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Insulin adjustment

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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.

Type of insulin Onset of Action Peak Action Duration Recommendation
Rapid: - Analogues
NovoRapid/ Humalog/ Apidra
10 - 20 Minutes 1-3 hours 3-5 hours Inject immediately prior to eating / or if a toddler up until 20 min after starting meal. Do not give more frequently than 3 hourly
Short Acting: - human insulin
Actrapid / Humulin R
Within 30 - 45 minutes 1-3 hours 6-8 hours Inject 20 min prior to eating
Long Acting: - human insulin
Protaphane / Humulin NPH
1 - 1.5 hours 4-12 hours 16-24 hours Give twice daily approximately 10-14 hours apart
Long Acting: - Analogues
Lantus 
Levemir (not funded in NZ)
  No pronounced peak Up to 24 hours Given either once or twice a day.
Cannot be mixed with other insulins.
Needs to be used with a fast acting insulin to cover meals
Pre-Mix: - Human
Mixture of Short acting and long acting
PenMix 30 / Humulin 30/70
Within 30 - 45 minutes 2-12 hours 16 to 24 hours Inject 20 min prior to eating.
If twice daily give approximately 10 - 14 hours apart
When dose is changed both short and long acting component is affected
Pre-Mix: - Analogues
Mixture of Rapid acting and Rapid that has been protaminated - (to add a long acting component)
NovoMix 30 / Humalog Mix25/ Humalog Mix50
10- 20 minutes  1-4 hours 16 to 24 hours Inject immediately prior to eating
If twice daily give approximately 10 - 14 hours apart
When dose is changed both short and long acting component is affected

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:

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:

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

Button 1

button option 2

Button option 3

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:

button option 4

button option 5

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

Click on the image for a printable version of this document

Insulin adjustment

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