Saskatchewan Insulin Adjustment Module Page 2 May 2010

Saskatchewan Insulin Adjustment Module Page 2

Saskatchewan Insulin Adjustment Module Page 3 TABLE OF CONENTS Introduction... 5 Development Background... 5 Purpose... 5 Developing The Policies, Procedures And Learning Package... 6 The Outcome... 6 Revisions For 2009... 7 Modifications For 2010... 8 How To Use The Template... 8 Resource Personnel... 11 Policy For Transfer Of Medical Function For Basic Insulin Dose Adjustment (Ida)... 12 Purpose... 12 Personnel... 12 Policies... 12 Procedures... 15 Policy Appendix... 16 Appendix A - Advanced Certification... 16 Appendix B - Sample Physician/Registered Nurse Signature Sheet... 16 Appendix C - Sample Competency Performance Checklist... 17 Competency Performance Checklist... 18 Appendix D Detailed Competencies For Self Assessment... 19 Appendix E - Sample Progress Report... 28 Appendix F - Commonly Asked Questions And Answers... 29 Learning About And Procedures For Insulin Dose Adjustment... 33 Endogenous Insulin... 33 Exogenous Insulin... 35 Insulin Approved For Use In Canada... 35 Potential Adverse Effects Of Subcutaneous Insulin Use... 36 Drugs That May Inhibit Or Potentiate Insulin Action... 36 Insulin Requirements... 37 Practical Aspects Of Insulin Management... 38 Variables Influencing Glycemic Control [Procedure]... 38 Useful Therapeutic Approaches Useful In The Prevention And Treatment Of Hypoglycemia [Procedure]... 40 Causes Of Fasting Hyperglycemia... 41 Switching To A Long-Acting Basal Insulin Analogue [Procedure]... 43

Saskatchewan Insulin Adjustment Module Page 4 Insulin Regimens And Adjustments... 45 Insulin Regimens... 45 Carbohydrate Counting... 47 Insulin Dose Adjustments (IDA) [Procedure]... 48 Pattern Management... 50 Variable Insulin Dose Adjustments... 51 Use Of Correction Factors... 51 Insulin Dose Adjustment (IDA) For Tests/Procedures When Fasting Is Required... 60 Principles To Consider For IDA For Procedures Which Require Fasting... 60 Use Of Clear Fluids For Procedure/Test Preparation... 61 Making The Decisions For IDA For MDIi Or BID Rapid/Short-Acting And Intermediate Insulin... 61 Making Insulin Dose Adjustments For Pre-Mixed Insulin... 62 Management Of Hypoglycemia While Fasting... 63 Managing Diabetes On A Clear Fluid Diet... 64 Client Assessment For Insulin Adjustment For Fasting For A Test/Procedure... 66 Managing Your Diet And Insulin For A Test Or Procedure... 68 Teaching Procedure For Self-Adjustment Of Insulin... 70 Practice Cases... 73 Answers To Practice Cases... 93 References...109 Additional Resources...111 1.0 Client Handouts On Insulin/Insulin Adjustment...111 2.0 Diabetes And Pregnancy...111 Acknowledgements...112

Saskatchewan Insulin Adjustment Module Page 5 ORGANIZATION OF THE SASKATCHEWAN INSULIN DOSE ADJUSTMENT (IDA) MODULE The Saskatchewan Insulin Dose Adjustment (IDA) Module was created in 2002. With changes in care and practice and to align with current Clinical Practice Guidelines, revisions have been made in 2005 and 2009. For ease of use, the 2009 Module is divided into three separate documents: 1. Introduction and Policy Template 2. Learning Module and Procedures 3. Practice Case and Answers INTRODUCTION Recent advances in diabetes care have enabled clients using insulin to attain near normal blood glucose control by means of self blood glucose monitoring (SBGM) and self-adjustment of insulin dosage. This level of self-care is encouraged because the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS) have demonstrated that improved glucose control reduces the risk of long-term complications of diabetes. Finally, the ability to adjust insulin dosages enables the person with diabetes to enjoy a more varied and flexible lifestyle while maintaining acceptable blood glucose control. It is recognized that clients require support while learning to self-adjust their insulin dosage. This support may require recommendations for appropriate IDA 1. DEVELOPMENT BACKGROUND In April, 2000 the Saskatchewan Advisory Committee on Diabetes presented its report, Diabetes 2000, to the Chief Medical Health Officer and the Deputy Minister of Health. To action Goal 5, Objective 5.4 a working group was formed in 2000. The membership of the group was voluntary and consisted of Certified Diabetes Educators from northern and southern Saskatchewan, representing both urban and rural diabetes education programs. The Canadian Diabetes Association facilitated the process. A member of the Saskatchewan Pharmaceutical Association audited the process in 2001. PURPOSE The Transfer of Medical Function policy and procedures template was developed to facilitate and ensure development and continuing competency for the Registered Nurse who meets the qualifications to adjust insulin promotion of self-care management and/or enhancing quality of life for people with diabetes achievement of optimal blood glucose control 1 Many professionals have the capacity to adjust insulin dosages. At present in Saskatchewan only the scope of practice of Registered Nurses permits this type of medication adjustment by Transfer of Medical Function.

Saskatchewan Insulin Adjustment Module Page 6 DEVELOPING THE POLICIES, PROCEDURES AND LEARNING PACKAGE In the preparation of this material consideration was given to several variables: needs and safety of clients who will benefit from the Registered Nurse practicing under this Transfer of Medical Function scope of practice of Registered Nurses experience needed to perform the procedures working relationships needed between the Registered Nurse practicing with a delegated medical function and the physician(s) applicability of a template for Transfer of Function to Health Regions 2 in Saskatchewan access (or not) by the Registered Nurse to lab data and medical history of clients The following steps were completed in the preparation of the original provincial template (2001): 1. Review of the Saskatchewan Registered Nurses Association (SRNA) Registered Nurse Scope of Practice documents: Special Nursing Procedures and Nursing Procedures by Transfer of Medical Functions (1993) and Guidelines for Nurses Prescribing and/or Distributing Drugs by Transfer of Function (1997). 2. Review of existing policies and procedures from Saskatchewan and other provinces, and review of selected literature and web sites. 3. Development of draft policies and procedures. 4. Review of policies and procedures by Membership of the Diabetes Educator Section in Saskatchewan Saskatchewan Registered Nurses Association Dr. M. Boctor, Endocrinologist and Professor of Medicine, University of Saskatchewan THE OUTCOME As a result of above, the Working Group made decisions about both the policies and the procedures. These decisions have been reviewed and affirmed for the 2009 edition of the template. A few of the most significant decisions are outlined below: Experience: IDA requires clinical experience beyond that of most Registered Nurses. Particularly, IDA requires that the Registered Nurse already have a sound foundation in the basics as a diabetes educator. In the 2009 edition of the Module more detailed competencies have been provided (Appendix E). The policy template continues to suggest two alternatives to equate experience: 2000 hours of practice as a diabetes educator or national certification as a diabetes educator (CDE). We recognize that CDECB 3 has reduced the qualifying practice hours to write the certification exam from 2000 to 800, but feel for competence and confidence in implementation of a Transfer of Function, more clinical practice and experience are needed. Therefore, we have retained our original recommendation of CDE status or 2000 hours of practice as a diabetes educator. Health Regions may choose to adjust the level of required experience for their own policy. 2 Health Region will be used throughout the document. The policy and procedures can also be applied by other health care organizations such as Tribal Councils. 3 Certified Diabetes Educator Certification Board www.cdecb.ca

Saskatchewan Insulin Adjustment Module Page 7 Basic Competencies: For the template to apply in most/all areas of the province, it was decided to define both basic and advanced competencies. This package only applies to the basic competencies. Not all diabetes educators will have sufficient exposure to or experience with some of the specialty areas such as pediatrics, insulin pumps or pregnancy to make advanced competencies an option. Region Decisions A critical aspect of the implementation process is the review and, as needed, customizing of the policy and procedures, by each Health Region. The Transfer of Medical Function is a Region-specific process. There are several options for the actual process. Registered Nurses and physicians in each Region must agree and be comfortable with the parameters that are Region specific. The policy, as currently written, applies only for clients whom the Registered Nurse assesses, teaches and reviews directly. The Transfer does not include the Registered Nurse doing IDA for clients of other health care providers such as Home Care Nurses, Dietitians, Pharmacists etc. If an organization wishes to extend the Transfer so that the Registered Nurse provides guidance to specific health care professionals then an additional policy will be needed. REVISIONS FOR 2009 The template was revised in 2009 to be congruent with the 2008 Clinical Practice Guidelines 4 and current diabetes care practices. The definition of basic IDA has been modified to address issues encountered by Registered Nurses who already practice under this delegated medical function. In the policy, basic continues to refer to IDA for adults with either type 1 or type 2 diabetes. The Registered Nurse, who has met the basic competencies, will consider IDA for routine situations when the person with diabetes is in the community setting and well any insulin schedule including intensive therapy/multiple injections, carbohydrate counting and development of carbohydrate to insulin ratios. management of insulin for exercise. Situations for IDA considered advanced and thus not covered by this module include: children with diabetes insulin pumps sick day management pregnancy in women with pre-existing diabetes (type 1 or type 2) gestational diabetes special circumstances (travel, shift work) 4 Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2008 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J. Diabetes. 2008;32(suppl 1):S1-S201.

Saskatchewan Insulin Adjustment Module Page 8 MODIFICATIONS FOR 2010 The module was modified in 2010 to add the section Insulin Dose Adjustment for Tests/Procedures When Fasting is Required, and additional case studies have been added. HOW TO USE THE TEMPLATE The purpose of the template is to provide guidance for Health Regions and other health care organizations to have the Registered Nurse, who meets the required competencies, adjust insulin doses. The following steps are helpful in applying the template: 1. Review the full module The module includes the policy template, the procedure module and the practice cases. As these are a guide, you may have to customize either the policy and/or the procedures to suit the particular organizational policies and/or client needs. For example, using insulin to carbohydrate ratios and/or correction factors for intensive IDA may not currently be common practice by physicians in the area and the Registered Nurse may not be exposed frequently to this as part of usual IDA. An organization may decide to exclude this component of the module from the Transfer of Medical Function. 2. Write the policy as it applies to the organization. If you are not familiar with the policies and procedures for a Transfer of Function within the organization, consult within the Nursing and/or Medical Departments for advice. Most health organizations will have guidelines for obtaining the Transfer of Function through a Medical Advisory Committee or a similar process. 3. Implement a process for the Registered Nurse to learn about IDA. The Registered Nurse must demonstrate competency to perform IDA. To learn more about IDA a Registered Nurse may do all or some of the following: a. The procedures are written to provide guidelines and to serve as a study guide. The Registered Nurse will need to read several of the references as well as the information in the procedures. In some cases, as the references are very detailed, only a summary is provided within the procedures section. To have the appropriate degree of understanding and skill necessary to achieve the competencies IDA, more detailed reading will be necessary. b. Some Registered Nurses may find it beneficial to take the Advanced Diabetes Education Certificate program at SIAST 5. Or, there is also the option of taking a single module through this program such as the one on medications. Obtaining the SIAST Advanced Diabetes Education Certificate does not mean the Registered Nurse is able to adjust insulin. The requirements of The Transfer of Medical Function must be completed. 5 For information about the SIAST diabetes program see http://programs.siast.sk.ca/vc/cont_ed_programs_courses/healthsciences/advanceddiabetes.htm Cited 23 December 2008.

