice, or suck on a sugar cane or lolly, or any other type of rapid sugar (15g) that is locally available. Recheck BGLs in 15 min and every 2-3 hours thereafter if possible.
  • If no breakfast available: If BGLs 5.5 – 16.6 mml/L / 100 - 300 mg/dL – reduce your usual pre-breakfast dose by 20 - 50% of (the lower the BGL the more reduction is needed); If BGLs are above 16.6 mml/L / 300 mg/dL have your usual breakfast insulin dose.
  • If no dinner available: If BGLs 5.5 – 16.6 mml/L / 100 - 300 mg/dL - reduce your evening dose by 20 - 50% of your usual dose (the lower the BGL the less insulin is needed); if BGL are above 16.6 mml/L / 300 mg/dL have your normal insulin dose.
  • If there is food available during the day and your BGL is between 5.5 – 16.6 mml/L / 100 – 300 mg/dL, you need to inject a small dose of 20-50% of your usual pre-breakfast dose before a meal during the day. The lower the BGL the less insulin is needed. If you can’t check your BGL only give 20-30%.  

Insulin dose adjustment for other circumstances

Physical Activity (playing sport, camps, school excursions)
Physical activity increased insulin sensitivity (makes insulin work more efficiently and over longer time), hence doses generally need to be reduced or more carbohydrate food eaten to avoid the risk of hypoglycaemia. Hypoglycaemia can occur during and many hours after the physical activity (up to 24 hours-and can last into the evening or night). The basic principles are if there is a change in usual level of physical activity:
  • More exercise than usual --> less insulin required to prevent hypoglycaemia
  • Less exercise than usual  -->  more insulin may be required to prevent hyperglycaemia
For more details on Physical Activity management see Ragnar Hanas book, Reference No 1, page 287-303.
 
Illness
Never stop insulin during sick-days, even if not able to eat normally. Insulin may need to be increased or decreased, based on the BGL and food intake – see March 2020 Bulletin  
 
Ramadan
People with diabetes and especially children with type 1 diabetes are generally exempt and strongly discouraged from fasting during Ramadan. However, some devout Muslims still want to take part in the fast. It is essential that they seek advice and receive intense education on dietary intake and insulin management from their diabetes team before participating in the fast.

It is important to accommodating for a lower basal/intermediate acting insulin requirement during fasting hours (doses may need to be reduced by 10-20%), and the need to adjust short/rapid acting insulin doses according to the amount of carbohydrate eaten with Iftar (evening meal after fast) and Sehar (morning meal) The amount of carbohydrate food in these meals should be counted and an insulin to carbohydrate ratio used to calculate the insulin dose (see Reference No 1-page 266-267).

For those on a twice daily regimen the recommendation is to take the usual morning dose (instead of the evening dose) before the sunset meal and to take only short-acting insulin at the time of the dawn meal.5  

Those on pre-mixed insulin regimen are strongly advised not to take part in the fast as it requires a fixed intake of carbohydrate foods at set times because the insulin profile has two peaks of activity. This may be difficult to use safely with fasting and is not advised (see ISPAD guidelines on Ramadan)5.
 
ISPAD has recently published a comprehensive review and guidelines for ‘Fasting during Ramadan by young people with Diabetes’, as an additional chapter.
Resources in English and Arabic are also available from Diabetes and Ramadan study group

Acknowledgement:

We would like to thank A/Prof Julia von Oettingen, Paediatric Endocrinologist, McGill University Division of Endocrinology, Montreal Children's Hospital, Canada, for her guidance and review of this bulletin.


References and further reading:
  1. Ragnar Hanas – Type 1 diabetes in children and adolescents, 7th edition, 2019. Chapter 15. Available from: https://lfacinternational.org/wp-content/uploads/2020/06/LFAC_@hanas48_FINAL_FILE_reduced.pdf
  2. Julia von Oettingen – MD & Amanda Perkins NP CDE. Adjusting Insulin doses. PowerPoint presentation for Liberia Workshop, 2016
  3. International Diabetes Federation (IDF), International Society for Pediatric and Adolescence Diabetes (ISPAD) and Life for a Child (LFAC). Pocketbook for the Management of Diabetes in Childhood and Adolescence in under-resources countries, 2nd Edition, IDF, 2017. Available from: https://lfacinternational.org/wp-content/uploads/2017/10/LFAC-ISPAD-Pocketbook-2nd-edition-low-res.pdf
  4. ISPAD Clinical Practice Consensus Guidelines 2018: Insulin treatment in children and adolescents with diabetes, Chapter 9, 2018. Available from: https://cdn.ymaws.com/www.ispad.org/resource/resmgr/consensus_guidelines_2018_/9.insulin_treatment_in_child.pdf
  5. ISPAD Clinical Practice Consensus Guidelines: Fasting during Ramadan by young people with Diabetes, Additional chapter, published Oct, 2019 https://cdn.ymaws.com/www.ispad.org/resource/resmgr/consensus_guidelines_2018_/deeb_et_al-2019-pediatric_di.pdf
 
For advice about COVID-19 and insulin supplies: https://www.jdrf.org/coronavirus/
 
 
Note: Some of the blood glucose level numbers in mmol/L and mg/dL have been rounded for practical use.  



 
For more information contact: 

Cecile Eigenmann
Education Manager
cecilee@diabetesnsw.com.au
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