Basal-Bolus Insulin with Multiple Daily Injections

Transcription

1 Basal-Blus Insulin with Multiple Daily Injectins Fcus n Children & Yuth Heather Nichl RN, MScN, CDE 2009 BC Children s Hspital

2 Acknwledgements: The cntributins f thers t the review and develpment f the basal-blus handuts are gratefully acknwledged: u Daniel L. Metzger*, MD, FAAP, FRCPC u Kathleen De Waele*, MD, Pediatrician, Clinical Fellw u Cristina Pepe*, RN, BSN, CDE u Sharleen Herrmann*, RN, BSN, CDE, *Endcrinlgy & Diabetes Unit, BC s Children s Hspital u Judy Lenard, RN, Medical Day Unit BC s Children s Hspital u Allisn Husband, RN, MN, CDE, Diabetes Clinic, Alberta Children s Hspital u Laurie Hasiuk, Learning & Develpment, Children s & Wmen s Health Centre f British Clumbia, fr desktp publishing u A special thanks t the yuth and parents wh reviewed drafts f the handuts! u LifeScan Canada is gratefully acknwledged fr prviding an educatinal grant t assist with the publicatin f this dcument. Prepared fr: British Clumbia s Children s Hspital Endcrinlgy & Diabetes Unit Vancuver, British Clumbia By: Heather Nichl RN, MScN, CDE 2009 BC Children s Hspital

3 Preface This bklet includes several handuts (infrmatin sheets) t help parents f children with diabetes and yuth learn mre abut basal-blus insulin with multiple daily injectins (MDI). The handuts are als available n the internet at Sme f the handuts will help yu understand what basal-blus insulin therapy is. Others will help yu decide if basal-blus with MDI is right fr yu. Several examples and practice questins are als included t help yu learn mre abut adjusting insulin and calculating insulin dses. Yu can read the infrmatin at yur wn pace and accrding t yur wn interests and learning needs. Yu d nt need t read all f the handuts at ne time. As yu read thrugh this bklet yu will ntice links t ther handuts that are available n the website fr the Diabetes Prgram at British Clumbia s Children s Hspital ( T access the ther handuts, g t ur website and click n the links f interest. Happy Learning! Nte: The infrmatin included in these handuts is nt a substitute fr educatin r advice frm yur diabetes educatin team and health care prviders. Fr pricing and rdering infrmatin C&W Bkstre Children s & Wmen s Health Center f BC 4480 Oak Street, Rm K2-126, Ambulatry Care Building Vancuver, BC V6H 3V4 Tel: (604) Ext 7644 Tll free: Ext 3 Fax: (604) bkstre@cw.bc.ca Web:

4 ENDOCRINOLOGY & DIABETES UNIT Diabetes Clinic: Tll Free: ext: 2868 Fax: Fast Track t Basal-Blus Infrmatin Click n the tpics that interest yu u An Intrductin t Basal Blus Insulin with Multiple Daily Injectins... 1 u What is a Basal Blus Apprach t Diabetes Management?... 2 u What are the Benefits f Basal Blus Insulin?.. 3 u What are Lantus and Levemir?... 4 u Why is Rapid-Acting Insulin als Used in a Basal Blus Plan?... 5 u Basal Blus Insulin Actin with Lantus r Levemir and Rapid-Acting Insulin... 6 u Basic Insulin Actin... 7 u What are a Crrectin Factr, Crrectin Blus and Insulin Scale?... 8 u Fitting Basal-Blus int Daily Life: Is MDI fr yu? u Are Yu Ready fr Basal Blus Insulin? u Getting the Mst Benefit frm Basal Blus Insulin u Guidelines fr Basal Blus Insulin Dse Adjustments With Lantus r Levemir and Rapid-Acting Insulin Insulin Dse Adjustments Guidelines fr Pattern Management Knw Which Insulin has the Greatest Effect n Each Bld Sugar Rapid-Acting Insulin fr Carbhydrate and High Bld Sugar Practice Insulin Dse Calculatins fr Bluses f Rapid-Acting Insulin u Cngratulatins and Next Steps u u An Intrductin t Basal- Blus Insulin with Multiple Daily Injectins Basal blus insulin plans fr diabetes management can include the use f an insulin pump r multiple daily injectins f insulin. The basal blus handuts in this package prvide infrmatin fr basal blus insulin with multiple daily injectins (MDI). Fr infrmatin abut insulin pumps, please see ur handut Insulin Pump Therapy. The handuts listed in the sidebar include infrmatin fr yuth and parents cnsidering basal blus insulin with MDI. They can be read as a cmplete package r individually. There are als sme exercises that yu can d t help yu decide if yu are ready fr basal blus insulin and t check yur understanding f key pints. Click n the tpics that interest yu. T dwnlad r print the entire basal blus package g t: Basal- Blus Insulin August 31, 2009 enddiab.bcchildrens.ca/pdf/basalblus.htm page 1 f 35 Prepared by Heather Nichl, RN, MScN, CDE fr

5 What is a Basal-Blus Apprach t Diabetes Management? T understand basal blus insulin, it is helpful t first understand what happens in the bdy when a persn des nt have diabetes. Insulin is nrmally prduced by the pancreas and is present in the bdy 24 hurs a day, every day. There are tw majr ways that insulin is prvided by the pancreas: basal and blus. 1. Basal insulin is cntinuus, backgrund insulin that the bdy needs t keep bld sugar in cntrl when n fd is eaten. Basal insulin is wrking even during perids f sleep. 2. Blus insulin is extra insulin that is released as needed t match fd intake. When a persn des nt have diabetes, the pancreas autmatically prduces the exact amunt f basal and blus insulin that is needed. The amunt f insulin is adjusted fr changes in activity level r fd and during times f stress and illness. Because the basal blus system wrks s well when a persn des nt have diabetes, fd can be eaten at any time and in any amunt and the bld sugar will still stay in a nrmal range!? A basal blus apprach t diabetes management tries t cpy r imitate what happens in the bdy f a persn wh des nt have diabetes. A lnglasting backgrund insulin, called basal insulin is needed every day as well as additinal bluses f rapid-acting insulin fr fd. Basal insulin usually makes up abut half (50%) f the ttal amunt f daily insulin. Blus insulin dses match the amunt f carbhydrate that is eaten. Blus insulin dses can als be given t bring dwn high bld sugars. Bld sugars must be checked several times each day t make decisins abut insulin dses. There are several different cmbinatins f insulin that can be used in a basal blus apprach t diabetes management. There are als different ways t give insulin. Tw examples f a basal blus apprach t diabetes management are: 1. Multiple Daily Injectins (MDI) with Levemir r Lantus (basal) and rapid-acting insulin (blus) OR an 2. Insulin Pump that prvides basal and blus insulin using rapid-acting insulin nly. Fr mre infrmatin n the use f Levemir r Lantus and rapidacting insulin, see ur handuts:what Are Lantus and Levemir? and Why Is Rapid-Acting Insulin Als Used in a Basal Blus Plan? and talk t yur diabetes educatr and dctr. Fr mre infrmatin n insulin pumps, please read ur handut Insulin Pump Therapy r talk t yur diabetes dctr and nurse. August 31, 2009 enddiab.bcchildrens.ca/pdf/basalblus.htm page 2 f 35