Saskatchewan Insulin Adjustment Module Page 9 c. Complete the practice cases. The answers are found at the end of module. If you are unsure about an area talk with Registered Nurses who are already practicing with a delegated medical function for IDA and/or your local physicians. d. Attend a provincial workshop on IDA when it is available Implement a process for the Registered Nurse to demonstrate competency in IDA There are two steps to demonstrate competency as part of the provincial template: 1. Write and successfully pass the provincial exam. The exam can be obtained from Primary Health Services Branch, Saskatchewan Health and is issued by the Branch and written in a supervised situation. The completed exam is returned to the Branch, marked and the results are sent to the candidate. A pass mark is 80%. Successful candidates will receive written documentation to use as part of their Transfer process. 2. Complete physician-supervised cases. The successful delegation of a medical function requires a good working relationship between the Registered Nurse and the physician(s) who participates. The Registered Nurse and physician(s) need to feel confident that clients with diabetes will receive optimal diabetes management. Therefore, the provincial template suggests that the Registered Nurse be supervised by a physician with a minimum of 3 client cases before obtaining the Transfer of Function. Ideally the 3 cases will represent a diversity of client situations which are likely to be encountered in practice. Through this practice supervision, the physician will be able to ensure the Registered Nurse demonstrates the required competencies. The supervising physician may be an endocrinologist, an internist or a family physician with an interest in diabetes management and a willingness to provide the supervision. Sign and Implement the Transfer of Function. A sample signature form for Transfer of Medical Function is provided in the policy template. Each organization will need to decide on the best implementation method to meet the needs of the Registered Nurse, the physician and the person with diabetes. In each situation below, the policy template was adapted to reflect the method chosen. Examples of implementation include: The Diabetes Program has a Medical Director who provides the case supervision for the Registered Nurse. The Director signs the competency sheet and the Transfer of Medical Function is authorized for all physicians in the Region. Physicians have the choice to opt out of the Transfer of Medical Function and may state that they do not wish to have the Registered Nurse provide the IDA service for their clients. The Diabetes Program may not have a Medical Director. A physician with an interest in diabetes management is asked to provide the supervision for the Registered Nurse. This physician signs the competency sheet to complete the Transfer of Function. The Registered Nurse then approaches individual physicians or physician group practices, explains the policy and procedures and requests their signatures for participation in the IDA service.

Saskatchewan Insulin Adjustment Module Page 10 Establish a policy for annual demonstration of competency. The competency performance checklist should be signed annually to ensure continuing competency. Ideally, the signing physician will be familiar with the practice of the Registered Nurse in IDA. There are several options to ensure continuing competency: A physician who is very familiar with the Registered Nurse s practice can complete the performance checklist based on ongoing and regular review over the year. A physician could complete a chart audit of 3-5 recent cases where the Registered Nurse was adjusting insulin. A physician could provide practice supervision similar to the initial competency assessment.

Saskatchewan Insulin Adjustment Module Page 11 RESOURCE PERSONNEL The following are Registered Nurses and/or Managers, who have experience with the Transfer of Medical Function and are willing to talk with others who are in the process of developing this delegation model. NAME HEALTH REGION TELEPHONE EMAIL Karen Butler Regina Qu Appelle 766-3777 Karen.Butler@rqhealth.ca Bev Kernohan Heartland 948-3323 bev.kernohan@hrha.sk.ca Nola Kornder Saskatoon 655-2147 nola.kornder@sasaktoonhealthregion.ca Carlene Schmaltz Kelsey Trail 862-7251 CSchmaltz.kthr@shin.sk.ca For more information about the provincial template or to apply for the IDA exam, contact: Leanne Neufeld Primary Health Services Branch Saskatchewan Health 3475 Albert Street Regina SK S4S 6X6 Ph: 787-0886 Fax: 787-0890 email: lneufeld@health.gov.sk.ca

Saskatchewan Insulin Adjustment Module Page 12 POLICY FOR TRANSFER OF MEDICAL FUNCTION FOR BASIC INSULIN DOSE ADJUSTMENT (IDA) PURPOSE A Registered Nurse, who has demonstrated competence to adjust insulin doses, may make changes to insulin doses and assist clients to make their own changes. Insulin doses will be adjusted for the purposes of optimizing blood glucose control, promoting self-care management and/or enhancing safety and quality of life. PERSONNEL A Registered Nurse who meets the criteria and demonstrates competency in IDA is eligible to obtain the Transfer of Medical Function. POLICIES Adjustment of insulin dosages may be done by a Registered Nurse who demonstrates competency and completes all the requirements for the Transfer of Function. Extensive experience in educating clients in diabetes self-care and demonstrated competence for adjusting insulin dosages are prerequisites. See Appendix E for a detailed overview of RN competencies for a Transfer of Function. Transfer of Function may be granted for Nurses to provide BASIC insulin dose adjustment. With additional training and experience, appropriate Registered Nurses may obtain an ADVANCED Transfer of Function. This policy defines both basic and advanced Transfer of Function, but applies only to the basic process. Experience To obtain the Transfer of Function, a Registered Nurse must have a minimum of two years of practice in the profession. In addition, the Registered Nurse must have at least 2000 hours of work time in diabetes education or hold national certification as a diabetes educator (CDE). To be prepared to write the provincial exam, obtain the Transfer of Function and implement it, Registered Nurses need to master several competencies. These are detailed in Appendix E. The major competency areas are: Works within professional and organization standards for Insulin Dose Adjustment (IDA) by Registered Nurses. Demonstrates current clinical and pharmacokinetic knowledge relevant to IDA. Understands meal planning principles and carbohydrate counting in relation to insulin and uses these in assessment, education and recommendations for IDA. Assesses blood glucose and appropriately interprets information to make changes to insulin doses(s) or other components of the diabetes treatment plan. Understands various insulin schedules and principles for IDA for conventional and intensive therapy. Assesses and addresses diabetes self-care learning needs and readiness to learn IDA. Communicates with the patient/client and other team members toward the goal of appropriate IDA.

Saskatchewan Insulin Adjustment Module Page 13 Basic Transfer of Medical Function 6 The basic delegation of medical function will apply to IDA for adults, with either type 1 or type 2 diabetes, for routine situations when the person with diabetes is in the community setting and well any insulin schedule including intensive therapy/multiple injections management of insulin for exercise. IDA for tests and procedures (to be added June, 2009) Maintenance of Transfer of Function Maintenance of the Transfer will be completed annually by the Registered Nurse. Physician-Registered Nurse Collaboration The Physician retains responsibility for the insulin schedule that is ultimately selected initial dose (amount, type of insulin, timing) and any subsequent adjustments to insulin type and/or timing; for example, moving an insulin dose from supper to bedtime or switching from a pre-mixed to short and intermediate-acting insulins. The Registered Nurse, Physician and client will collaborate to establish the appropriateness for both Registered Nurse involvement and client participation in IDA. The Registered Nurse and Physician will collaborate on a regular basis to ensure that the client is receiving optimal insulin doses. Conditions Registered Nurses and Physicians This procedure will only be considered for specific clients referred by a Physician who is willing to be available to provide ongoing advice and support to the Registered Nurse. Both parties must mutually agree to this. Neither a Physician nor a Registered Nurse will be obliged to participate in this particular delegation of a medical function unless there is mutual agreement. A Registered Nurse and Physician(s) who wish to use this Transfer of Medical Function will sign an agreement to indicate their mutual willingness to participate in all the responsibilities of the delegation of the medical function. 7 When a medical function has been delegated and accepted by Nursing, the Registered Nurse is responsible and accountable for competent performance. The Transfer of Medical Function is applied only with clients whom the Registered Nurse assesses, teaches and reviews directly. The delegation of this medical function does not include the Registered Nurse doing IDA for other health care providers such as Home Care Nurses, Dietitians, Pharmacists etc. Insulin doses will be changed according to the IDA guidelines. There will be appropriate resources to facilitate client learning. The Registered Nurse will continuously assess a client s metabolic status and refer a client to their physician in all situations that are beyond their scope of practice, and/or situations where 6 Advanced Transfer of Function is not covered by this policy. See Policy Appendix for skills covered in Advanced Transfer. Health Regions have the option of defining basic to suit their needs. 7 A sample form is provided in the Policy Appendix B. The Registered Nurse and Physician signatures mean the Transfer applies to all the appropriate clients as designated in the Health Region Policy

Saskatchewan Insulin Adjustment Module Page 14 the clients metabolic control is deteriorating despite adjustments made to the insulin or other components of the treatment plan. If the client is seen for periodic follow-up or returns to the Diabetes Education Program, the Registered Nurse may continue to guide the client who requires ongoing interventions to maintain blood glucose control with agreed periodic contact with the physician of record. If the client does not demonstrate the potential for, or interest in safe self-adjustment of insulin, the attending Physician will resume responsibility for the client s insulin dosage. It is understood by all parties that the Registered Nurse will only be available to support clients in IDA during regular working hours [insert Region schedule] Conditions Clients The policy applies to clients who are living independently in the community and do not reside in an acute care setting or long term care facility. To receive education about IDA and/or support in actually making the adjustments, clients will meet the following conditions: Able and willing to frequently monitor blood glucose, record and report the results. Able and willing to contact the Registered Nurse on a regular basis for assistance and further education regarding IDA. Not acutely or severely ill (examples: immediately post-op, end stage renal disease). Demonstrate an interest in improving control and having regular follow-up. Has had a consultation with a Dietitian and has a suitable nutrition strategy to support IDA. Client Assessment The process of teaching clients to adjust insulin will include the following: Initial assessment of the client s learning needs, style, barriers and resources. Provision of self-education materials appropriate to the individual needs of the client. Confirmation of the accuracy of the client s self blood glucose monitoring results by means of an annual laboratory to meter comparison and periodic observation of the client s technique. Confirmation that the client is aware of the symptoms of hypoglycemia and demonstrates an understanding of the appropriate treatment and prevention of hypoglycemia. Confirmation that the client is aware of insulin action (onset, peak, duration). Client has the knowledge and skill level to either follow a diet which is consistent in carbohydrate intake or can accurately determine his carbohydrate intake of foods. Precautions There is a potential for hypoglycemia or hyperglycemia when adjusting insulin doses. Documentation and Reporting A detailed note will be written for each client s outpatient visit. This will contain relevant data, assessment and plan including any changes in insulin dose. A copy of the note will be sent to the client s physician. 8 If the client s visits are frequent and close together, as a minimum, a summary letter will be written monthly and sent to the client s physician. 8 See sample form in Appendix D

Saskatchewan Insulin Adjustment Module Page 15 PROCEDURES Transfer of Medical Function The following diagram outlines the process to achieve a Transfer of Medical Function. Health Region reviews provincial guidelines/template + revises as needed Region Medical Advisory Committee approves Transfer Registered Nurse who meets criteria Reviews policy + procedures Attends provincial course 9 (if available) AND/OR Completes self study program Writes exam and submits to Provincial Diabetes Coordinator After successful completion of the exam, the Registered Nurse is supervised by local Physician(s) for a minimum of 3 appropriate client cases Physician(s) signs documentation of Registered Nurse s competency for IDA according to the Health Region s policy and Transfer is completed Health Region s policy determines procedure for implementation within Region with some/all physicians Procedures for Adjusting Insulin Doses A Registered Nurse practicing a delegated medical function to adjust insulin doses will follow the procedures outlined in the Saskatchewan Insulin Dose Adjustment Module. If the procedures are amended by the Health Region, changes will be documented in the Module. 9 Registered Nurses are encouraged to invite a physician to attend with them

Saskatchewan Insulin Adjustment Module Page 16 POLICY APPENDIX APPENDIX A - Advanced Certification Advanced certification is NOT included in this provincial template. Advanced certification may include some or all of the following specialty areas of IDA. Inclusion of these areas in an individual Registered Nurse s certification will depend on the experience of the Registered Nurse with the IDA specialty and the frequency that s/he will perform the dose adjustments. The advanced certification areas include: a. Children with diabetes b. Insulin pumps c. Sick day management d. Pregnancy in women with pre-existing diabetes (Type 1 or Type 2) e. Gestational diabetes f. Special circumstances (travel, shift work) APPENDIX B - SAMPLE PHYSICIAN/REGISTERED NURSE SIGNATURE SHEET The following is a SAMPLE sheet which may be used within a Health Region for the Registered Nurse and Physician(s) to sign once the Registered Nurse has successfully demonstrated the competencies for IDA.

