14. Insulin adjustment

Integrating on-going diabetes management into daily activities: Insulin adjustment

Once your child's blood glucose levels have stabilised (most levels within the target range) a few weeks following diagnosis, many families are at a stage where they can start making decisions about the insulin doses based on the blood glucose levels and daily activities. Insulin adjustment generally is based on the identification of "patterns" or "trends" in the blood glucose levels over a few days.

It helps to have a clear understanding of how each of the types of insulin work to be able to adjust the insulin in a safe way.

You can read a transcript of this video here.

Insulin adjustment guidelines

Routine insulin adjustment

Adjustment of your usual insulin dose is recommended when there are:

• 2 or more low blood glucose levels (<4mmols) at the same time of the day

• 3 or more blood glucose levels >7 (before meals) or >10 before bed at the same time of the day.

We would generally suggest a 10-20% adjustment of the dose you are going to change. For example if the usual dose of Protaphane is 10 u then 10% of 10u = 1u. Therefore you would change your normal Protaphane dose to 11unit of Protaphane if the blood glucose levels had been high or 9U if the levels had been too low.

It is important to check whether any insulin adjustments are effective over the following 2 days.

Only one insulin adjustment should be made at a time.

On occasions where there are multiple blood glucose levels outside the target range of 4-7 mmol, adjustments should be made in order of priority:

1. Act on low blood glucose levels first.

2. Aim for the first blood glucose in the morning to be within target.

3. Then focus on other problem areas throughout the day.

Insulin requirements may increase or decrease dramatically during illness or changes to routine so it is important to liaise with the diabetes team if:

• blood glucose levels are persistently >15 or < 4mmols throughout the day

• Insulin adjustments are not having the desired effect

• Ketones are present

• Your child has had a severe hypoglycaemia event

For further advice on how to adjust insulin, click on the insulin regimen below that your child is currently using:

Twice Daily Insulin (insulin given before breakfast and before dinner)

Look for blood sugar levels 3 days above 7mmol [before meals), OR 2 days under 4mmol at the same time of the day

If blood sugar levels are above 7mmol before meals at the same meal or >10 at bed-time for 3 days in a row:

If blood sugar levels are under 4mmol at the same time of day for 2 days in a row:

Three times daily insulin (insulin given before breakfast, before dinner and before bed)

Look for blood sugar levels 3 days above 7 pre-meals or 10mmol at bed-time, OR 2 days under 4mmol at the same time of the day

If blood sugar levels above target:

If blood sugar levels are below target:

Basal Bolus insulin (long acting insulin given either before breakfast, or before dinner/bed and fast acting insulin given before meals)

Look for blood sugar levels 3 days above 7 mmol pre-meals, OR 2 days under 4mmol at the same time of the day

If blood sugar levels are above 7mmol pre-meals at the same time of day for 3 days in a row:

If blood sugar levels are under 4mmol at the same time of day for 2 days in a row:

Afternoon tea insulin

It is quite common for children with diabetes to have a tendency to develop higher blood glucose levels before dinner. This is sometimes related to the amount of carbohydrate food eaten at lunchtime but more often related to the amount of food eaten at afternoon tea. There is a limit to how high we can increase morning intermediate acting insulin (Protaphane or Humulin NPH) to address high pre dinner levels.

The amount of carbohydrate eaten at afternoon tea is generally limited to less than 30grams. If your child is going to eat more than 30grams carbohydrate (more than two snacks containing carbohydrate) at afternoon tea it is very likely that an additional dose of short acting insulin such as NovoRapid or Humalog or Apidra will be needed. Your diabetes team will work together with you to individualise a plan around afternoon tea insulin that suits your child's specific needs.

Giving extra insulin for levels above target range

In some situations it is appropriate to give an extra injection of fast acting insulin such as NovoRapid, Humalog or Apidra to bring blood glucose levels that are above target range into target range. It is important to consider when the most recent dose of fast acting insulin has been given before giving any additional doses. There is a risk that doses given too close together can overlap and cause hypoglycaemia. It is recommended that doses of fast acting insulin are given no more frequently than 3 hourly for this reason. We generally do not recommend that additional doses of fast acting insulin are given after 8pm due to the increased risk of hypoglycaemia overnight.