6 What are the Benefits f Basal-Blus Insulin? One f the gals f using basal blus insulin in diabetes is t keep bld sugars in a healthy range as ften as pssible. This is imprtant fr feeling and grwing well during childhd and fr preventing future health prblems. Basal blus insulin als has ther advantages including the pssibility f a mre flexible lifestyle. Fr example, there can be mre flexibility with amunts and timing f fd. Wrds that are ften used t describe the rewards f effective basal blus therapy are mre freedm, mre flexibility and a better quality f life. Many peple will say that mre wrk is invlved, but the health and persnal rewards are wrth it! Basal blus insulin, cmbined with strng knwledge and skills, can imprve: bld glucse cntrl, which has immediate and lng-term health benefits flexibility in day-t-day living with diabetes bld sugars during and after physical activity A basal blus apprach that includes Levemir r Lantus as the basal (backgrund) insulin and rapidacting insulin as the blus insulin can be especially useful if yu: are having difficulty with vernight bld glucse cntrl are having prblems with lw bld sugars, especially during the night desire mre flexibility in meal and snack times and amunts want t sleep in smetimes plan t travel acrss time znes r d shift wrk T benefit fully frm a basal blus apprach t diabetes management requires mtivatin t: give basal insulin every day and rapid-acting insulin fr each meal and sme snacks. (This usually means giving insulin at least 4 times a day). check bld sugars at least fur t six times each day recrd and review bld sugars make infrmed decisins abut insulin, activity and fd. Other names that are smetimes used fr basal blus insulin are: flexible intensive therapy, intensive diabetes management, and MDI which stands fr multiple daily injectins. August 31, 2009 enddiab.bcchildrens.ca/pdf/basalblus.htm page 3 f 35

7 What are Lantus and Levemir?? Lantus (als knwn as insulin glargine) and Levemir (als knwn as insulin detemir) are lng-lasting basal insulins. Basal insulin is a wrd that is used t describe the slw, steady release f insulin that is needed even when n fd is eaten. Sme peple refer t basal insulin as backgrund insulin.??? Lantus and Levemir start t wrk in abut minutes and can last fr up t hurs. Bth insulins have quite a flat, steady actin thrughut the day and night. Because f their flat actin, they are nt effective in cntrlling bld sugars after eating. Peple wh use Lantus r Levemir als need rapid-acting insulin when they eat. Imprtant infrmatin abut Lantus and Levemir: D nt mix Lantus r Levemir in a syringe with any ther insulin. Mixing will change the insulin actins and they will nt wrk prperly. given twice a day is ften given at breakfast and at dinner r bedtime. Talk t yur diabetes team abut gd times t give yur insulin. Lantus and Levemir are clear insulins. Read the label t avid cnfusin with ther clear insulins. D nt use the insulin if it lks cludy. Start a new vial r cartridge f Lantus every 4 weeks. Start a new cartridge f Levemir every 6 weeks. (The insulins lse strength and sterility if pen lnger). If yu are switching frm NPH insulin t Lantus r Levemir insulin, yur dctr may start yu n a lwer dse than yur previus ttal daily dse f NPH t help prevent hypglycemia (lw bld sugar). Lantus and Levemir may nt last 24 hurs in all peple. Sme peple may need t give them twice a day. This is cmmn when Levemir is used. Give yur basal insulin (Lantus r Levemir) at the same time each day. A cmmn time t give basal insulin nce a day is at bedtime. Basal insulin that is The amunt f rapid-acting insulin that is needed fr fd r t crrect high bld sugars may be different when using Lantus r Levemir than the amunt that was used when yu were n NPH. D nt inject Lantus r Levemir int a muscle. T decrease the pssibility f injecting int a muscle: 1) gently pinch up a small hill f fat at the injectin site 2) avid muscular areas where there is nt much fat. A small number f peple may feel a burning sensatin where they inject Lantus. Lantus and Levemir are nt currently apprved fr use in pregnancy. Lantus and Levemir are mre expensive than NPH, and the cst may nt be fully cvered by BC PharmaCare r sme health plans. Lantus and Levemir are currently licensed in Canada fr children 6 years and lder. Discuss this with yur dctr if yu are cnsidering using either insulin in a child. August 31, 2009 enddiab.bcchildrens.ca/pdf/basalblus.htm page 4 f 35

8 Why is Rapid-Acting Insulin Als Used in a Basal-Blus Plan? Rapid-acting insulin is used as the blus part f a multiple daily injectin (MDI) basal blus plan. It is given befre carbhydratecntaining meals and snacks t keep bld sugars frm rising t high after eating. Like the pancreas, which prduces extra insulin t match fd that is eaten, bluses f rapid-acting insulin are given fr fd. Rapidacting insulin is given when fd is eaten and in amunts that match the fd. This allws fr mre flexibility with the amunts and timing f meals and snacks. Carbhydrate cunting and Insulin-t-Carbhydrate (CHO) Ratis are tw imprtant tls fr matching insulin and fd in a basal blus plan. Fr mre infrmatin see ur handuts: Carbhydrate Cunting and Rapid-Acting Insulin fr Carbhydrate and High Bld Sugar. Yu can als test yur carb cunting knwledge by ding the Carb Cunting Quiz - answers are included! Rapid-acting insulin can als be given t quickly lwer high bld sugars. Rapid-acting insulin starts t wrk in abut 15 minutes and is wrking very hard in abut 90 minutes. Giving extra rapid-acting insulin fr high bld sugars can shrten the amunt f time that the bld sugar is high. (A Crrectin Factr r an Insulin Scale can be used t help yu decide hw much extra rapid-acting insulin t give fr high bld sugars. Fr mre infrmatin n Crrectin Factrs and Insulin Scales see ur handuts What are a Crrectin Factr, Crrectin Blus and Insulin Scale? and Rapid-Acting Insulin fr Carbhydrate and High Bld Sugar.) Can Regular (fast-acting) insulin be used in a basal blus plan? Regular fast-acting insulin (Humulin R r Nvlin Trnt) may be mre suitable than rapidacting insulin fr sme peple. Fr example, if a child r teen wants t eat a carbhydrate snack every mrning and des nt want t give a blus f rapid-acting insulin t cver the snack, Regular insulin may be mre suitable t cver bth the breakfast and the snack. Discuss this with yur diabetes health team. Rapid-acting insulin nly lasts fr abut 3 4 hurs. Because f its shrt actin, it must be used alng with a lnger-acting, backgrund (basal) insulin. Three brands f rapid-acting insulin are available in Canada: NvRapid Humalg and Apidra August 31, 2009 enddiab.bcchildrens.ca/pdf/basalblus.htm page 5 f 35