Saskatchewan Insulin Adjustment Module Page 17 HEALTH REGION PHYSICIAN/REGISTERED NURSE SIGNATURE SHEET TRANSFER OF FUNCTION INSULIN DOSE ADJUSTMENT has achieved competency to adjust insulin for clients with [Name of Registered Nurse] diabetes according to policy. We have read the Health Region policy for insulin dose adjustment and agree to the conditions outlined in the policy. Signed: Physician Signed: Diabetes Nurse Educator Date: APPENDIX C - SAMPLE COMPETENCY PERFORMANCE CHECKLIST On the following page is a sample sheet to be used within a Health Region for the Registered Nurse and Physician(s) to sign for annual Transfer of Function of the Registered Nurse for IDA.

Saskatchewan Insulin Adjustment Module Page 18 COMPETENCY PERFORMANCE CHECKLIST Registered Nurse: PERFORMANCE CRITERIA 1 Identifies variables in diabetes management which may be appropriate alternatives to IDA eg. diet, exercise, injection sites 2 Insulin increase is based on a pattern of blood glucose readings above target. OBSERVED NOT OBSERVED COMMENTS 3 Insulin decrease is based on a pattern of blood glucose readings below target, unexplained hypoglycemia or change in routine which would necessitate an insulin reduction 4 Insulin to carbohydrate ratios are created according to guidelines 5 Insulin correction factors or insulin grids are created according to guidelines 4 Physician is consulted for non-standard situations and/or failure of IDA to improve control. 6 Documentation is completed according to established standards. Acceptable competency Competency NOT acceptable Physician Signature: Date:

Saskatchewan Insulin Adjustment Module Page 19 APPENDIX D DETAILED COMPETENCIES FOR SELF ASSESSMENT The following resources have been adapted, with permission, from tools in development by the British Columbia Registered Nurses Insulin Dose Adjustment Working Group in preparation for Insulin Dose Adjustment (IDA) by Registered Nurses in BC. What is beyond the scope of practice of the Registered Nurse? Once an RN has obtained a basic Transfer of Function for Insulin Dose Adjustment (IDA) in Saskatchewan, there still may be quandaries about the extent of the scope of practice. To provide clarification, the following has been adapted from the BC IDA document. IDA is beyond the scope of nursing practice in the following situations: Insulin initiation. A physician order is required for initiation of insulin doses in all insulin naïve people with diabetes. Intravenous (IV) insulin During Diabetic Ketoacidosis (DKA) Surgery (pre, intra or post operatively) During labor & delivery During inpatient hospitalization. Physicians are responsible for insulin orders and IDA for inpatients. In any situation which exceeds the RN s level of competency If a physician is unable to provide consultation for IDA as required (see consultation list below) and / or if a physician or alternate RN is not available to do IDA in the RN s absence. Physician Consultation Required: Physician must be consulted and notified regarding IDA in the following situations: Insulin doses dropping with no apparent cause Recurrent or severe hypoglycemia with no apparent cause Glycemic control is not improving or is deteriorating despite adjustments made to insulin or other components of the treatment plan. Total daily dose exceeds what is generally expected for age / body type Client shows signs/symptoms of DKA, dehydration or other serious problems Recurring / persistent vomiting or diarrhea Disordered eating pattern Significant error in dose or timing of insulin administered by person or caregiver Situations requiring prolonged fasting (eg for religious or medical purposes) Change in brand or type of insulin Change in frequency of injections; for example BID to MDI Change to different regimen (e.g. conventional therapy to basal-bolus with MDI or pump) For clients with additional complex medical or endocrine conditions which may influence insulin requirements or client safety In all situations that are beyond the RN s scope of practice and/or competency level

Saskatchewan Insulin Adjustment Module Page 20 Note: Client education regarding IDA is an important component of nursing practice. However, when the client does not demonstrate the potential for, or interest in, safe self-adjustment of insulin, the RN will formulate a plan for ongoing reassessment of the client's insulin dosage, learning needs and potential for learning IDA, in collaboration with the physician. COMPETENCY FRAMEWORK The purpose of the following competency framework and experience record is to help guide and support Registered Nurses in their scope of practice for IDA. 10 This framework and experience record provides a template that can be customized to: suit the needs and policies of practice settings / organizations assist RNs and organizations with assessing, developing and/or tracking RN competencies for IDA. Space is included for making notes relevant to each competency. Competencies in this framework are organized according to the main, overarching competencies required for IDA. Each main competency is accompanied by indicators which will enable an individual or organization to observe and track competency. The competencies and indicators can also serve as a guide for self study, professional development, and may assist individuals preparing to write the IDA competency exam. Competencies for IDA include knowledge and application competencies. RNs must develop and maintain both types of competencies in order to perform IDA as part of their nursing practice. Knowledge competencies can be acquired through self study, which includes but is not limited to the reading material and learning activities and/or attending relevant workshops. Application competencies require clinical experience, including observation of a competent practitioner (RN or Physician), supervised/joint practice, and independent practice. 10 The original framework was developed by British Columbia Registered Nurses Insulin Dose Adjustment Working Group for use within British Columbia s Health Regions where RNs are authorized under the Health Professions Act (2005) and CRNBC to perform insulin dose adjustment with limits and conditions. http://www.crnbc.ca/downloads/433-scope.pdf cited 26 march 2009

Saskatchewan Insulin Adjustment Module Page 21 Competency PROFESSIONAL STANDARDS Works within professional and organization standards for IDA by RNs Competency Indicator Observe or Complete Self- Study Joint Practice Joint Practice Independent Notes Accepts responsibility for performing IDA and understands the professional and legal implications of doing so Identifies and works within the scope of practice for Registered Nurses as defined by the SRNA and the employing health agency / organization Identifies limits of own knowledge and skill and works within them Demonstrates initiative to advance and maintain knowledge and skills needed for safe IDA Performs IDA often enough to maintain confidence and competence Records accurate, clear and timely clinical notes of insulin dose adjustments and related patient education or advice Date/Initial Date/Initial Date/Initial Date/Initial Learning Activities and Experiences completed in this competency area. YES: Date: Signature of RN: Date: Signature of Mentor(s) Date: Signature of Mentor(s)

Saskatchewan Insulin Adjustment Module Page 22 Competency CLINICAL AND PHARMACOKINETIC KNOWLEDGE Demonstrates current clinical and pharmacokinetic knowledge relevant to IDA Competency Indicator Observe or Complete Self- Study Joint Practice Joint Practice Independent Notes Describes the major types of diabetes including basic pathophysiology, distinguishing characteristics, and rationale for different treatment plans according to type of diabetes. Identifies non-pharmacological and pharmacological approaches to treating different types of diabetes Describes the pharmacokinetics and action time of all insulins available in Canada including onset, peak, duration and how these may be altered (e.g. by lipohypertrophy, age, pregnancy, renal impairment etc) Identifies drugs that may inhibit or potentiate the action of insulin Identifies potential side effects of insulin therapy and how to avoid/minimize and manage them (e.g. hypoglycemia, lipohypertrophy, weight gain, in rare cases allergy) Describes basic physiologic insulin requirements in type 1 and type 2 diabetes in adults as well as usual starting doses based on age, weight, diagnosis etc. Date/Initial Date/Initial Date/Initial Date/Initial Learning Activities and Experiences completed in this competency area. YES: Date: Signature of RN: Date: Signature of Mentor(s) Date: Signature of Mentor(s)

Saskatchewan Insulin Adjustment Module Page 23 Competency MEAL PLANNING, CARBOHYDRATE COUNTING AND INSULIN DOSES Understands meal planning principles and carbohydrate counting in relation to insulin and uses these in assessment, education, and recommendations for IDA Competency Indicator Describes glycemic responses to different food groups / types Describes the purposes of consistent CHO use and or CHO counting and identifies potential advantages/disadvantages of each, according to the client s situation Calculates, uses and evaluates insulin: carbohydrate ratios Calculates, uses, and evaluates insulin sensitivity factor, correction doses/or insulin scales Identifies dietary, activity, and / or IDA that can be made to improve blood glucose excursions associated with food Identifies dietary and/or IDA for physical activity Identifies effect of alcohol consumption on blood glucose values and provides education and advice to minimize risk/and prevent hypoglycemia Works collaboratively with dietitians and makes appropriate client referrals for nutrition education and support Observe or Complete Self- Study Joint Practice Joint Practice Independent Date/Initial Date/Initial Date/Initial Date/Initial Notes Learning Activities and Experiences completed in this competency area. YES: Date: Signature of RN: Date: Signature of Mentor(s) Date: Signature of Mentor(s)

Saskatchewan Insulin Adjustment Module Page 24 Competency ASSESSMENT & INTERPRETATION: BLOOD GLUCOSE Assesses blood glucose and appropriately interprets information to make changes to insulin dose(s) or other components of diabetes treatment plan Competency Indicator Identifies age appropriate blood glucose goals and rationale for these Identifies situations in which standard blood glucose goals may need to be modified Perform a comprehensive assessment of the client s blood glucose: reviews recorded blood glucose values obtains pertinent information regarding diet, activity, insulin, and any other factors which may be influencing blood glucose ensures client s meter accuracy Identifies patterns of hyperglycemia or hypoglycemia, or changes in routines which require adjustment of insulin and/ or other components of treatment plan Identifies when, why and how to assess for nocturnal hypoglycemia and potential rebound hyperglycemia Analyzes relationship between blood glucose levels, insulin or other medications, nutritional intake/meal plan, and activity levels and identifies appropriate adjustments/course of action Interprets assessment data and plans appropriate intervention based on data Communicates assessment findings to relevant team members as appropriate Observe or Complete Self- Study Joint Practice Joint Practice Independent Date/Initial Date/Initial Date/Initial Date/Initial Notes Learning Activities and Experiences completed in this competency area. YES: Date: Signature of RN: Date: Signature of Mentor(s) Date: Signature of Mentor(s)

Saskatchewan Insulin Adjustment Module Page 25 INSULIN SCHEDULES AND DOSE ADJUSTMENTS Understands various insulin schedules and principles for IDA for conventional or intensive therapy Competency Indicator Observe or Complete Self- Study Joint Practice Joint Practice Independent Notes Uses established principles and guidelines for IDA based on patterns Identifies situations when an insulin scale or correction dose needs to be used and/ or adjusted Uses pattern management principles to establish, adjust and evaluate baseline doses for different insulin schedules Identifies when a change in the time of insulin administration would be appropriate and consults with MD as required by organization s policy Applies exercise guidelines appropriate to the patient/client insulin schedule Applies guidelines appropriate to the client for short term IDA for a test or procedure Describes principles and concepts of basal-bolus insulin therapy Uses pattern management to evaluate and adjust basal doses for MDI Calculates and applies insulin sensitivity factors, correction doses and/or insulin scales for MDI Calculates and uses insulin to carbohydrate ratios Integrates pattern management principles with correction and supplemental doses for intensive therapy with MDI Applies principles of basal-bolus therapy to optimize blood glucose control and/or quality of life (e.g. increased flexibility) with: MDI Completes comprehensive assessment of learning needs & provides timely, client centered education for IDA Provides client/family education, as appropriate, using sound educational theories and principles. Date/Initial Date/Initial Date/Initial Date/Initial Learning Activities and Experiences completed in this competency area. YES: Date: Signature of RN: Date: Signature of Mentor(s) Date: Signature of Mentor(s)

Saskatchewan Insulin Adjustment Module Page 26 Competency DIABETES SELF-CARE LEARNING NEEDS Assesses and addresses diabetes self-care learning needs and readiness to learn insulin dose adjustment Competency Indicator Observe or Complete Self- Study Joint Practice Joint Practice Independent Notes Assesses knowledge, ability and readiness to learn principles / guidelines for: basic IDA according to blood glucose patterns intensive therapy with MDI Identifies specific learning needs and formulates learning plan with patient/ client to address basic IDA Evaluates learning and plans follow-up as appropriate to patient/family needs and circumstances. Date/Initial Date/Initial Date/Initial Date/Initial Learning Activities and Experiences completed in this competency area. YES: Date: Signature of RN: Date: Signature of Mentor(s) Date: Signature of Mentor(s)

