Adjusting insulin doses

Hyperglycaemia

Insulin-related causes of hyperglycemia are often related to the basal insulin doses, so start with checking the pre-breakfast (fasting) glucose levels and go from there.

Step 1: Check the fasting glucose levels to assess the basal insulin dose* (See below)

For each scenario, suggested management options are provided:

Step 2: Check the post-meal glucose levels – and compare them with the pre-meal glucose

Check the post-meal glucose levels (1 – 2 hours after eating) – and compare them with the pre-meal glucose

Less than 5 mmol/L

5 – 10 mmol/L

Above 10 mmol/L

Back to previous

Above 10 mmol/L

Trend	Explanation	Suggested action
Stable Post-meal glucose is less than 3 mmol/L lower or higher than the pre-meal glucose level	The dose of rapid-insulin matched well for your food, but did not correct for the high glucose level before eating	Your patient is giving correction doses: Increase the correction dose ie. more insulin is needed to reduce the glucose level (ISF, insulin sensitivity factor) Give the dose of rapid-acting insulin 15-30 minutes before the meal, so its peak action coincides with the glucose spike from absorbed carbohydrate Increase the dose of basal insulin by 10% to improve pre-meal glucose levels
		Your patient is not giving correction doses with meals: Add correction doses of rapid-acting insulin to lower the high glucose levels at meals. It is added to the meal-time dose A safe correction dose to start is: 1 unit to lower glucose by 3 mmol/L Give the dose of rapid-acting insulin 15-30 minutes before the meal, so its peak action coincides with the glucose spike from absorbed carbohydrate Increase the dose of basal insulin by 10% to improve pre-meal glucose levels
Rising Post-meal glucose is at least 3 mmol/L higher than the pre-meal glucose level	The dose of rapid-insulin is not enough to match the carbohydrate in the meal	Your patient counts carbohydrate Increase the carbohydrate ratio, so more insulin is given for the same serve of carbohydrate eg. 1 unit to match 15g will now be 1 unit to match 10g. Increase the correction doses of rapid-acting insulin and add them to the meal time dose Give the dose of rapid-acting insulin 15-30 minutes before the meal, so its peak action coincides with the glucose spike from absorbed carbohydrate Check carbohydrate counting skills – refer your patient to a dietitian and/or diabetes educator for a refresher. Online resources and carbohydrate-counting Apps may help optimise accuracy If your patient doesn’t use correction doses, a safe correction dose to start is: 1 unit to lower glucose by 3 mmol/L
		Your patient doesn’t count carbohydrate Increase the usual dose of rapid-acting insulin for that meal by 10% Add correction doses to this at meals to lower the high glucose levels. A safe correction dose to start is: 1 unit to lower glucose by 3 mmol/L

Hypoglycaemia

When the hypoglycaemic event was caused by insulin, reduce the dose immediately. Work out which insulin was active at that time and adjust that insulin.

During the day, hypoglycaemic events that occur within 3 hours of eating a meal are most likely due to the rapid-acting insulin. Hypoglycaemic events are due to the basal insulin when they occur during fasting or more than 4 hours after eating a meal.

Reduce the insulin dose if hypoglycemic events occur overnight, or if there is a regular pattern of daytime hypos.

Erratic glucose levels

Sometimes it seems like there is no pattern at all in the glucose levels that you see.

There are a number of reasons for this, and many of them lie in the non-insulin causes of hyper- and hypoglycemia:

High glucose levels all night	High glucose levels just before breakfast	Hypoglycemia overnight, followed by high glucose level before breakfast
Change Lantus to bedtime Add Bedtime dose to the mane Lantus (BD) Change Lantus to Toujeo for a longer duration of action	Change Lantus to bedtime Add Bedtime dose to the mane Lantus (BD) Change Lantus to Toujeo for a longer duration of action	Reduce Lantus dose by 10-20% Consider changing Lantus to either: Toujeo, which has a lower risk of hypos OR Levemir which has a shorter duration of action, so hypos overnight are less likely

High glucose levels all night	High glucose levels just before breakfast	Hypoglycemia overnight, followed by high glucose level before breakfast
Ensure Lantus is given at bedtime and increase dose by 10% every week until pre-breakfast glucose levels are 5 – 8 mmol/L Consider changing to Toujeo once daily to simplify regimen	Ensure Lantus is given at bedtime and increase dose by 10% every week until pre-breakfast glucose levels are 5 – 8 mmol/L Consider changing to Toujeo once daily to simplify regimen	Ensure Lantus is given at bedtime and decrease dose by 20% Consider changing to Toujeo once daily to simplify regimen

High glucose levels all night	High glucose levels just before breakfast	Hypoglycemia overnight, followed by high glucose level before breakfast
Increase the dose of Toujeo if daytime glucose levels are all high too Change the Toujeo to bedtime	Change the Toujeo to bedtime	Reduce Toujeo dose by 10-20% Consider changing Levemir mane, which has a shorter duration of action, so hypos overnight are less likely

High glucose levels all night	High glucose levels just before breakfast	Hypoglycemia overnight, followed by high glucose level before breakfast
Change to once daily Toujeo, given at bedtime or mane depending on the patients’ preference	Change to once daily Toujeo at bedtime	Change to mane Toujeo

High glucose levels all night	High glucose levels just before breakfast	Hypoglycemia overnight, followed by high glucose level before breakfast
Give Levemir at bedtime and increase dose by 10% every week until pre-breakfast glucose levels are 5 – 8 mmol/L Change to Toujeo if concerned about overnight hypos.	Give Levemir at bedtime and increase dose by 10% every week until pre-breakfast glucose levels are 5 – 8 mmol/L Change Levemir to Toujeo for a longer duration of action	Give Levemir at bedtime and decrease dose by 20% Consider changing Levemir to mane Consider changing Levemir to Toujeo for a longer duration of action and lower risk of hypos

Info for Medical Professionals

Adjusting insulin doses

Step 1: Check the fasting glucose levels to assess the basal insulin dose* (See below)

Check the fasting glucose levels to assess the basal insulin dose

Step 2: Check the post-meal glucose levels – and compare them with the pre-meal glucose

Check the post-meal glucose levels (1 – 2 hours after eating) – and compare them with the pre-meal glucose

Use this guide to adjust your patient’s insulin regimen

Non-insulin causes of hyper- and hypoglycemia