9 Basal-Blus Insulin Actin with Lantus r Levemir and Rapid-Acting Insulin The fllwing tw pictures shw the actins f Lantus r Levemir (basal) and rapid-acting insulins Humalg, NvRapid r Apidra (blus) wrking t prvide basal blus insulin fr 24 hurs. Rapid-acting insulin is needed t cver carbhydrate-cntaining meals and may als be needed fr snacks. Lantus r Levemir is needed even if n fd is eaten. Basal: Lantus r Levemir Blus: rapid-acting (Humalg, NvRapid r Apidra) Humalg/NvRapid/Apidra Lantus/Levemir Breakfast Bed Dinner Lunch Breakfast Humalg/NvRapid/Apidra Lantus/Levemir Breakfast Snack Dinner Snack Lunch Breakfast Lantus/Levemir and rapid-acting insulin with meals and snacks August 31, 2009 enddiab.bcchildrens.ca/pdf/basalblus.htm page 6 f 35

10 Basic Insulin Actin Actin Prfiles f Cmmn Insulins Lantus/Levemir Regular/Trnt Humalg/NvRapid/Apidra NPH hurs INSULIN NAME STARTS STRONGEST LASTS Humalg/NvRapid/Apidra minutes minutes 4-5 hurs Regular / Trnt minutes 2-4 hurs 5-8 hurs NPH 1-3 hurs 5-8 hurs up t 18 hurs Lantus / Levemir 1-1½ hurs nne hurs August 31, 2009 enddiab.bcchildrens.ca/pdf/basalblus.htm page 7 f 35

11 What are a Crrectin Factr, Crrectin Blus and Insulin Scale? Either a Crrectin Factr r an Insulin Scale can be used in a basal blus plan t bring high bld sugars back int yur target r gal range. Using a Crrectin Factr r Insulin Scale allws yu t crrect high bld sugars by giving additinal rapid-acting insulin at meal times and ther times. Crrectin Factr: A Crrectin Factr is an estimatin f hw much 1 unit f rapid-acting insulin will lwer the bld sugar. (Anther term fr the Crrectin Factr is the Insulin Sensitivity Factr, r ISF). Crrectin Factrs must be individually set fr each persn. Fr example, ne persn may find that 1 unit f rapid-acting insulin lwers their bld sugar by 2 mml/l, while anther persn may find that 1 unit f rapid-acting insulin lwers their bld sugar by 3 mml/l. Yur diabetes team will estimate yur Crrectin Factr fr yu r will teach yu hw t d this. Once yu knw yur Crrectin Factr, yu can calculate hw much rapid-acting insulin is needed t bring a high bld sugar back int yur target range. The amunt f rapid insulin that is given fr a high bld sugar is referred t as a Crrectin Blus r a Crrectin Dse. Crrectin Blus: The frmula that is used t calculate a Crrectin Blus (Crrectin Dse) is: Crrectin Blus = Current Bld Sugar - Target Bld Sugar Crrectin Factr Example: Current Bld Sugar = 15 Target Bld Sugar = 7 Crrectin Factr = 2 Crrectin Blus = = 4 units f rapid-acting insulin Practice Questin: Use the example belw t practice figuring ut hw much rapid-acting insulin t give: Example: Current Bld Sugar = 10.7 Target Bld Sugar = 8 Crrectin Factr = 5 What is the crrectin blus? Crrectin Blus = Current Bld Sugar (10.7) - Target Bld Sugar (8) Crrectin Factr (5) = 0.54 Answer: Crrectin Blus = ½ unit f rapid-acting insulin (runded dwn t nearest half-unit). Ntes: 1. Only give a Crrectin Blus if the amunt needed is at least a ½ unit. 2. Crrectin Factrs may change ver time depending n yur sensitivity t insulin. If yu ntice a pattern where yur bld sugars d nt cme back int the gal range within 3 4 hurs f giving a Crrectin Blus, it may mean yur Crrectin Factr needs t be changed. August 31, 2009 enddiab.bcchildrens.ca/pdf/basalblus.htm page 8 f 35

12 Insulin Scale: Sme peple find it easier t have their pre-meal blus dses written n an Insulin Scale instead f calculating the dse each time they need rapidacting insulin. An Insulin Scale prvides a list f hw much insulin t give befre a meal. The amunt f insulin listed n a scale includes a Crrectin Blus (already calculated) and takes int accunt the pre-meal bld sugar level as well as the amunt f carbhydrate that is usually eaten at that meal. Insulin Scales are smetimes called Crrectin Scales, Variable Insulin Dse Scales r Sliding Scales t emphasize that the dse f rapid-acting insulin is nt always the same. When a bld sugar is higher r lwer than the gal bld sugar, mre r less rapid insulin is given accrding t the amunt listed n the Insulin Scale. When using a scale, it is still imprtant t THINK abut the dse f insulin. Cnsider the amunt f fd and activity that yu are planning, as these will als affect the amunt f insulin needed. Fr example, if yu are ging t eat mre than usual, yu may need mre insulin than the amunt listed n yur scale. Or, if yu are ging t be mre active than usual, yu may need less insulin than the amunt listed n yur scale. Yur diabetes team can prvide yu with an insulin scale r shw yu hw t set up yur wn scale. Example: An example f an Insulin Scale fr Alisa is shwn belw. In the example, a Crrectin Factr is built int the scale: the dse f rapid-acting insulin ges up by 1 unit fr every 4 mml/l that the bld sugar is abve Alisa s gal range f 4 8 befre meals. Alisa usually eats the same amunt f carbhydrate (CHO) each day. Althugh her carbhydrate intake is the same, her dse f rapid-acting insulin varies accrding t her pre-meal bld sugar level. Bld Sugar Breakfast Rapid Lunch Rapid Dinner Rapid Less than 4 (treat lw!) Abve NOTES: Pre-meal BG gal: 4-8 Usual Meal CHO: Usual Meal CHO: Usual Meal CHO: Crrectin Factr: 55 grams 60 grams 60 grams 1 unit lwers bld sugar by abut 4 mml/l Check ketnes if BG >15 Insulin:CHO Rati: 1:15 Insulin:CHO Rati: 1:20 Insulin:CHO Rati: 1:20 August 31, 2009 enddiab.bcchildrens.ca/pdf/basalblus.htm page 9 f 35