Saskatchewan Insulin Adjustment Module Page 27 Competency COMMUNICATION Communicates with the patient/client and other team members towards the goal of appropriate insulin adjustment Competency Indicator Observe or Complete Self- Study Joint Practice Joint Practice Independent Notes Involves client in reviewing and interpreting blood glucose values to make informed decisions about adjustments to the treatment plan Deals sensitively with patients questions, emotions and concerns Assesses learning needs and provides clear, relevant instructions to the patient about insulin and IDA (e.g. what insulin(s) to change, specific doses, and expected outcomes) Confirms patient s understanding of instruction or advice provided Builds relationships with patients/clients to promote self-care and learning and does not encourage ongoing dependence on health professionals for IDA Negotiates learning plan to assist patients/ clients in developing knowledge, skills and confidence for self-adjusting insulin doses Notifies and/or consults with other team members as appropriate Records relevant data on the appropriate records Date/Initial Date/Initial Date/Initial Date/Initial Learning Activities and Experiences completed in this competency area. YES: Date: Signature of RN: Date: Signature of Mentor(s) Date: Signature of Mentor(s)

Saskatchewan Insulin Adjustment Module Page 28 APPENDIX E - SAMPLE PROGRESS REPORT 11 Health Region Progress Report Date: Client: PHN: Date of Birth: Physician: Clinic Location: Present Insulin Doses: Brand: NovoNordisk, Eli Lilly, Sanofi-Aventis Pre-breakfast Pre-noon Pre-supper Bedtime Other Write out full name(s) of insulin, do not use abbreviations Issues with insulin measurement/injection: none Hypoglycemia: Physical Activity: Nutrition: Usual Pattern of Blood Glucose Readings: Target ac meals: Target post meals: Fast PC brk Lunch PC Lunch Supper PC Supper HS Other times: Assessment: [client progress, changes, client concerns] Plan: [recommended insulin changes, other plans, follow-up] Educator s Signature: 11 Adapted with permission from a Heartland Health Region resource

Saskatchewan Insulin Adjustment Module Page 29 APPENDIX F - Commonly Asked Questions and Answers 1. I have a Transfer of Function for Insulin Adjustment. I am finding that some physicians expect me to take sole and ongoing responsibility for insulin dose management for their patients. How do others handle this? ANSWER The intent of the Transfer process is to work collaboratively with physicians and teach people with diabetes and their families to be as independent as possible in diabetes selfmanagement. If this is an ongoing concern, you may need to Have a discussion with the physician about your scope of practice and workload management Involve your supervisor in supporting and explaining the intent of the delegated medical function Use the process of the annual renewal of the delegated function to educate physicians. Bev Kernohan, Heartland Health Region has found this helpful. Annually, after she renews her Transfer of Function, she sends a letter to all the physicians in the Health Region. This letter is reproduced at the end of the Question/Answer section. Bev has given permission for others to use or adapt her letter. 2. Why is sick day management not included in the basic competencies? How can I help my clients with sick day management? ANSWER Not having a Transfer does not preclude an educator from teaching someone how to adjust insulin during illness. This competency is considered advanced because a basic premise of the transfer is management of the well adult. Also, most educators work days, Monday- Friday and would not necessarily be available to take on responsibility for ongoing insulin adjustments during an inter-current illness. 3. With a Transfer of Function to adjust insulin, can I change the time of day the insulin is given without contacting a physician? What if I am making this change for client safety? ANSWER If your Health Region uses the template developed for the Saskatchewan module, any change in insulin timing must be done by physician order. It is always an option for a Health Region to adjust the template to their own needs and, for example, permit changing of the time of day insulin is given. This could be a general statement or have limitation; for example, related to client safety. Each Health Region has a procedure for changing policies and in particular those which involved a delegated medical function. Make sure you are aware of your Region s policies and procedures.

Saskatchewan Insulin Adjustment Module Page 30 4. Now that I have a Transfer of Function other professionals (Home Care Nurse, Pharmacist) sometimes call me and ask me to make insulin dose adjustments for their patients. Usually I do not know the patient or have not made a recent assessment. How should I handle this? Can I make insulin dose recommendations? ANSWER The template for the Transfer of Function policy, as written, in the provincial module is clear that the Transfer only applies to clients actually being seen by the RN. It is not intended to cover situations where the RN is not involved with the patient and unable to do his/her own assessment. Possible options to handle this scenario would be Indicate the terms or conditions of your policy with the delegated medical function and what you can and cannot do Make general suggestions, indicating that the calling professional will need to get a physician order to give the recommendation to the patient. Reinforce your scope of practice. You may also wish to document the conversation and indicate not only your suggestions but also the advice to seek a physician order. If you, your nursing department and your medical colleagues feel you can give advice to other professionals, then have a written policy to this effect in your Health Region/organization.

Saskatchewan Insulin Adjustment Module Page 31 SAMPLE ANNUAL LETTER TO FAMILY PHYSICIANS 12 Dr Insert Date Medical Transfer of Function for insulin adjustment, by the Diabetes Nurse Educator Bev Kernohan RN, BSN, CDE This year I have applied with the Senior Medical Manager, Dr., and have attained an annual renewal of the Medical Transfer of Function for insulin adjustments with patients who have Type 1 and 2 diabetes. I have practiced with this Medical Transfer in Heartland Health Region for the past years. I am sending this letter to all physicians practicing in Heartland Health Region as per request from Management. If I am not presently involved with the diabetes management of your clients, this permission will only be applicable if I become involved with their management in the next year. This letter is to confirm whether you do or do not wish to have this transfer applied to the insulin-using patients in your practice, which through the referral process, I become involved in their diabetes management. As a physician you retain the responsibility for the insulin regimen that is ultimately selected - initial dose: amount, type of insulin, timing and any subsequent adjustments to insulin type/or timing. This Transfer will allow me to adjust the insulin dose only. For the clients under Home Care, it will not allow me to give the Home Care Nurses an order to change the insulin; they still require a written order from a physician. If I am working with a client who is also a client of Home Care and they are pre-filling the syringes, I will send to the physician my recommendations and he/she will make the final decision and implement the necessary insulin changes. I am firmly committed to this process and I will continue to communicate any changes in doses of insulin back to the physician. I will continue to instruct the client to have regular contact with their physician for ongoing management of their diabetes. I, as a Registered Nurse, will refer all clients to their physician in all situations that are beyond the scope of my practice and/or in situations where the client s metabolic control is deteriorating despite adjustments made to the insulin or other components of the treatment plan. You are not obliged to participate in this medical transfer of function for insulin adjustment unless you agree to. I will continue to see patients referred to me for education purposes even if you opt not to participate in this transfer of medical function. Continued on next page 12 Developed by Bev Kernohan, Heartland Regional Health Authority. Used and adapted with permission. March, 2009

Saskatchewan Insulin Adjustment Module Page 32 Please indicate below whether you wish to have patients in your practice participate in this transfer of medical function for insulin adjustment. I give permission to Bev Kernohan to adjust the dosage of insulin of patients in my practice. Name of Physician PRINT NAME AND SIGNATURE Date I do not give permission to Bev Kernohan to adjust the dosage of insulin of patients in my practice. Name of Physician PRINT NAME AND SIGNATURE Date Retain a copy and fax or send a copy back to Bev Kernohan by May 12 th,, 2008 Box 130, Biggar, Sask. S0K-0M0 fax 948-2011, phone 948-6041 if you require info.

Saskatchewan Insulin Adjustment Module Page 33 LEARNING ABOUT AND PROCEDURES FOR INSULIN DOSE ADJUSTMENT Endogenous Insulin Learning Objectives Upon completion of this section you will be able to: Describe the hormonal regulation of blood glucose in the non-diabetic individual. Define key metabolic processes and whether insulin facilitates or inhibits the process. Describe briefly insulin's effect on cellular glucose uptake in the following organs/tissues: brain, liver, muscle, fat. Describe how obesity in the non-diabetic may alter normal insulin secretion. Name the potential metabolic effects of hyperinsulinemia. Describe the metabolic effects of an absolute lack of insulin. Hormonal Regulation of Blood Glucose in the Individual without Diabetes Blood glucose levels are constantly monitored by the alpha and beta cells of the Islet of Langerhans in the endocrine pancreas. If glucose levels are dropping, the alpha cells are stimulated to secrete glucagon which stimulates certain metabolic processes (glycogenolysis in the liver primarily) which modulate the blood glucose and keep it in the normal range. If glucose levels are rising, the beta cells secrete insulin which stimulates certain metabolic processes (glycogenesis, lipogenesis, cellular glucose uptake) which modulate the blood glucose and keep it in the normal range. Other hormones stimulated by dropping blood glucose values are epinephrine, cortisol, and growth hormone. These hormones and glucagon are termed 'counter-regulatory' in that they all have 'anti-insulin' action in raising blood glucose values. Insulin secretion is also stimulated by ingestion of protein because insulin is required for protein synthesis. Average daily insulin secretion by the non-diabetic pancreas is about 30 units Metabolic Process Glycogenesis Lipogenesis Gluconeogenesis Definition the formation of glycogen from glucose. Glycogen is stored in the liver and muscles. the formation of fat from its substrates, glycerol and fatty acids. the breakdown of fat and protein to form glucose and by products. Stimulated or Inhibited by Insulin Stimulated Stimulated Inhibited Glycogenolysis the breakdown of glycogen into glucose. Inhibited

Saskatchewan Insulin Adjustment Module Page 34 Insulin s Effect On Cellular Glucose Uptake Insulin is not required for glucose uptake by brain cells. Insulin facilitates glucose uptake by liver cells. Insulin facilitates glucose uptake by muscle cells. Insulin facilitates glucose uptake by fat cells. How Obesity Alters Normal Insulin Secretion in the Non-diabetic Person Obese individuals may have abnormal insulin secretion, often resulting in: a. higher circulating insulin levels than a normal weight non-diabetic individual. b. abnormal timing of post-prandial insulin secretion. In addition, obese non-diabetic individuals have been shown to have a decreased number of insulin receptors and decreased sensitivity of receptors to insulin, resulting in a resistance to the action of insulin. Potential Metabolic Effects Of Hyperinsulinemia Glycogenesis often resulting in a glycogen saturated liver. Excessive lipogenesis often resulting in increased adipocyte deposition of lipid. Inhibition of lipolysis and glycogenolysis Hypoglycemia may develop postprandial as a result of the above processes. Eventually there will be pancreatic burnout and insulin levels will drop. Metabolic Effects Of Lack Of Insulin An absolute insulin deficiency will cause: decreased glucose uptake by liver, muscle, fat cells. excessive glycogenolysis, lipolysis, gluconeogenesis. inhibited glycogenesis and lipogenesis resulting in hyperglycemia and hyperosmolar diuresis. Nearly exclusive cellular utilization of fatty acids for energy production results in accumulation of ketone bodies in the blood causing ketoacidosis. These metabolic changes eventually lead to either type 1 or type 2 diabetes. With type 2 diabetes, there is often a broader underlying disorder known as metabolic syndrome. Metabolic syndrome is characterized by several abnormalities including: abdominal obesity, hypertension, dyslipidemia, insulin resistance and dysglycemia. 13 13 2008 Clinical Practice Guidelines, page S11

Saskatchewan Insulin Adjustment Module Page 35 Exogenous Insulin Learning Objectives Upon completion of this section you will be able to: List the sources, manufacturers, and trade names of commercially available insulins in Canada. Describe the action time of the various insulins available in Canada including onset, peak, and duration of action. Describe the potential adverse effects of subcutaneous insulin use. Describe other medications which affect insulin action Describe insulin requirements in type 1 and type 2 diabetes. Insulin Approved for Use in Canada The following table indicates the insulin types currently available in Canada. It is referenced to the 2008 Clinical Practice Guidelines 14 and may need periodic updating by users of this module. TYPES OF INSULIN Insulin type(trade name) Onset Peak Duration Prandial (bolus) insulins Rapid-acting analogues (clear) Insulin aspart (NovoRapid) Insulin lispro (Humalog) Insulin glulisine (Apidra) Short-acting insulins (clear) Humulin-R Novolin ge Toronto 10-15 min 10-15 min 10-15 min 1-1.5 h 1-2 h 1-1.5 h 3-5 h 3.5-3.75 h 3-5 h 30 min 2-3 h 6.5 h Inhaled insulin 10-20 min 2 h 6h Basal Insulins Intermediate-acting (cloudy) Humulin N 1-3 h 5-8 h Up to 18 h Novolin ge NPH Long-acting basal insulin analogues (clear) Insulin detemir (Levemir) Insulin glargine (Lantus) Premixed Insulins Premixed regular insulin NPH (cloudy) Humulin 30/70 Novolin ge 30/70, 40/60, 50/50 Premixed insulin analogues (cloudy) Biphasic insulin aspart (NovoMix 30) Insulin lispro/lispro protamine (Humalog Mix 25 and Mix 50) See notes on next page 90 min Not applicable Up to 24 h (glargine 24 h, detemir 16-24 h) A single vial or cartridge contains a fixed ratio of insulin (% of rapid acting-acting or short-acting insulin to % of intermediate-acting insulin) 14 2008 Clinical Practice Guidelines, page S47.

