Adjusting Insulin Doses

Everyone with diabetes, including you, will need to adjust your insulin doses at
some time. There are several reasons why a person may need an insulin
adjustment. These reasons include the following:

you are in the honeymoon period

you are having a growth spurt
you are going through hormonal changes (especially during teenage years)
you have changes in your activity level
your are sick or under stress
you are attending special events such as birthdays, holidays, and vacations

Before you make any adjustments to your insulin doses it is important to know what your
target blood glucose range is. Research has shown that keeping your blood glucose levels
in a range closer to normal significantly improves your overall health, decreases your risk for
developing diabetes related complications, and improves blood glucose control. A study
performed by the DirectNet Study Group found that approximately 95% of children without
diabetes have fasting blood glucose levels between 70-100 mg/dl and random blood
glucose levels between 70-130 mg/dl. Therefore, the Children’s Mercy Diabetes Center has
developed our own blood glucose guidelines based on these findings.

The Children’s Mercy Hospital Diabetes Center

Recommended Blood Glucose Target Ranges (mg/dl)

Age Suggested Blood

Glucose Level
Age 5 years or younger 80 -180 mg/dl
Age 6 years and older 70 -140 mg/dl

The American Diabetes Association recommends different blood glucose target ranges than our
recommendations. You can find the ADA recommendations at their website: www.diabetes.org.

Once you know what your blood glucose target range is, you can start to look at your blood
glucose patterns. The CMH diabetes team recommends looking at your blood glucose
patterns for at least five days before any changes are made to your insulin doses. When
looking at your blood glucose results it is important to look for blood glucose levels that are
above or below your target range and also what time of day the pattern occurs. You also
want to consider other things that can cause your blood glucose to increase or decrease.
 What affects your blood glucose?

What makes blood glucose increase? What makes blood glucose decrease?
Foods or drinks with carbohydrates Exercise
Stress Insulin
Illness (cold, fever, flu, or other infection) Honeymoon phase

The best way to remember your blood glucose results and variables that may affect the
results is to keep written records using a logbook or computer management system.

Before you start to make adjustments to your insulin doses it is important to know which
type of insulin, basal or bolus, is working at the time you have hyperglycemia (high blood
glucose level) or hypoglycemia (low blood glucose level).

Basal (background or long-acting) insulin (Lantus or Levemir) keeps your blood glucose in
target between meals, once your bolus insulin has worn off, and during the night.

Bolus (rapid or meal-time) insulin (Humalog, Novolog, or Apidra) works to keep your blood
glucose in target range 2-3 hours after eating a meal or snack with carbohydrate.

Once you know what insulin is working during the time of day you have hyperglycemia or
hypoglycemia adjustments can be made. At CMH we recommend that you adjust one insulin
dose at a time. Once you make an adjustment you should wait at least five days to see if the
adjustment worked before any further changes are made; however, if you are having
frequent hypoglycemia, it is appropriate to make changes after 2 days.

INSULIN ONSET PEAK EFFECTIVE DURATION

DURATION
Long Acting
Lantus®(glargine) 1 hour None 20-24 hours 24 hours
Levemir®(detemir) 1 hour Flat 12 – 23 hours 24 hours
Rapid Acting
Novolog® (aspart) 5 -15 minutes 2-2½ hours 3 - 4 hours 4 hours
Humalog® (lispro) 5 -15 minutes 2 hours 3 – 4 hours 4 hours
Apidra®(glulysine) 5 -15 minutes 2 hours 3 – 4 hours 4 hours

Which insulin should be adjusted?