13 CHECK YOUR UNDERSTANDING: Using the Insulin Scale n page 9, and assuming usual meal sizes and activity levels: 1. Hw much rapid-acting wuld yu give if the bld sugar befre lunch is 14.7? 2. Hw much rapid-acting wuld yu give if the bld sugar befre dinner is 5.2? 3. If Alisa plans t eat an extra 15 grams f carbhydrate (CHO) at breakfast, shuld she take the amunt f insulin shwn n her scale? Anther Example f an Insulin Scale: Here is anther example f what an Insulin Scale culd lk like. The scale belw shws hw crrectin dses can be used fr bld sugars utside f the gal range. In this example the gal bld sugar range befre meals is 4 6 mml/l. The scale includes a standard insulin dse and uses a Crrectin Factr f 2 (already calculated). As shwn n the scale, the insulin dse changes fr every 2 mml/l that the bld sugar is abve r belw the gal range. Answers: 1. 5 units units. 3. N. The amunt f insulin n the scale is fr the amunt f CHO she usually eats. If she plans t eat mre CHO than usual, she will need mre insulin. Using her Insulin:CHO Rati fr breakfast, she will need an extra 1 unit f rapid insulin fr an extra 15 grams f carbhydrate. Nte: The amunt f insulin listed n the scale des nt take int accunt changes in carbhydrate r activity. If a different amunt f carbhydrate is ging t be eaten r activity levels will be different than usual, a different amunt f insulin will be needed. Bld Sugar Breakfast Rapid Lunch Rapid Dinner Rapid Less than 4 (treat lw!) Standard dse Standard dse Standard dse Greater than Usual Meal CHO: Usual Meal CHO: Usual Meal CHO: Reminder: The dses listed n yur Insulin Scale smetimes need t be adjusted. August 31, 2009 enddiab.bcchildrens.ca/pdf/basalblus.htm page 10 f 35

14 Fitting Basal-Blus int Daily Life: Is MDI fr Yu? Yu may have already dne sme reading abut a basal blus apprach t diabetes management but still want a better idea f what it wuld invlve in real life. This handut prvides three examples t give yu a picture f what a basal blus insulin plan culd lk like in the life f a child r teen with diabetes. Mike is 16 years ld, Jenny is 11 and Cammie is 2½. As yu will see, each plan is individualized accrding t the interests and needs f the child and family. Reviewing these examples may help yu decide if yu are interested and ready t start n basal blus insulin t. A checklist is als included in a separate handut t help yu decide if yu are interested and ready t switch t basal blus insulin therapy. (See ur handut: Are Yu Ready fr Basal Blus Insulin?). Yur diabetes team can als give yu infrmatin t help yu make an infrmed decisin abut starting n a basal blus insulin plan. MDI August 31, 2009 enddiab.bcchildrens.ca/pdf/basalblus.htm page 11 f 35

15 EXAMPLE One: MIKE, 16 YEARS OLD Mike switches frm using insulin three times a day t a basal blus plan with Lantus nce a day at bedtime and rapid insulin befre each meal and snack. Mike knws he will need t d his bld sugar and insulin mre frequently than befre, but he thinks the lifestyle gains will definitely make it wrthwhile. He is lking frward t mre flexibility with fd, better bld sugar cntrl during and after physical activity, and f curse sleeping in as lng as his parents will let him! Mike has been using insulin pens fr bth his NPH and rapid (Humalg) insulin fr abut a year. He likes pens and will cntinue using them. Backgrund Infrmatin: Mike has had type 1 diabetes fr 10 years. He is very active in sprts and has recently started training with a cmpetitive swim team. He has been having difficulty with his bld sugars since training, and he is frustrated that his meal times have been interfering a bit with his training schedule. He wants t imprve his bld sugars s he will have plenty f energy when he is training. He als wants mre flexibility with meal times and the amunt he eats. Mike desn t want t fllw a set meal plan r schedule but he wants t keep his bld sugars in his target range as ften as pssible. Mike and his parents feel he will d better using an Insulin-t-Carbhydrate Rati* and a Crrectin Factr* t calculate hw much insulin t give fr fd r high bld sugars. Fr the past while, Mike s irregular snacks and eating times have been a surce f stress between him and his parents. They all like the idea f learning t use basal blus insulin. Sample Basal Blus Plan fr Mike Basal Insulin: Lantus 28 units at 10:30 pm (befre bed) Blus insulin befre meals: Humalg dse calculated by using his: Ntes: 1) Insulin:Carbhydrate rati f 1 unit f Humalg fr every 10 grams f carbhydrate PLUS Crrectin Blus fr high bld sugar: 1 unit f Humalg fr every 2 mml/l ver his target bld sugar f 7 mml/l befre meals = ttal dse f rapid-acting insulin (Humalg) befre meals Mike als gives bluses f rapid-acting insulin if he eats carbhydrate-cntaining snacks. 2) T prevent lw bld sugars during the night, Mike uses a higher bld glucse target and less insulin fr bedtime bluses. *Fr mre infrmatin abut Insulin-t-Carbhydrate Ratis and Crrectin Factrs, see ur handut: Rapid-Acting Insulin fr Carbhydrate and High Bld Sugar. August 31, 2009 enddiab.bcchildrens.ca/pdf/basalblus.htm page 12 f 35