Please contact your diabetes team for an individualised plan around giving additional insulin for high blood glucose levels.

Changes to Routines

After a few weeks getting used to living with diabetes most families will want to understand how to safely make changes to the insulin regime to better suit regular lifestyle activities. Changes to usual routines require changes to the usual insulin regime. For any special events (parties, sports events etc.) it is important that families contact the diabetes team for advice on an individualised plan for the insulin doses. An individualised plan for insulin adjustment for special events will reduce the likelihood of hypoglycaemia.

For further advice on how to change insulin for routines link on the insulin regime you child is currently using:

Twice or three times daily insulin (insulin given before breakfast and before dinner)

Getting Up Later

• Sleeping in is part of the enjoyment of holidays and weekends and may be integrated successfully into a diabetes regimen. No particular changes need to be made if the morning injection time is only one and a half hours different from usual.

• We generally recommend that the usual routine not be altered by more than 3 hours

• If your child is going to sleep in and you give the normal morning insulin later than usual, this may cause an overlap of insulin at dinner time

You will need to compensate by either:

• Moving the whole day's routine later, or

• Reducing the morning intermediate acting dose of insulin and/or the evening short acting insulin

Getting Up Earlier

No changes need to be made to insulin or food if the injection time is less than one hour difference from usual.

For earlier starts you can either:

• Give an extra morning tea if all other meals are to be eaten at the usual times, or

• Bring the whole day's routine forward with extra blood glucose testing in the evening to assess the need for additional food or insulin

Going to Bed Later

Usually eating extra supper is sufficient, the amount will depend on what your child has been doing.

Adolescents who are planning on being out very late (i.e.: going to a bar/ nightclub or a party) will need to significantly reduce the usual night insulin dose. Extra blood glucose testing before bed is recommended. 

Eating Out Later than Usual

If you are going out for a meal at a restaurant or will be eating at a later time, give a snack at the usual time that dinner would be eaten but delay the dose of insulin to immediately before dinner at the restaurant or wherever you are eating. If this dose is later than 8pm you feel need to check a BGL 3 hours later.

Basal Bolus insulin (long acting insulin given either before breakfast or before dinner/bed and fast acting insulin given before meals)

Getting Up Later

• No changes need to be made if the basal insulin (Lantus/Levemir) is normally given at night. 

• If the basal insulin is normally given in the morning injection time cannot be more than only one and a half hours different from usual. 

• If your child is going to sleep in and you give the normal breakfast insulin later than usual, this may well cause an overlap of insulin at lunchtime. Keep an eye on the time. Bolus doses of short acting insulin should be given 2-3hours apart.

Getting Up Earlier

• No changes need to be made if the basal insulin is normally given at night

• No changes need to be made if the basal insulin is normally given in the morning and is less than one hour difference from usual. 

• For significantly earlier starts where basal insulin is normally given in the morning try to give the basal insulin at the usual time

• If you are going to use a dose of short acting insulin for an early breakfast and then add in an additional morning snack requiring insulin also, this may cause the insulin to overlap. Keep an eye on the time. Bolus doses of insulin should be given 2-3hours apart.

Going to Bed Later

• Usually eating extra supper is sufficient, the amount depending on what your child has been doing.

• Adolescents who are planning on being out very late (i.e.: going to a bar/ nightclub or a party) will need to significantly reduce the usual night insulin dose. Extra blood glucose testing before bed is recommended. Link to the adolescent going out and staying out information

Eating Out Later than Usual

If you are going out for a meal at a restaurant or will be eating at a later time, give your child the usual dose of short acting insulin with the later dinner at the restaurant. If this dose of insulin is later than 8pm it is recommended that you check a blood glucose level around 3 hours after

Let's go over the main points. Think you've got it sorted? Read through our one page summary.

Think you've got it sorted now?

If you have read through the information above and watched the videos, and you feel confident that you understand this topic, print off and fill in the evaluation form below (you might need to ask someone to print this off for you) and return to the nurse on your ward. If you have any questions, note them down on this form and your diabetes nurse specialist will discuss them with you.

Insulin Adjustment: Evaluation

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