Saskatchewan Insulin Adjustment Module Page 36 NOTES: CPGs recommend reference to the most current edition of the Compendium of Pharmaceuticals and Specialties (CPS: Canadian Pharmacists Association; Ottawa, Ontario, Canada and product monographs for detailed information. * Insulin glulisine (Apidra) Released January 2009 not covered by Saskatchewan Drug Plan * Inhaled insulin has been approved for use in Canada, but is not yet commercially available. Its use is not covered in this module. Learning Activity 1. Using the above table, draw sample diagrams to use with clients to illustrate the onset, peak and duration for insulins commonly used in your practice. 2. See the following website and review the current devices for insulin measurement and injection [resource is updated annually] http://www.diabetes.ca/about-diabetes/literature/consumer-guide cited 23 Dec 2008 Potential Adverse Effects Of Subcutaneous Insulin Use Adverse effects of exogenous insulin use may include hypoglycemia, lipoatrophy, lipohypertrophy (if rotation of sites is not observed), weight gain, insulin resistance (presence of IgG antibodies), and in rare cases localized insulin allergy (presence of IgE antibodies). Hypoglycemia will be discussed further in the next section Drugs That May Inhibit Or Potentiate Insulin Action Inhibit Thiazide diuretics Glucagon Prednisone Thyroid Hormone Potentiate Propranolol Alcohol MAO inhibitors Salicylates (1.5-6 g/day) Use of Beta Blocking Drugs Non-selective beta blocking agents such as propranolol (Inderal ) potentiate the action of insulin by reducing glycogenolysis from the liver. They are also dangerous because they block the sympathetic nervous system response to epinephrine secreted during a hypoglycemic episode. They thereby block the early warning signs of hypoglycemia that are mediated by the sympathetic nervous system.

Saskatchewan Insulin Adjustment Module Page 37 Learning Activity 1. Review the above medications and be familiar with the effects for insulin users. Insulin Requirements Insulin requirements will vary with each individual. The next section provides information on the options for insulin regimens and the use of insulin with oral anti-hyperglycemic agents. General guidelines suggest: 15 For type 1 diabetes, when weight is within 20% of normal, usual insulin requirements are 0.5 to 0.7 units/kg of body weight per day. These requirements will be lower during the honeymoon phase (0.2-0.6 u/kg). For type 2 diabetes the insulin requirement will be individualized depending on the degree of insulin deficiency and insulin resistance. At the low end requirements may be only 5-10 unit/day. At the high end insulin requirements may be hundreds of units per day. 15 Franz, MJ, editor. (2001) A Core Curriculum for Diabetes Education, 4 th edition: Diabetes Management Therapies. American Association of Diabetes Educators, p. 103

Saskatchewan Insulin Adjustment Module Page 38 PRACTICAL ASPECTS OF INSULIN MANAGEMENT Learning Objectives Upon completion of this chapter you will be able to: Describe the causes of fasting hyperglycemia Describe the indications for insulin use in type 2 diabetes Describe and implement the procedures listed below Procedures Variables influencing glycemic control to assess before IDA is performed Use of insulin with oral anti-hyperglycemic agents in type 2 diabetes Therapeutic approaches useful in prevention and treatment of hypoglycemia in those prone to asymptomatic hypoglycemia Important points to consider when switching a client from short-acting to rapidacting insulin Important points to consider when switching a client from intermediate-acting insulin to a long-acting basal insulin analogue Variables Influencing Glycemic Control [PROCEDURE] Variables influencing glycemic control which should be assessed before initiating insulin or changing a dose include: - diet: carbohydrate content, timing and delayed gastric emptying - activity - monitoring technique - concurrent illness/infection - concurrent medications - unusual stresses - injection site problems variable absorption lipodystrophies - insulin administration problems inaccurate dose missed doses, extra doses timing of dose - weight changes - menstrual cycle - length of time between carbohydrate intake and blood glucose monitoring - pregnancy - insulin antibodies - abnormal glucose counter-regulation - alcohol use

Saskatchewan Insulin Adjustment Module Page 39 Using A Combination of Insulin and Oral Antihyperglycemic Agents [AHA] The 2008 CPGs recommend the timely addition of anti-hyperglycemic agents (either orally or with insulin) if 16 : Glycemic targets are not achieved within 2-3 months of lifestyle management. Current agents are not successful in achieving glycemic targets. This may require medication adjustment and/or additional medications to attain target A1C in 6-12 months. There is marked hyperglycemia (A1C > 9%), antihyperglycemic agents need to be initiated concomitantly with lifestyle management and consideration needs to be given to initiating combination therapy with 2 oral AHAs or initiating insulin. LEARNING ACTIVITY 1. Read the CPG pages S53 to S58. Use the current version of the Compendium of Pharmaceuticals and Specialties (CPS) and create of a table of oral antihyperglycemic agents and the recommendations for their use with insulin. See the pink-edged pages to find specific diabetes medications. 2. Discuss your table with other diabetes practitioners and your physician leader to gain local consensus on current practice, safety issues and important points for client education when combining insulin with an OAA. 16 2008 CPG, page S53

Saskatchewan Insulin Adjustment Module Page 40 Useful Therapeutic Approaches Useful In the Prevention And Treatment Of Hypoglycemia [PROCEDURE] Learning Activity Read the following resources: 2008 Clinical Practice Guidelines section on hypoglycemia and read the related guidelines on driving and diabetes Begg IS, Yale J-F, Houlden, RL, Rowe RC, McSherry J. 2003. Canadian Diabetes Association s Clinical Practice Guidelines for Diabetes and Private and Commercial Driving. Can J Diabetes. 27; 2:128-140. Available at http://www.diabetes.ca/files/diabetes%20and%20driving%20guidelines-- June%202003--FINAL.pdf cited 24 Dec 2008. The following measures are important in the prevention and treatment of hypoglycemia particularly in those prone to asymptomatic or severe hypoglycemia: frequent home blood glucose monitoring (four times daily) appropriate self-adjustment of insulin dose consistent carbohydrate intake or carbohydrate counting with appropriate insulin:carbohydrate ratio appropriate timing of meals and snacks preparation for increase in physical activity and management during and post activity if needed, the target range for blood glucose control should be higher, e.g. instead of 4-7 ac meals, 6-10. In practice, this should result in downward adjustment of the appropriate insulin dose if results are less than 6. for severe hypoglycemia, family members should be instructed in the administration of Glucagon wear diabetes identification teachers, co-workers, family, friends should be informed of potential hypoglycemia, its signs, and what action to take if possible, identify with the client: his/her earliest perception/sensation that blood glucose may be dropping and the usual blood glucose at that time the history of hypoglycemia, including the frequency, severity, usual treatment and usual prevention strategies if he/she has hypoglycemia unawareness 17 and how this has been and will be managed 17 See Jones et al (2009) for more information about hypoglycemia unawareness

Saskatchewan Insulin Adjustment Module Page 41 Causes Of Fasting Hyperglycemia There are three potential causes for fasting hyperglycemia: The Somogyi Phenomenon The Somogyi phenomenon, also known as rebound hyperglycemia, has been defined as hyperglycemia (not caused by excessive dietary intake) following a hypoglycemic episode. The etiology is believed to be increased production of counter-regulatory hormones in response to hypoglycemia. Not all clients demonstrate this phenomenon. Signs suspicious of this phenomenon are fasting hyperglycemia, headache or nausea upon wakening in the morning especially if the client reports nocturnal symptoms such as nightmares, poor sleep, tossing and turning, and perspiration. In addition, fasting hyperglycemia unresponsive to increases in the appropriate insulin dose is suspicious of Somogyi phenomenon. Signs during the waking hours may be hyperglycemia following an insulin reaction despite appropriate dietary treatment of the hypoglycemic episode. To rule out or confirm Somogyi phenomenon at night, the client should test their blood glucose 6-8 hours after the p.m. intermediate insulin dose. If this reading is low, it will confirm the Somogyi phenomenon. If it is normal or high, Somogyi is ruled out. Daytime Somogyi phenomenon can be confirmed by questioning the client on precisely how they treated the hypoglycemic episode that precedes hyperglycemia. Difficulty may arise if asymptomatic, undocumented hypoglycemia during the day results in a rebound hyperglycemia. Additional blood glucose testing between meals is required to demonstrate this problem. Over-treatment of hypoglycemia is much more common than daytime Somogyi. Recent studies have pointed out that although the Somogyi effect causes some degree of excessive post-prandial hyperglycemia the following morning, it does not cause extreme hyperglycemia and instability. In other words, the magnitude of the Somogyi effect may be over-estimated. Waning Insulin Joslin s Diabetes Deskbook (2003) notes the waning effect of the insulin dose given the previous evening can also be a factor in fasting hyperglycemia. The duration of action of the overnight insulin is insufficient and leads to a gradual rise in blood glucose level from bedtime to morning. It may be difficult to differentiate this from the Dawn Phenomenon discussed below. Dawn Phenomenon The Dawn Phenomenon refers to the increased production of glucose by the liver and decreased sensitivity to the action of insulin that occurs between 0400 and 0800 hours in people with and without diabetes. Therefore higher levels of insulin are required to maintain euglycemia during these hours. Nocturnal surges of growth hormone cause the transient insulin resistance. These surges are normal physiological events that are not a result of counter-regulatory responses to hypoglycemia. A bedtime dose of intermediate-acting insulin would likely reach its peak during the dawn and counteract the hyperglycemic effects of this phenomenon.

Saskatchewan Insulin Adjustment Module Page 42 Considerations When Switching From Short-Acting Insulin To a Rapid Acting Insulin Analogue [PROCEDURE] Rapid-acting insulin analogues closely duplicate the action of the body s endogenous insulin in response to food ingestion. The rapid onset and short duration, as compared to short-acting insulin, benefit people with diabetes by providing: inject and eat convenience improved post-prandial glucose control less risk of hypoglycemia between meals and overnight Rapid-acting insulin analogues are suited to people who want improved glycemic control and more flexibility in their schedule. It is beneficial for type 1 or 2, children and adults, those new to insulin as well as those already using insulin. It is particularly suitable for people on MDI, i.e. TID or QID regimens or pumps. When transferring to a rapid-acting insulin analogue: The same dose may be used as short-acting insulin, assuming the usual dose is effective and safe Your client, though, may feel more secure taking about 10 to 20% less initially until the effect can be gauged. The dosage of intermediate insulin or long acting basal insulin analogue may have to be increased and/or divided into two injections per day to provide adequate basal coverage. Since short-acting insulin has a longer action, it tends to have an overlap in coverage with the intermediate-acting insulin. A rapid-acting insulin analogue has a shorter duration which can result in rising blood glucose prior to the next meal. Examples of use of a rapid-acting insulin analogue: Rapid analogue before meals, Intermediate at bedtime Rapid analogue before meals, Intermediate before breakfast and bedtime Rapid analogue before meals, Long-acting basal insulin analogue in the evening Be sure to discuss regimen changes with the client s physician. Reminders for Using a Rapid-Acting Insulin Analogue When mixing insulins, use only with the same brand of insulin; for example, do not mix a NovoNordisk brand insulin with an Eli Lilly brand insulin. If the rapid analogue is mixed with intermediate-acting insulin, inject immediately to prevent blunting of the rapid insulin action after mixing. Do not mix any insulin with a long-acting basal insulin analogue Inject rapid-acting insulin within 15 minutes of a meal. Monitor blood glucose regularly. Initially, monitoring 7 to 8 times per day for about one week (a.c. meal and 2 hours p.c.) may be required to determine the correct doses.