16 A Sample Day fr Mike 7:30 am Wake up. 10: am Decide n snack. 12:00 Nn 3:45 pm 5:30 pm 6:30 pm 10:00 pm 10:30 pm 3:00 am Check and recrd bld sugar. Decide what t eat fr breakfast. Give blus f rapid (Humalg) insulin befre breakfast. (Add tgether the Carbhydrate Blus and, if needed, a Crrectin Blus. Mike gives a Crrectin Blus fr bld sugars higher than his target f 7 mml/l.) Depending n the type and size f the snack, a blus f rapid insulin might be needed. (Mike uses an Insulin:CHO Rati t calculate the amunt f Humalg t give fr snacks that cntain carbhydrate.) Check bld sugar. Decide what t eat fr lunch. Give blus f rapid insulin (Humalg) befre lunch. (Add tgether the Carbhydrate Blus and, if needed, a Crrectin Blus.) Get ready fr an hur and a half f intense swimming. Check bld sugar befre getting in the water and decide n what snack is needed. Mike des nt need a blus fr his afternn snack n swim days. (Hwever, n nn-swim days he needs t blus fr his afternn snacks which generally include lts f carbhydrate!) Frm previus experience swimming and ding lts f bld sugar checks, Mike knws what his bld sugar needs t be and hw much he needs t eat fr his bld sugar t be k when he swims. Check bld sugar after swimming. Check bld sugar befre dinner Give blus f Humalg befre dinner. (Add tgether the carbhydrate blus and if needed, a crrectin blus.) Check bld sugar and decide n bedtime snack. Depending n his bld sugar and what he is ging t eat, he may need sme rapid-acting insulin. T prevent lw bld sugars during the night, Mike has a different Insulin:Carbhydrate Rati and a different Crrectin Factr t use at bedtime. He has a higher bld glucse target and gives less insulin fr bedtime bluses, especially n active days. Give Lantus befre bed. Wake up and check bld sugar. (This des nt need t be dne every night; hwever, Mike s training was very intense tday and he wants t make sure he des nt have a delayed lw bld sugar.) August 31, 2009 enddiab.bcchildrens.ca/pdf/basalblus.htm page 13 f 35

17 EXAMPLE Tw: JENNY, 11 YEARS OLD Jenny switches frm using NPH and NvRapid insulin twice a day t a basalblus plan with Levemir twice a day and NvRapid befre each meal. changing t a basal blus plan, Jenny and her parents met with her dctr and diabetes educatr t make sure they had enugh infrmatin abut the prs and cns f basal blus insulin and t make sure they had a plan that suited them well. They decide t switch t basal blus t help imprve Jenny s bld sugars and t gain mre flexibility with meal and snack times. They als like the idea f being able t sleep in lnger than usual n weekends. They will cntinue using a meal plan t guide fd chices but they als want t learn t use an Insulin:CHO Rati fr mre flexibility with meal and snack sizes. They decide that an insulin pen and an insulin scale will make it is easier fr Jenny t give her NvRapid at schl. Jenny and her parents already knw hw t use an insulin scale and want t keep using ne as part f deciding hw much insulin t give befre breakfast, lunch, dinner and Jenny s bedtime snack. Backgrund Infrmatin: Jenny has had type 1 diabetes fr three years. She and her family have been using a meal plan and infrmatin frm Beynd the Basics t make chices abut her fd. They feel a meal plan wrks well fr them, and they have a gd understanding f hw much carbhydrate is in each fd chice. They knw hw t include variety in Jenny s meals and snacks by trading different types and amunts f fd accrding t the fd chice system. Jenny eats quite cnsistently frm day t day but there are times she wuld like t eat mre r less than the amunt included in her meal plan. They wuld als like t have mre flexibility with meal times, especially at dinner time and n weekends. After meeting with her diabetes team, Jenny and her parents make a plan fr starting n basal blus insulin. They als see the dietitian at the clinic t review her meal plan and learn abut any special cnsideratins fr snacks n a basal blus plan with Levemir. They will be in cntact with the diabetes nurse regularly during the first cuple f weeks t review Jenny s bld sugars and insulin dses. Once her baseline dses have been established, they will be given an Insulin:CHO Rati t adjust her rapid insulin fr changes in meal r snack sizes. They als sign up fr a wrkshp t gain mre knwledge and cnfidence fr adjusting insulin n their wn. August 31, 2009 enddiab.bcchildrens.ca/pdf/basalblus.htm page 14 f 35

18 Jenny s Basal Blus Plan Basal insulin: Levemir 6 units befre breakfast and 6 units at bedtime AND Blus insulin befre meals: NvRapid is given accrding t an Insulin Scale. Jenny s gal bld glucse range is 4-8 mml/l. Her Insulin Scale includes a standard insulin dse fr her usual carbhydrate at meals. It als includes a Crrectin Factr (already calculated) fr bld sugars abve gal range. If Jenny s bld sugar is lwer than 4 befre a meal, it must be treated immediately her mealtime blus will als be smaller than usual. Jenny s Crrectin Bluses at bedtime are smaller than during the day in rder t prevent hypglycemia during the night. Bld Sugar Breakfast Rapid Lunch Rapid Dinner Rapid Bedtime Rapid < * 3* 4* -* ½ 3½ 4½ ½ 4½ 5½ ½ 5½ 6½ 2½ >20 6½ 6½ 7½ 3½ Jenny s standard dse fr rapid insulin is shwn with a *. This is the amunt f rapid insulin she takes befre each meal if her bld sugar is in the gal range and she is ging t fllw her usual meal plan and activity levels. If she is ging t eat a different amunt f carbhydrate than usual at meal time, her insulin dse will be increased r decreased by using her Insulin:CHO Rati. She has a specific rati fr each meal. These were calculated with the help f the diabetes team after Jenny s standard insulin dses were set. Ntes: 1) Rapid-acting insulin may als be given if Jenny is ging t eat extra snacks. 2) If Jenny is planning t d mre exercise than usual after her meals, her dse f Rapid-acting insulin will be lwer than the usual amunt nted n the scale. 3) Jenny nly has a crrectin blus at bedtime if her bld sugar is abve 14 mml/l. Her crrectin bluses at bedtime are abut half the amunt f thse used during the day. August 31, 2009 enddiab.bcchildrens.ca/pdf/basalblus.htm page 15 f 35