Blood glucose showing a high pattern Dose of insulin to increase
Before breakfast or overnight Evening long-acting insulin
Before lunch Morning rapid-acting insulin
Before dinner Lunchtime rapid-acting insulin
Before bed Dinnertime rapid-acting insulin
 Which insulin should be adjusted?
Blood glucose showing a low pattern Dose of insulin to decrease
Before breakfast or overnight Evening long-acting insulin
Before lunch Morning rapid-acting insulin
Before dinner Lunchtime rapid-acting insulin

Before bed Dinnertime rapid-acting insulin

Adjusting your basal insulin:

Basal insulin doses (Lantus and Levemir) are most often adjusted by about 10 percent of
the current dose. A general rule to follow when adjusting the basal insulin dose is:

Current basal insulin dose Adjust by

10 units or less ½ -1 unit
10-20 units 1-2 units
20-30 units 2 units
More than 30 units 2-4 units

After you adjust your basal insulin dose it is important to wait 5 days to evaluate the results
before any further adjustments are made. However, if you are having frequent hypoglycemia,
it is appropriate to make changes after 2 days.

Adjusting your bolus insulin:

Bolus insulin doses (Humalog, Novolog, Apidra) are adjusted based on your 2 hour post
meal blood glucose result. The goal is to have your 2 hour post meal result change no more
than 40 mg/dl from your pre-meal blood glucose reading. Also, by 4 hours after your meal
your blood glucose should be near your target blood glucose range.

Current bolus insulin ratio Increase or decrease by

1 unit per 20 grams of carbohydrate or higher 3-5 grams at a time

1 unit per 20 grams of carbohydrate or less 2-3 grams at a time

Like before, you want to wait at least 5 days to evaluate the changes before any additional
changes are made.

If your blood glucose is above target 2 hours after your meal you need more insulin to cover
the carbohydrate, so your insulin to carbohydrate ratio needs to be decreased.

For example: if you’re using a ratio of 1 unit per 15 grams of carbohydrate the ratio
should be decreased to 1 unit per 12 grams of carbohydrate.

If your 2 hour post meal blood glucose reading decreases more than 40 mg/dl from your
pre-meal blood glucose then you’re taking too much insulin and need to increase your ratio.
For example: if you’re using a ratio of 1 unit per 15 grams of carbohydrate the ratio should
be increased to 1 unit per 17 grams of carbohydrate.

Examples of basal and bolus adjustments

Date Breakfast After Lunch After Dinner Night Lantus Meal Comments
Breakfast Lunch ratio
Sun 103 5
Mon 69
Tue 57
Wed 68
Thu 61
Fri 94
Sat 56

Pattern of hypoglycemia before breakfast. Decrease to 4 ½ units of Lantus.

Date Breakfast After Lunch After Dinner Levemir Insulin:carb ratio

Breakfast Lunch Dose
Sun 176 221 21 D
Mon 154 134
Tue 139 142
Wed 163 197
Thu 125 146
Fri 141 162
Sat 155 156

Pattern of hypoglycemia before breakfast. Increase to 23 units of Levemir.

Date Breakfast After Lunch After Dinner Lantus Insulin:carb ratio -

Breakfast Lunch Dose Humalog
Sun 101 168 19 1:15

Mon 115 204

Tue 97 149

Wed 89 152

Thu 120 171

Fri 102 136

Sat 94 120
 Pattern of blood glucose increasing 40 mg/dl or more after breakfast. A decrease to
1 unit of Humalog per 12 grams of carbohydrate would be appropriate.

Date Breakfast After Lunch After Dinner Lantus Insulin:carb ratio -

Breakfast Lunch Novolog
Sun 124 80 10 1:15
Mon 137 74
Tue 118 63
Wed 99 82
Thu 104 59
Fri 96 54
Sat 108 62

Pattern of blood glucose decreasing 40mg/dl or more after lunch. An increase to 1 unit
of Novolog per 18 grams of carbohydrate would be appropriate.

References:
http://www.rch.org.au/diabetesmanual/manual.cfm?doc_id=2979&doc. Retrieved August
31, 2007.
Walsh, J. & Roberts, R. (4th ed). (2006). Pumping insulin. San Diego: Torrey Pines
Press.
Wolpert, H. (2002). Smart pumping for people with diabetes. American Diabetes
Association.