Saskatchewan Insulin Adjustment Module Page 43 Precautions A rapid-acting insulin analogue is not recommended in conjunction with acarbose (Prandase) as acarbose slows the digestion of carbohydrate, possibly resulting in hypoglycemia. Advise your client to avoid strenuous exercise within 2 hours after taking a rapid-acting insulin analogue. If a person must exercise in that timeframe, recommend a reduction in the rapid analogue dose by 50%. Exercise 2-4 hours after rapid analogue may not result in hypoglycemia. People with gastroparesis should use a rapid-acting analogue with caution. Extra blood glucose monitoring is needed to determine the timing of injection with the rise of blood glucose after food is absorbed. Insulin may need to be administered after the meal to match with the rise in blood glucose. Switching To a Long-Acting Basal Insulin Analogue 18 [PROCEDURE] Two brands of long-acting basal insulin analogues are available in Saskatchewan: Lantus (insulin glargine) and Levemir (insulin detemir). Either one can be used as a basal insulin. Lantus has a duration of up to 24 hours. Levemir has a duration of 16-24 hours. Both are clear insulins. Indications for Use Can be used with either type 1 or type 2 diabetes where a basal insulin is required Precautions for Use Do not mix with any other insulin As with all insulins, long acting insulin analogues may cause hypoglycemia For persons with renal or hepatic dysfunction, insulin requirement may be lower due to decreased insulin metabolism. Frequent blood glucose monitoring is required. Use in pregnancy should be cautious and only if clearly needed. Use in lactation has not been established. Client Education with Long-Acting Basal Insulin Analogue Advise the client not to mix with any other insulin or dilute the long-acting insulin analogue. Long-acting insulin analogues are clear insulins and should not be used if cloudy. Long-acting insulin should be stored in a refrigerator, 2ºC to 8ºC. It should not be allowed to freeze. If refrigeration is impossible, the vial can be kept unrefrigerated up to 28 days away from direct heat and light as long as the temperature is not greater than 30ºC. Discard after 28 days if unrefrigerated. As the insulin is acidic, there may be mild discomfort at the injection site In addition, the usual education related to insulin use should be provided Dosage and Administration For insulin naïve clients with type 2 diabetes already treated with oral anti-hyperglycemic agents, the recommended starting dose is 10 units once daily with subsequent adjustment according to client needs 18 See details about each insulin s properties in the current version of CPS.

Saskatchewan Insulin Adjustment Module Page 44 Change over to a long-acting insulin analogue from intermediate acting insulin: o in clinical studies when the transfer was from once daily NPH human insulin or ultralente, the initial dose was not changed. o in studies where the transfer was from twice daily NPH to once daily long-acting insulin analogue at bedtime, the initial dose was reduced by a minimum of 20% of the previous total daily dose of intermediate or long-acting insulin.

Saskatchewan Insulin Adjustment Module Page 45 Insulin Regimens And Adjustments Learning Objectives Upon completion of this section you will be able to: Describe the insulin regimens Describe carbohydrate counting Describe and implement the procedures listed below Procedures Definition and implementation of IDA: a. Initiating an Insulin Regimen and Establishing Client Goals b. Pattern management c. Variable insulin doses: i) correction factor for low/high glucose readings ii) use of insulin:carbohydrate ratios Principles of IDA for exercise or increased physical activity. Insulin Regimens Insulin regimens must be planned to meet the metabolic requirements of the individual while being able to control the blood glucose level throughout the 24 hour day. Commencing insulin and stabilizing the glucose levels calls for different approaches depending on individual requirements and the intensity of therapy, considering the client s lifestyle and routines. Type 1 The DCCT has shown that individuals with Type 1 diabetes will benefit from metabolic control as close to normal glucose levels as possible. This level of blood glucose control appears to slow the auto-immune destruction of beta cells thus leaving well controlled individuals with greater beta cell reserve one year following diagnosis than individuals with higher blood glucoses levels. Therefore, newly diagnosed type I individuals may benefit from two to four injections of insulin per day aimed at keeping pre-prandial glucoses less than 7 mmol/l. To achieve glycemic targets in adults with type 1 diabetes, multiple daily injections (prandial [bolus] and basal insulin) or the use of CSII is the treatment of choice. 19 Basal insulin is the amount of insulin required to counteract hormonal and other variables potentially causing hyperglycemia between meals and overnight. Bolus insulin is the insulin used to cover glucose rise as a result of food intake. Typically this can range from 40-60% of the total daily requirement for insulin. The 2008 CPG recommend a basal/bolus regimen with: Rapid-acting insulin analogues (aspart or lispro), in combination with adequate basal insulin, should be considered over regular insulin to improve A1C while minimizing the occurrence of hypoglycemia and to achieve postprandial glucose targets. 20 A long-acting insulin analogue (detemir, glargine) may be considered as an alternative to NPH as the basal insulin 21 to reduce the risk of hypoglycemia, including nocturnal hypoglycemia. 22 19 2008 Clinical Practice Guidelines, p. S49. Recommendation 1, Grade A, Level 1A. 20 2008 Clinical Practice Guidelines, p. S49. Recommendation 2, Grade B, Level 2.

Saskatchewan Insulin Adjustment Module Page 46 A total daily dose of 0.5-1.0 units/kg of body weight is usually required. The total daily dose is distributed according to the type of insulin regimen initiated 23. It is the physician s responsibility to determine the initial dose and regimen. If the RN practicing under a delegated medical function feels that regimen changes should be made, i.e. number of injections or type of insulin she/he must do so in collaboration with the physician. Insulin action times must be taken into account when deciding which insulin to adjust for a particular blood glucose problem at one time of day. Caution must be observed once euglycemia is attained. As glucose toxicity is overcome for those newly diagnosed with type 1 diabetes, beta cell function improves and may synergistically work with injected insulin to cause hypoglycemia ie. the honeymoon period has begun. Be prepared to reduce the injected dosage quickly in these individuals as indicated by blood glucose results. Requirements may be <0.5 units/kg body weight/day 24. Type 2 The individual with type 2 diabetes may benefit from several types of insulin regimens. bedtime intermediate-acting or long-acting basal insulin analogue and daytime oral AHA 25 a.c. breakfast and supper rapid or short/intermediate mixture including pre-mixed insulins t.i.d. insulin pre-meal (short or rapid acting) and intermediate or long-acting at breakfast and/or supper. The second injection of intermediate or long-acting may also be given at bedtime (q.i.d insulin) If adding h.s. intermediate or long-acting basal insulin analogue to daytime oral AHA, increase the dosage regularly (every 3-4 days) until the fasting glucose reaches the target range 25. Because of insulin resistance, the dosage requirement may vary widely between clients, but it will not benefit the client to stop increasing the dose short of the glycemic target. When using daytime insulin for the type 2 individual, consider insulin action times in deciding which insulin to increase or whether to add another type of insulin to improve glucose control at a particular problem time of day. Again because of insulin resistance, very high daily total doses (100-200 units) may be required to achieve the glycemic target range. A hindrance to stabilizing clients on insulin therapy is that insulin action times may vary from individual to individual. Use insulin action times as a guideline to adjust your client s insulin but be prepared to recognize how the insulin is working in your client. 21 2008 Clinical Practice Guidelines, p. S49. Recommendation 4, Grade B, Level 2. 22 See 2008 CPG p S 40 for levels of evidence. 23 See the above reference for examples of insulin distribution with different regimens. Also see the chapter on intensifying insulin therapy in The Essentials for examples of calculating insulin doses. 24 2008 Clinical Practice Guidelines, p. S150. 25 See 2008 Clinical Practice Guidelines p S197-198 for guidelines for insulin initiation in people with type 2 diabetes

Saskatchewan Insulin Adjustment Module Page 47 Carbohydrate Counting To use insulin to carbohydrate ratios for IDA, the Registered Nurse must be familiar with carbohydrate counting. Ideally the client will be referred to a Registered Dietitian to learn about carbohydrate counting. Both the Dietitian and Registered Nurse can support the client in the learning process and provide reinforcement in preparation for IDA by the client. There are several criteria to consider when suggesting a client use carbohydrate counting and subsequently an insulin to carbohydrate ratio to adjust insulin: the person s motivation to learn a new skill. ability to perform simple math skills. the person s willingness and ability to use resources (nutrient information, food labels and tools (measuring cups, weigh scales)) to accurately determine carbohydrate content of meals and snacks. For those who have been frustrated by fluctuating blood glucose levels, it may be helpful for them to use nutritional scales 26. accurate and detailed food records will enhance the process and help assess the client s ability to carbohydrate count and support client skill development. A. Read the following resources: Learning Activities 1. Ensure you are familiar with the CDA resource, Beyond the Basics and basic carbohydrate counting resources. You can review the background information at http://www.diabetes.ca/for-professionals/resources/nutrition/. 2. If you are a DES member you can view a presentation on basic carbohydrate counting and complete the exercises at http://www.diabetes.ca/for-professionals/members-only/ You must sign in using your DES membership number. 3. Learn how to read Nutrition Facts labels, see http://www.diabetes.ca/aboutdiabetes/nutrition/healthy-eating/ and through this site you can access other resources. Take the virtual grocery store tour. 4. Obtain a resource for carbohydrate values of common foods such as: a. Nutrient Value of Some Common Foods (2002). Health Canada. http://www.publications.gc.ca/pub?id=316070&sl=0 Available free b. Holzmeister L. The Diabetes Carbohydrate and Fat Gram Guide, 3rd edition. American Diabetes Association. www.diabetes.org c. Netzer, CT. The Complete Book of Food Counts, 8 th edition. 2008; New York:Dell Publishing. ~ $10 in paperback. d. Borushek, Allan. The CalorieKing Calorie, Fat and Carbohydrate Counter, 2009. ~ $11 in paperback e. For fast foods, treats etc see http://www.bcchildrens.ca/services/specializedpediatrics/endocrinologydiabetes Unit/ForFamilies/default.htm go to diabetes/nutrition handouts f. USDA on line nutrient data base http://www.nal.usda.gov/fnic/foodcomp/search/ f. http://www.elook.org/nutrition/search.php ALL REFERENCES cited 30 december 2008 26 The Essentials, Chapter 10.

Saskatchewan Insulin Adjustment Module Page 48 B. Practical Applications 1. Complete the exercises with a resource from selection above. 2. Keep a food record for three days, being as specific as you can with amounts and calculate your carbohydrate intake for each meal. Consult with a dietitian colleague to get some feedback or answers to your questions. Insulin Dose Adjustments (IDA) [PROCEDURE] Initiating an Insulin Regimen and Establishing Client Goals A written (in-person or by fax), verbal or telephone order is required from the attending physician prior to the initiation of insulin therapy, specifying the type, dose and time of insulin. This order will be discussed with the Registered Nurse and client prior to the initiation of insulin therapy. Verbal/telephone orders must be signed according to Health Region policy. See an example of this form on page 45. Physician s orders will be documented in the client s chart Subsequent alteration in the type of insulin or significant changes in the time at which insulin is to be given will be discussed with the Registered Nurse, the physician and the client. Target Blood Glucose Levels the following can serve as standard reference points Recommended targets for glycemic control A1C FPG/preprandial PG (%) (mmol/l) 2-hour postprandial PG (mmol/l) Target for most patients 7.0 4.0 7.0 5.0 10.0 (5.0 to 8.0 if A1C targets not being met) 2008 Clinical Practice Guidelines, page S30. NOTE: treatment goals and strategies must be tailored to the individual with consideration given to individual risk factors. Individualized Goals: Individualized goals for blood glucose control will be specified in the client s chart and will be determined collaboratively with the physician, the Registered Nurse, the client, significant others and other health care providers. Factors which may be considered in setting goals include the age of the client (eg. seniors) and other health problems.