19 A Sample Day fr Jenny 7:30 am Check bld sugar. Give Levemir with insulin pen. Use Insulin Scale t decide n amunt f rapid-acting insulin t give fr usual breakfast. Give NvRapid with insulin pen. Eat breakfast and leave fr schl. 10:3 am Break-time. As usual, Jenny des nt eat a mrning snack as she prefers t just have fun with her friends. Smetimes she eats a snack that cntains very little carbhydrate and des nt require a blus f rapid-acting insulin. 12:00 Nn 3:30 pm 6:00 pm 8:00 pm 9:30 pm 3:00 am Check bld sugar. Plan t eat usual lunch which she brings frm hme. Use Insulin Scale t decide n amunt f NvRapid insulin t give befre lunch. (Jenny has a cpy f her Insulin Scale in her bag and ne in her lunch kit as a back-up.) Give NvRapid with insulin pen and eat lunch. Althugh Jenny smetimes eats an afternn snack she desn t want ne tday. She knws that fr her usual afternn snack which cntains 15 grams f carbhydrate she needs t give 1 unit f NvRapid insulin. Tday, because she is nt ging t eat a snack, she desn t need t take any NvRapid insulin until dinner time. Check bld sugar. Plan t eat mre carbhydrate at supper tnight her favrite dessert! Use Insulin Scale and Insulin:CHO Rati t decide n insulin dse: *Insulin Scale PLUS additinal rapid insulin fr planned larger meal = ttal amunt f rapid t give befre dinner. Use Insulin:CHO Rati t decide n amunt f additinal rapid insulin t give fr the dessert. Jenny needs 1 unit f rapid fr every 15 grams f carbhydrate. They estimate the dessert cntains 30 grams f carbhydrate. She will eat this in additin t her usual supper. Using the Insulin: CHO Rati they decide Jenny needs an additinal 2 units f NvRapid. Check bld sugar 2 hurs after dinner tnight t see hw well the insulin dse matched her fd. Check bld sugar befre bed. It is 8.2, s n bedtime snack is needed. Jenny is happy abut this as she is still full frm dinner and dessert. (She knws she needs t eat a snack at bedtime if her bld sugar is less than 7 mml/l.) Give Levemir befre bed. Check bld sugar. Jenny and her parents are glad this des nt need t be dne every night! But they knw it needs t be dne smetimes t make sure Jenny is getting the right amunt f Levemir insulin and nt getting t lw while she is sleeping. August 31, 2009 enddiab.bcchildrens.ca/pdf/basalblus.htm page 16 f 35

20 EXAMPLE Three: CAMMIE, 2½ years ld Cammie is 2½ years ld. She has had diabetes since the age f 18 mnths. Her parents wuld like t be able t let Cammie sleep thrugh nap times withut having t wrry abut whether r nt she has eaten a snack. They wuld als like t have mre flexibility with her diabetes management s they can better respnd t her variable appetite and fd interests. They are used t giving Cammie insulin twice a day and d nt mind the idea f giving her mre frequent injectins. They talk t the diabetes team and decide that a basal blus plan with Levemir and NvRapid (rapid-acting) insulin wuld be a gd chice fr Cammie. They will use insulin pens fr her NvRapid and Levemir insulins. They chse the Pen Junir because it measures half-units which Cammie ften needs. They will learn t calculate her NvRapid insulin dses using a Crrectin Factr and an Insulin:CHO Rati. They understand that her Levemir dse, her Crrectin Factr, and her Insulin:CHO Rati will all need t change as Cammie grws. Instead f fllwing a meal plan as they have in the past, they will fcus n verall nutritinal needs and will als learn hw t cunt and estimate carbhydrates. They need t learn mre abut insulin dse adjustments and carbhydrate cunting and are keen t d this. Backgrund Infrmatin: Althugh they have sme learning needs, Cammie s parents are already in a gd psitin t make a switch t basal blus insulin. They are already used t checking her bld sugars every day befre meals and they usually check during the night at least nce a week. They have a gd understanding f insulin dse adjustments fr pattern management as they previusly cmpleted the On-Line Insulin Dse Adjustment Educatin Prgram fr parents and have been making adjustments n their wn fr a few mnths. They nw need t learn hw t use a Crrectin Factr and Insulin:CHO Ratis t calculate dses f NvRapid. They will discuss this with the diabetes nurse during their clinic visit. They will als cmplete the practice questins included in ur handut Guidelines fr Basal Blus Insulin Dse Adjustments with Lantus r Levemir and Rapid-Acting Insulin. They have sme understanding f carbhydrate cunting frm previus teaching they received n the Gd Health Eating Guide and frm ur handut Carbhydrate Cunting. Hwever, they will discuss carb cunting with the dietitian t ensure they understand it well enugh t be flexible and reach Cammie s target bld sugars. Sample Basal Blus Plan fr Cammie Basal insulin: Levemir 2 units at breakfast and 2 units at dinner (supper) time Blus insulin befre meals: NvRapid: Insulin:Carbhydrate rati: 1 unit f rapid per 40 grams f carbs (r ½ unit fr 20 grams) PLUS Crrectin Blus fr high bld sugar: Cammie is just 2½ years ld and small amunts f insulin make a big difference t her bld sugar. When her bld sugars are abve 12 mml/l, her parents give her a Crrectin Dse f NvRapid. They knw that ½ a unit will lwer Cammie s bld sugar by abut 6 mml/l. = ttal dse f rapid-acting insulin (NvRAPID) befre meals August 31, 2009 enddiab.bcchildrens.ca/pdf/basalblus.htm page 17 f 35

21 A Sample Day fr Cammie 8:00 am Wake up. Check and recrd bld sugar. Give Levemir insulin. Estimate hw much carbhydrate Cammie will eat fr breakfast. Give rapid insulin befre breakfast. (Add tgether the Carbhydrate Blus and the Crrectin Blus fr bld sugars greater than 12 mml/l.) Nte: If Cammie was a fussy eater her parents culd give her rapid insulin after breakfast s they culd better match the insulin dse with the amunt f carbhydrate eaten. 10:0 am Cammie has a small snack. It cntains less than 10 grams f CHO s she des nt need any insulin fr it. 11:00 am 12:00 nn 1:15 pm 3:30 pm 5:30 pm 11:00 pm Cammie is sleepy and fussy. She needs t have a nap. Check bld sugar t make sure she is nt lw befre ging t sleep. Settle Cammie fr her nap. This is Cammie s usual lunch time. Cammie s basal dse f Levemir has been wrking well s her mther des nt wake Cammie t eat lunch at her usual lunch time. When Cammie awakens she will be hungry and ready fr lunch her mther will check her bld sugar and give her blus insulin at that time. Cammie wakes up frm her nap. Cammie s mther checks her bld sugar and gives Cammie her blus insulin befre lunch (Carbhydrate Blus + Crrectin Blus if needed.) Cammie is full f energy and playing with her surprise visitr her 5-year-ld cusin. Her mm checks her bld sugar and gives her a small snack. Check bld sugar befre dinner. Give Levemir insulin. Give blus f NvRapid insulin befre dinner. (Carbhydrate Blus + Crrectin Blus if needed.) 7:30 pm Check bld sugar and get Cammie ready fr bed. If her bld sugar is less than 7 mml/l at bedtime, Cammie s parents make sure she has a snack that cntains carbhydrate and prtein. Cammie s parents are tired after a busy day. They expect t have a gd sleep tnight and d nt plan t get up t check Cammie s bld sugar during the night. They have recently dne sme bld sugar checks at abut 3 clck in the mrning and are cnfident that Cammie s bld sugars will be k n her current dse f Levemir insulin. August 31, 2009 enddiab.bcchildrens.ca/pdf/basalblus.htm page 18 f 35

22 Are Yu Ready fr Basal-Blus Insulin? There are many advantages t using basal blus insulin in diabetes management. Are yu ready t start? Cnsider the fllwing: Prs: What d yu see as the main advantages (prs) f basal blus insulin? Cns: What d yu see as the main disadvantages (cns) f basal blus insulin? And: r D yu want t imprve yur bld sugars and have a mre flexible lifestyle? r Are bth yu and yur parents interested? r Are yu already in the habit f checking bld sugars at least 4 times a day and d yu keep recrds? r D yu make adjustments t insulin based n patterns in bld glucse? r D yu want t learn mre abut insulin dse adjustment t imprve bld sugars and gain flexibility? r D yu fllw a meal plan and/r cunt carbhydrates? r Have yu thught abut hw insulin will be given at schl? r Have yu cnsidered the cst f Lantus r Levemir insulin cmpared t NPH? r Are yu willing t maintain regular cntact with yur diabetes team, especially during the first few weeks after yu start n basal blus insulin? r In yur pinin, d the prs f basal blus insulin utweigh the cns? If yu answer YES t mst f the questins n this page, this culd be a gd time t start n a basal blus plan. Talk t yur diabetes team and cntinue with yur reading abut basal blus insulin. If yu d nt answer YES t mst f the questins n this page, yu may nt yet be ready t start basal blus insulin. Hwever, if yu are interested in basal blus insulin, there are things yu can d t get ready. Discuss this with yur diabetes educatin team and make a plan. August 31, 2009 enddiab.bcchildrens.ca/pdf/basalblus.htm page 19 f 35

23 Getting the Mst Benefit frm Basal-Blus Insulin In rder t get the mst benefit frm yur new basal blus insulin plan, yu will need t: r Give insulin several times each day. r Check yur bld sugar befre each meal and at bedtime. r Match yur rapid-acting insulin dses with the fd yu eat. r Check yur bld sugar tw hurs after eating ften enugh t knw if yur insulin dse and fd are well matched. r D sme bld sugar checks at abut 3:00 am. r Recrd yur bld sugars and ther imprtant infrmatin. r Use infrmatin frm bld sugar checks t make decisins abut adjustments fr insulin, activity and/r fd. r Stay in tuch with yur diabetes team, especially during yur first cuple f weeks n basal blus insulin. r Wrk with yur diabetes team t develp yur knwledge, cnfidence and skills fr using basal blus therapy. P P P P Checklist fr Learning: r Learn insulin dse adjustments fr pattern management. r Wrk with a dietitian t develp the knwledge yu need fr healthy eating and maintaining a healthy bdy weight. r Learn carbhydrate cunting. If yu d nt knw hw t carbhydrate cunt but yu want mre flexibility with yur fd, yu will need t learn. Plan t see a dietitian r attend a carbhydrate cunting wrkshp. Yu can als read ur Carbhydrate Cunting handut. r Learn hw t use an Insulin:Carbhydrate Rati when yu are making insulin dse adjustments fr changes in fd. r Learn hw t match insulin dses t changes in fd and/r activity. r Learn hw t use a Crrectin Factr r an Insulin Scale t respnd t bld sugars utside f the gal range. r Review yur bld sugar recrds t see hw well yur insulin dses, Insulin:CHO Ratis, and Crrectin Factrs are wrking. Learn as much as pssible befre starting n yur basal blus insulin plan. August 31, 2009 enddiab.bcchildrens.ca/pdf/basalblus.htm page 20 f 35

24 Guidelines fr Basal-Blus Insulin Dse Adjustments with Lantus r Levemir and Rapid-Acting Insulin Adjusting insulin fr a basal blus insulin plan includes: 1. adjusting basal insulins (Lantus r Levemir) and/r blus insulins (Humalg r NvRapid) based n patterns in bld sugars 2. adjusting rapid-acting insulin t quickly bring dwn high bld sugars by using a Crrectin Factr r an Insulin Scale 3. adjusting rapid-acting insulin t match fd by using an Insulin:CHO Rati (CHO=carbhydrate) 4. adjusting insulins fr physical activity r ther events Yur diabetes dctr and nurse will wrk with yu initially t help establish the baseline dses fr yur Lantus r Levemir and rapid insulins. Hwever, it is als imprtant t learn t adjust insulin yurself. Talk t yur diabetes nurse educatr r attend a wrkshp t learn mre abut adjusting insulin. The fllwing infrmatin prvides sme general guidelines fr adjusting insulin based n patterns in bld sugars. There are als several examples f hw t calculate the amunt f rapid-acting insulin t give fr high bld sugar r carbhydrate-cntaining fd. Several questins are included s yu can practice figuring ut insulin dses n yur wn. The guidelines and examples included in this handut are nt meant t replace ther educatin sessins r the advice f yur dctr. *Nte: In this handut the term rapid insulin refers t rapid-acting insulin. There are three types f rapid-acting insulin available in Canada: NvRapid, Humalg and Apidra. August 31, 2009 enddiab.bcchildrens.ca/pdf/basalblus.htm page 21 f 35

25 Insulin Dse Adjustments Guidelines fr Pattern Management Pattern management invlves adjusting insulin dses based n patterns in bld glucse. A pattern is a cnsistent trend where the bld sugar is either t high r t lw at the same time f day, r in the same situatin fr several days in a rw. Fr example, if the bld sugar is fine each day befre dinner but it is t high fr three days in a rw befre the bedtime snack, yu can say there is a pattern f high bld sugar befre bed. T change this pattern, it is imprtant t think abut which insulin is having the greatest effect at the time the bld sugar is t high (e.g. befre the bedtime snack.) The fllwing guidelines briefly highlight pints t cnsider when making insulin dse adjustments based n patterns in bld glucse. Fr a mre detailed descriptin f insulin dse adjustments, see ur handut Guidelines fr Insulin Adjustment. General Guidelines: Knw yur bld sugar gals If bld sugars are nt in target (gal) range, cnsider reasns Lk fr patterns (trends in bld sugars ver abut 3 days) Decide which insulin needs t be adjusted Adjust fr lw bld sugars first When bld sugars are utside f the gal range at mre than ne time f day, fix the first prblem first. (Fr example, if the bld sugar is high befre lunch and befre dinner, start by adjusting insulin t lwer the bld sugars befre lunch.) If all sugars are high, begin with imprving the bld sugar befre breakfast Change 1 insulin at a time Always assess the effect f dse changes Call yur diabetes health prfessinal when yu need help Questins t ask yurself when yu are making adjustments fr patterns: When is yur bld sugar utside f the gal range? Is yur bld sugar t high r t lw at this time? Which insulin has the greatest effect n the bld sugar at this time? Des the insulin need t be changed, r wuld it be mre suitable t make changes t yur diet r activity? Des the dse need t be increased r decreased? REMINDER: Insulin dses change ver time. If yu see patterns f high r lw bld sugars, yu als need t cnsider if yur basal insulin needs t be changed and/r if yur Crrectin Factr, Insulin Scale r Insulin:CHO Ratis need t be changed. August 31, 2009 enddiab.bcchildrens.ca/pdf/basalblus.htm page 22 f 35