Saskatchewan Insulin Adjustment Module Page 49 Diabetes & Heart Health Centre 27 Diabetes Educators xxx, RD xx, BScN, RN, CDE xxx-xxxx Ext xxx xxx-xxxx Ext xx FAX Date: XXXXXXXXXXX To: XXXXXXXXXX Fax: XXXXXXXXXX From: XXX @ xxx-xxxx FAX BACK Date: To: Attention: XXX Fax: (306) xxx-xxxx From: Diabetes Medication/Insulin Review Please Complete & Return ASAP! Client: XXXXXXXXXXXX PHN: XXX XXX XXX DOB: XX XXX XXXX Background information: XXXX blood sugar levels are continuing to increase and due to his Humalog Mix 25 we are unable to fine tune his insulin dose to maximize his blood sugar control. His present dose is Humalog Mix 25 8 units q a.m. and 24 units q p.m. Recommendation: Stop Humalog Mix 25 Start Humulin N 10 units at breakfast (an of 4 units) and 10 units at HS (a of 8 units and moved from supper to HS). Try and be fairly consistent with the time of this Humulin N insulin. Start Humalog 3 units at breakfast (an of 1 unit) and 6 units (same dose) at supper. Take this insulin immediately before eating XXX is to monitor his blood sugar QID ac and pc on at least 5 days prior to his next appointment on Feb 11, 2009. XXX was encouraged to call if he had any questions or concerns. Please sign below and return to me if you wish to initiate this change or wish to make different recommendations so that I will have a signed record for my files. I will continue to send progress notes following visits with any insulin adjustments. Yes, please go ahead with the above recommendations: No, I would like to: Date Signature 27 Developed by Kelsey Trail Health Region Diabetes and Heart Health Centre. Used with permission.

Saskatchewan Insulin Adjustment Module Page 50 Some special situations which may require individualization of goals include: elderly or ill clients The same glycemic targets apply to otherwise healthy elderly individuals as to younger people. In persons with multiple co-morbidities, a high level of functional dependency and/or limited life expectancy the goal should less stringent. Try to avoid symptoms of hyperglycemia and prevent hypoglycemia 28 Women planning a pregnancy must strive for tighter glucose control (A1C < 7% (<6% if safely achievable 29 ) to decrease the risk of congenital abnormalities and further problems in pregnancy. Hypoglycemia unawareness (failure to sense hypoglycemia) may place clients at risk of life threatening hypoglycemia. The target blood glucose levels for therapy for these clients should be adjusted upward. The goal should be to avoid severe or unrecognized hypoglycemia. Pattern Management Modifications are made in the base (usual) insulin dose based on blood glucose patterns. Patterns are consistent trends in blood glucose that occur at the same time of day for three to four days in a row. This method presupposes that the person has a consistent pattern of meals, carbohydrate intake and activities, has no concurrent illness and is free from unusual stress. Basic Principles of Insulin Dose Adjustment Make IDA to usual insulin dose based on blood glucose patterns. Adjust first to eliminate low blood glucose readings. Remember night time hypoglycemia may be reported as nightmares, poor sleep, tossing and turning or perspiration. Remember there may be several possible reasons for fasting hyperglycemia. Adjust only one insulin dose at a time (unless this will cause a low blood glucose level at a later time). Consider that when one insulin is increased, another may need to be decreased. Increase insulin when there is a pattern of repeating high glucose results. DO NOT increase insulin on the basis of sporadic or single high readings. Wait at least 3-4 test days between each IDA to have sufficient data to determine a pattern. Use a combination of pre-prandial and post-prandial blood glucose levels to guide adjustments. 28 2008 Clinical Practice Guidelines, p. S181 29 2008 Clinical Practice Guidelines, p. S170

Saskatchewan Insulin Adjustment Module Page 51 IDA in most circumstances will be by 10% increments. For example: o Usual dose of less than 10 units, adjust by 1 unit o Usual dose of 10-20 units, adjust by 1-2 units and so on Assessment of Blood Glucose Patterns Assess frequency and timing of any hypoglycemia, including nocturnal hypoglycemia and possible rebound hyperglycemia. Ensure clients are familiar with strategies to prevent and treat hypoglycemia. Provide guidelines to monitor ketones (in those who are high risk) during periods of hyperglycemia or illness. Provide the client with guidelines for when to notify the Registered Nurse or physician. Ensure the client is aware of the need to contact the physician when one of the following occurs: Hyperglycemia with ketones (moderate or large) and/or illness Experiences recurrent hypoglycemia with no apparent cause or severe hypoglycemia requiring assistance to treat Is unable to eat or drink (for any reason) Is vomiting or has persistent nausea Blood glucose levels continue to fluctuate with no apparent cause Hyperglycemia is not responding to increases in insulin dose Variable Insulin Dose Adjustments Two types of IDA may be used: a. Correction Factor - adjustment of the insulin dose to correct for a high or low blood glucose level. b. Insulin to Carbohydrate Ratio - adjustment of the insulin dose in advance of carbohydrate intake based on carbohydrate content of the meal or snack. Use of Correction Factors 30 Short or rapid-acting insulins may be given according to a correction factor to compensate for a pre-meal blood glucose above or below target. In some literature this is also referred to as the insulin sensitivity factor. For those who eat consistent carbohydrate only, a correction factor guides a person to make adjustments to the usual dose of short or rapid-acting insulin according to pre-meal blood glucose levels. For those who count carbohydrate, the pre-meal dose of short or rapid-acting insulin is determined by use of both the correction factor for glucose levels above or below the target AND the amount of carbohydrate to be consumed at the meal. 30 In resources and the literature many terms are used in place of correction factor. These include: insulin sensitivity factor; insulin grid or scale; algorithm.

Saskatchewan Insulin Adjustment Module Page 52 Correction factors must be designed on an individual basis taking into consideration the person s: target blood glucose range sensitivity to insulin total daily dose of insulin insulin type short or rapid acting insulin IDA to the base insulin dose should not be made if the person has a concurrent illness or is experiencing stress. Use of rapid or short-acting insulin at bedtime is not usually recommended because of the risk of nocturnal hypoglycemia. However, a conservative dose of short or rapid-acting insulin can be used for an excessively elevated blood glucose reading at bedtime. Use of rapid or shortacting at bedtime may be indicated if glucose levels are high and ketones are present or if the individual routinely has a large bedtime snack. Use of this insulin at bedtime should be discussed with the physician. Any change to a pre-existing correction factor should be sent to the attending physician using a progress note or fax information sheet. Methods to Develop Correction Factors The basic principles to remember when developing a correction factor are: 1. Consider the individual s target range for glucose control and willingness to supplement for values out of the target range. 2. Teach your client to adjust the appropriate basal dose of insulin or the insulin to carbohydrate ratio if they have to correct regularly. If your client has not seen a dietitian in some time and you suspect inconsistency in carbohydrate intake or difficulties with counting carbohydrate, refer the client to a dietitian. Consider how sensitive your client is to rapid or short-acting insulin when developing the correction factor. Construct the factor conservatively (that is, err on the hyperglycemic side initially), evaluate for effectiveness, and revise if necessary. 3. A correction factor is effective when: Using short-acting insulin, the blood glucose returns to target range (ideally 4-7 mmol/l) prior to the next meal/snack ie: in 4 to 6 hours. Using rapid-acting insulin, the blood glucose returns to target range as with short-acting insulin. The 2 hour pc reading is also useful when making initial IDA. There are two methods which can be used to develop a correction factor 31,32. 31 Sources: Building Competency in Diabetes Education: Advancing Practice, p2-41 to 2-43 and Lightfoot,

Saskatchewan Insulin Adjustment Module Page 53 1. The Rule Method Divide either 100 (for rapid-acting insulin) or 85 (for short-acting insulin) by the person s TDD (total daily dose). The resulting number represents the drop in blood glucose for each unit of insulin. Note, it may be appropriate to use the rule of 85 for those who are insulin resistant no matter which type of insulin is being used. EXAMPLE: TDD = 48 units 100/48 = 2.08, rounded to 2 mmol/l This means 1 unit of rapid-acting insulin will drop the blood glucose by 2 mmol/l 2. Use a pre-set standard of 1 to 3 units for 2.2 to 2.8 mmol/l desired change in the blood glucose level. Start conservatively using 1 unit and increase based on feedback from the blood glucose readings. EXAMPLE: In the example below, a correction factor of 1 unit has been used for every 2 mmol/l above the target glucose. PRE-MEAL GLUCOSE TWO HOURS POST-MEAL (using rapid-acting insulin and a consistent carbohydrate intake) 10.2 14.6 9.5 15.8 11.3 13.5 If the correction factor is working, the post-meal glucose will be at about the same level or slightly lower than the pre-meal glucose. This assumes a consistent carbohydrate intake and that the usual dose provides the correct ratio of insulin to carbohydrate. The next step would be an increase in the pre-meal correction factor to 2 units for every 2 mmol/l above the target. Pay attention to the next pre-meal blood glucose as it can be difficult to achieve target post-meal glucose without making the next pre-meal glucose too low. Using the Correction Factor Once a correction factor has been determined, the client can use it in two ways. Clients who find math a challenge will likely prefer the second method. C and Pytka ES (2004) Making Carbs Count: Advanced Carbohydrate Counting for Intensive Diabetes Management. Seminar presented at the 2004 CDA Professional Conference, Quebec City, Quebec. Available on CDA web site, DES members section www.diabetes.ca 32 See practice cases for exercises to develop correction factors

Saskatchewan Insulin Adjustment Module Page 54 1. Calculation for each blood glucose reading To use this method the individual does a pre-meal blood glucose test subtracts the target blood glucose from the result divides by the correction factor EXAMPLE: Current blood glucose level pre-noon = 11.9 mmol/l Target blood glucose level = 7 mmol/l Correction factor = 2 [one unit of insulin lower glucose by 2 mmol.] (11.9 7)/2 = 2.4 units, rounded to 2 units This amount of insulin will be added to the usual dose or the amount of insulin being taken for the carbohydrate to be eaten at the meal. 2. Written grid or scale for insulin IDAs Using this method the educator will create a grid for the client to use based on the correction factor. The grid indicates the number of units to be added to or subtracted from the base dose. EXAMPLE: The TDD is 50 units. 100/50 = 2 [rule method] 1 unit will decrease blood glucose by 2 mmol/l Dose of rapid or short-acting insulin BLOOD GLUCOSE Morning Noon Supper < 4.0-1 -1-1 4.1-7.0 6 10 12 Intermediate or Long-Acting Insulin Lantus 22 units at bedtime TARGET RANGE Usual doses 7.1-9.0 +1 +1 +1 9.1-11.0 +2 +2 +2 11.1-13.0 +3 +3 +3 13.1-15.0 +4 +4 +4 >15.1 +5 +5 +5 For some clients it is necessary to write in the actual dose rather than the amount to be added to the usual dose. In this situation the values in the morning column would read: 5, 6 (usual dose), 7, 8, 9, 10, and 11 respectively. Two more rows can be added to the grid for clients who are carbohydrate counting:

Saskatchewan Insulin Adjustment Module Page 55 A line for the usual carbohydrate at the meal A line for the insulin to carbohydrate ratio Insulin to Carbohydrate Ratio If a person is planning to eat a variable amount of carbohydrate at meals he can anticipate the resulting variability in blood glucose and minimize it by decreasing or increasing the premeal dose of short or rapid-acting insulin. Remember carbohydrate to insulin ratios vary from person to person and may differ from meal to meal. For example, some individuals are more insulin resistant at breakfast than at supper. An insulin resistant person may require 5 gms of CHO per unit of insulin as compared to a thin or fit person or a child needing 20 gms of CHO per unit. Experimenting to get the right ratio requires some time and effort involving frequent blood glucose monitoring and documentation of food intake. The advantages of using the method are: a. greater flexibility and quality of life b. decreased risk for disordered eating. c. reflects more normal eating practices where people gauge how much food they are hungry for, rather than a set amount they have to eat. The disadvantages of this method are: a. hypoglycemia if the anticipated rise in blood glucose does not occur. Clients should be reminded that a compensatory correction can be safely made at the next meal time. b. weight gain if a person frequently increases insulin to allow for extra food. NOTE: Initially, it is suggested that carbohydrate content at meals and snacks remain consistent when first establishing insulin to carbohydrate ratios. Once a baseline is established, greater flexibility and variability of carbohydrate intake will be possible. There are three methods to determine the insulin to carbohydrate ratio 1. Pattern Management. This method can be used when the amount of insulin taken provides adequate control based on changes in pre versus post-meal blood glucose of no more than 3 mmol/l at 1 hour pc. Divide the number of grams of carbohydrate taken at a meal by the number of units of insulin given at the meal. The result will yield: 1 unit of insulin per xx grams of carbohydrate. EXAMPLE Meal time carbohydrate = 66 grams Meal time insulin = 7 units 66/7 = 9.4 Therefore, 1 unit of insulin would be taken for every 9 grams of carbohydrate.