26 Knw Which Insulin Has the Greatest Effect n Each Bld Sugar In rder t adjust insulin dses, yu need t knw which insulin has the greatest effect n each bld sugar. NOTE: The fllwing chart shws which insulin has the greatest effect n each bld sugar fr a persn wh takes Lantus r Levemir nce a day in the evening (at bedtime r at dinner) and rapid insulin (NvRapid, Humalg r Apidra) befre meals. INSULIN Evening Basal (Lantus r Levemir) Breakfast Rapid (NvRapid, Humalg r Apidra) Lunch Rapid (NvRapid, Humalg r Apidra) Dinner Rapid (NvRapid, Humalg r Apidra) AFFECTS = = = = = = = = BLOOD SUGAR Overnight Breakfast 2 hurs after breakfast Lunch 2 hurs after lunch dinner 2 hurs after dinner bed NOTE: It is cmmn fr Levemir t be given tw times a day (mrning and evening). The mrning Levemir has its greatest effect n the bld sugar befre dinner. See the fllwing Bnus Questins fr mre infrmatin abut using Levemir tw times a day. Check yur understanding Answer the questins n the next pages t check yur understanding f insulin actin. August 31, 2009 enddiab.bcchildrens.ca/pdf/basalblus.htm page 23 f 35

27 CHECK YOUR UNDERSTANDING: The fllwing questins include examples f bld sugar recrds fr a persn wh takes Lantus r Levemir nce a day in the evening (at dinnertime r at bedtime) and rapid-acting insulin befre breakfast, lunch and dinner. This persn des nt usually snack between meals. QUESTIONS: 1. Which insulin has the greatest effect n the bld sugar befre dinner? 2. Which insulin has the greatest effect n the bld sugar befre breakfast? 3. Lk at the fllwing bld sugar recrd and decide which insulin needs t be changed. In this example, yu can assume the amunts f activity and fd are similar each day. DATE BLOOD SUGAR Breakfast After Breakfast Lunch After Lunch Dinner After Dinner Bed MONDAY TUESDAY WEDNESDAY Lk at the fllwing bld sugar recrd and decide which insulin needs t be changed. In this example, yu can assume the amunts f activity and fd are similar each day. DATE BLOOD SUGAR Breakfast After Breakfast Lunch After Lunch Dinner After Dinner Bed MONDAY TUESDAY WEDNESDAY August 31, 2009 enddiab.bcchildrens.ca/pdf/basalblus.htm page 24 f 35

28 5. Lk at the fllwing bld sugar recrd and decide which insulin needs t be changed. In this example, yu can assume the amunts f activity and fd are similar each day. DATE BLOOD SUGAR Breakfast After Breakfast Lunch After Lunch Dinner After Dinner Bed MONDAY TUESDAY WEDNESDAY Lk at the fllwing bld sugar recrd and decide which insulin needs t be changed. In this example, yu can assume the amunts f activity and fd are similar each day, except fr Tuesday mrning when there was mre exercise than usual. DATE BLOOD SUGAR Breakfast After Breakfast Lunch After Lunch Dinner After Dinner Bed MONDAY TUESDAY WEDNESDAY ANSWERS: 1. The rapid insulin given at lunch has the greatest effect n the bld sugar befre dinner. 2. The evening Lantus r Levemir has the greatest effect n the bld sugar befre breakfast. 3. The rapid insulin at dinnertime needs t be changed. (Mre insulin is needed. There is a pattern f high bld sugars befre bed.) 4. The evening Levemir r Lantus needs t be changed. (Less insulin is needed. The bld sugar befre breakfast has been lw fr tw days in a rw.) 5. The rapid insulin befre breakfast needs t be changed. (Mre insulin is needed. There is a pattern f high bld sugars after breakfast and befre lunch.) 6. The rapid insulin befre lunch needs t be changed. (Mre insulin is needed. There is a pattern f high bld sugars befre dinner.) August 31, 2009 enddiab.bcchildrens.ca/pdf/basalblus.htm page 25 f 35

29 BONUS QUESTIONS: When and why is basal insulin given tw times a day? Levemir is a basal insulin that is given ne r tw times a day depending n the amunt that is given and hw lng it lasts. Fr sme peple, Levemir lasts up t 24 hurs and can be given nce a day in the evening. Fr ther peple, Levemir des nt last 24 hurs and needs t be given twice a day nce in the mrning and nce in the evening at dinner r bedtime. Tip: One way t tell if Levemir is needed in the mrning is t lk at the bld sugars after lunch and befre dinner. If the bld sugars are always k tw hurs after lunch and high befre dinner it may mean that a mrning dse f Levemir is needed. Answer the fllwing bnus questins t learn mre abut using Levemir insulin tw times a day. 1. Is rapid insulin still needed if Levemir is given tw times a day (nce in the mrning and nce in the evening)? 2. Tina is n Levemir insulin nce a day at bedtime. She als gives NvRapid befre breakfast, lunch and dinner. Mst days she des nt eat an afternn snack, but when she des she gives NvRapid t cver the carbhydrate in her snack. Review Tina s bld sugar recrd and answer the fllwing questin: Des Tina need Levemir in the mrning as well as the evening? Why? DATE May 4 Insulin ª May 5 Insulin ª May 6 Insulin ª May 7 Insulin ª Breakfast 5.2 After Breakfast BLOOD SUGAR Lunch After Lunch NvRapid 3 NvRapid NvRapid 3 NvRapid NvRapid 3 NvRapid NvRapid 3 NvRapid 6 After Dinner Dinner 12.1 NvRapid NvRapid NvRapid NvRapid 7 During Bed Night 7.2 Levemir Levemir Levemir Levemir 16 August 31, 2009 enddiab.bcchildrens.ca/pdf/basalblus.htm page 26 f 35