Saskatchewan Insulin Adjustment Module Page 56 2. Rule of 500 In this method 500 is divided by the TDD This method will yield the same insulin to carbohydrate ratio for all meals. IDA may be needed based on actual results, observations of what works and use of method #1. EXAMPLE TDD = 63 units 500/63 = 7.9 Therefore, 1 unit of insulin would be taken for every 8 grams of carbohydrate 3. Averages of Pre-meal insulin and carbohydrate intake In this method: the bolus or pre-meal insulin doses are added for the full day. the amount of carbohydrate average/day is determined. the carbohydrate/day is divided by the total pre-meal or bolus insulin. EXAMPLE: Total pre-meal or bolus insulin/day = 28 units Average grams of carbohydrate eaten/day = 140 grams 140/28 = 5.0 Therefore, 1 unit of insulin would be taken for every 5 grams of carbohydrate

Saskatchewan Insulin Adjustment Module Page 57 1.0 Insulin Dose Adjustment for Exercise or Increased Physical Activity IDA for exercise or physical activity depends heavily on your client s response to insulin, the intended activity and its timing in relation to food and insulin. Thus, blood glucose monitoring is required to ensure safe and effective IDA. Physical activity may enhance the effect of exogenous insulin by increasing glucose uptake by muscle cells and intracellular glucose metabolism. The temporal effect on blood glucose levels will vary depending on the person and intensity and duration of activity. Depletion of glycogen stores may occur with moderate to intense exercise and may result in hypoglycemia many hours after exercise. For some this can be as long as 24 hours. It is important to note that recognition of hypoglycemia may be delayed during vigorous exercise due to the masking of early warning signs. 1.1 Guidelines for IDA for exercise are: a. People with type 1 diabetes who have a urine ketone level > 8.0 mmol/l or blood ketone level > 3.0 mmol/l 33 should not exercise. Metabolic deterioration will occur with exercise. b. Blood glucose monitoring should be employed initially before, during and after new exercise routines to determine its effect on glycemic levels for the individual. c. Exercise at consistent times of the day will facilitate more reliable IDA. d. Compensatory food intake may be used to prevent hypoglycemia without IDA or as an adjunct. The client should have a source of short-acting glucose available during exercise. See accompanying table. Adequate hydration is also important. e. Anticipatory IDA for exercise without compensatory carbohydrate intake may be recommended as follows 34. These are guidelines and will need to be evaluated with each individual. f. Insulin injection into an exercising limb may speed insulin absorption and action. If possible, Insulin should be injected into a non-exercised part of the body prior to exercise; for example, inject in the abdomen rather the leg before running. g. Following prolonged exercise, subsequent meal doses of rapid or short-acting insulin may need to be reduced by 20-50%. 35 i. IDA may also be needed to the basal insulin dose(s). The bedtime basal insulin may need to be decreased by 10-30% followed prolonged endurance exercise, particularly if this has happened during the evening. 33 2008 Clinical Practice Guidelines, page S48 34 Rabasa-Lohoret R, Bourque J et al. Guidelines for Premeal Insulin Dose Reduction for Postprandial Exercise of Different Intensities and Durations in Type 1 Diabetic Subjects Treated Intensively with Basal-Bolus Insulin Regimens (Ultralente-Lispro). Diabetes Care 2001;24(4):625-630. 35 Jones H. editor. (2009). Building Competency in Diabetes Education: The Essentials. Diabetes Educator Section, Canadian Diabetes Association: Toronto, Ontario.

Saskatchewan Insulin Adjustment Module Page 58 May, 2010 These are only initial conservative recommendations to be evaluated by blood glucose monitoring and revised as necessary. Exercise Time Immediately post-meal Morning or Afternoon Very early in morning Post Prolonged activity* Insulin Type Pre-meal Bolus Morning Basal Previous evening basal Meal or Basal Intensity of Exercise Mild Moderate 20-50% Strenuous 50% Prolonged > 3 hours* Up to 80% 30-50% Adjust with exercise intensity Trained athletes may require up to 80% reduction No more than 50% reduction Adjust with exercise intensity Post activity pre-meal doses, may reduce by 20-50% Bedtime basal insulin, may reduce by 10-30% * Prolonged activity may have a delayed glucose lowering effect Source: The Essentials, 2009, Chapter 10.

Saskatchewan Insulin Adjustment Module Page 59 May, 2010 Extra Food For Extra Exercise 36 Adult Guidelines must be adjusted for pediatric clients You may have already taken less insulin. However, you may need to eat extra food depending on your blood glucose results before you start exercising always test! The following table tells you how much food to eat. Remember, these are only guidelines. Table 2 Exercise Light for one hour (Walking, Bowling) Blood Glucose Levels Less than 6 mmol/l Carbohydrate Amount 15 grams Moderate for one hour (Tennis, Cycling, Swimming, Sexual Intercourse, House Cleaning, Golfing) Strenuous for one hour (Hockey, Racquetball, Football, Competitive Sports) Less than 6 mmol/l 30 grams of carbohydrate before exercise. An additional 10 15 grams of carbohydrate is required for each additional hour. 6 10 mmol/l 15 grams of carbohydrate 11 17 mmol/l Food intake should not be increased. Moderate urine Do not exercise until diabetes ketones >8 mmol/l control improves. or blood ketones >3 mmol/l are present Less than 6 mmol/l 45 grams of carbohydrate before exercise. An additional 10-15 grams of carbohydrate is required for each additional hour. 6 10 mmol/l 30 grams of carbohydrate NB. Small amounts at frequent intervals are preferable for prolonged activity 11 17 mmol/l [no ketones] Moderate urine ketones >8 mmol/l or blood ketones >3 mmol/l are present 15 grams of carbohydrate Do not exercise until diabetes control improves. 36 Original from Learning to Live With Diabetes Nova Scotia Diabetes Centre. Revised and updated based on Clinical Practice Guidelines and Beyond the Basics, CDA (2005).

Saskatchewan Insulin Adjustment Module Page 60 Insulin Dose Adjustment (IDA) for Tests/Procedures When Fasting is Required Principles to Consider When Adjusting Insulin for Procedures Which Require Fasting 1. Client assessment: a. What is the current insulin regimen and what are the flexibilities eg MDI versus pre-mixed insulin? b. What is the usual pattern of blood glucose across the day? c. What is the current frequency and timing of hypoglycemia? Does this person have hypoglycemia unawareness? d. Is the client able and willing to do extra blood glucose monitoring possibly before, during and after the test/procedure? e. How independent is the client now in IDA so he/she can adapt the instructions given by the RN, if needed? f. Does the client know how to convert carbohydrate to liquids? g. What support person(s) are available to assist with care? h. Does the client have previous experience with this type of fasting? How was it handled in the past and how did the changes work? i. If the client provides sufficient notice, suggest he/she request the procedure be done as early as possible in the day to minimize blood glucose and insulin issues. j. Ask client if he/she has been given instructions by any other care provider. 2. Test/Procedure: a. What are the test/procedure instructions already given to the client? b. What length of time will likely be required for fasting? c. Does the procedure require clear fluids for a period of time prior to the test? d. What will be the impact on ability to eat solids or drink liquids post- procedure? e. Are there any expected outcomes from the procedure which may affect blood glucose monitoring or ability for self-care? f. Will the procedure require sedation and/or an IV? What IV solution will be used saline or dextrose?

Saskatchewan Insulin Adjustment Module Page 61 Use of Clear Fluids for Procedure/Test Preparation A document to guide clients in the use of clear fluids has been prepared by Regina Qu Appelle Health Region and is located at the end of this section. Making the Decisions for Insulin Dose Adjustment for MDI or BID Rapid/Shortacting and Intermediate Insulin a. Prior to giving client guidelines, request, if possible, daily blood glucose monitoring and recording for at least 3 days pre-visit. This will help to determine the usual patterns. b. Assess usual blood glucose levels. c. Adjusting insulin for overnight fasting prior to procedure i. If using long-acting basal insulin: no adjustment is needed unless there has been recent unexplained hypoglycemia or the usual fasting blood glucose is below 5. ii. If using an intermediate acting insulin: if usual fasting blood glucose is below 10, or there are concerns about overnight or early morning hypoglycemia, reduce the intermediate at supper or in the evening prior to the fast. Reduce by a minimum of 10-20% depending on the results of the assessment. The percent reduction needs to be tailored to the individual client. iii. Consider whether or not a bedtime snack is needed. Most procedures will allow food/drink consumption until late evening. d. Adjusting insulin for fasting day of procedure/test i. Adjust the first injection of rapid or short-acting insulin on the day of the procedure. Usually this insulin dose would be eliminated or delayed, depending on the timing of the procedure. ii. Adjust the morning intermediate or long-acting basal insulin analogue. 1. If the procedure time is relatively short, the probability of eating afterwards is high and the client does not usually have problems with morning hypoglycemia, no change in dose may be necessary or a minor reduction of 10-20% could be made. 2. If the length of the procedure is more than 2 hours, or unknown, or there are concerns for hypoglycemia, delay the intermediate until after the procedure is completed reduce the long acting basal insulin by 10%

Saskatchewan Insulin Adjustment Module Page 62 e. Adjusting insulin post-procedure/test i. If the intermediate insulin analogue injection is delayed, then the formula below can be used as a guide. If the basal insulin is reduced, there may be an impact later in the day. ii. Consider the results of the calculation against the usual blood glucose readings and client s ability and confidence in adapting the result to the situation he finds at the time a dose decision needs to be made. Some clients may need to call a care provider to get advice depending on number of hours without insulin, ability to eat/drink and current blood glucose reading. Formula: Number of hours injection delayed divided by 24 (number of hours in a day) and then multiplied by 100 = the percent to reduce the usual dose. Example: Usual morning dose of NPH 20 units is delayed by 4 hours. 4/24 = 0.167 x 100 = 16.7% 20 units x 16.7% = 3.34 rounded to 3 Reduce dose from 20 to 17 units iii. Once the individual is back to usual eating, a correction of rapid/short-acting insulin may be necessary as well as rapid/short-acting insulin to cover any food or drink taken. iv. Clients who are not used to adjusting their own insulin may need a grid to guide them or may need to call a care provider for specific advice. Making Insulin Dose Adjustments for Pre-mixed Insulin a. Prior to giving client guidelines, request, if possible, daily blood glucose monitoring and recording for at least 3 days pre-visit. This will help to determine the usual patterns. b. Assess usual blood glucose levels. c. Adjusting insulin for overnight fasting prior to procedure If usual fasting blood glucose is below 10, or the usual pattern shows the blood glucose drops overnight or, if there are concerns about overnight or early morning hypoglycemia; reduce the pre-mix supper dose prior to the fast. Reduce by a minimum of 10-20% depending on the results of the assessment. The percent reduction needs to be tailored to the individual client.

Saskatchewan Insulin Adjustment Module Page 63 d. Adjusting insulin for fasting day of procedure/test This insulin dose may be eliminated or delayed, depending on the timing and/or length of the procedure. Some clients may benefit from using basal NPH only on the morning of the procedure, at or below the usual dose provided by the pre-mixed insulin. e. Adjusting insulin post-procedure/test If the fasting time has been relatively short and the client will be able to eat/drink post-procedure, when the procedure is completed, he could test blood glucose and take the usual or a slightly reduced insulin dose and then eat. To account for the delay in injection time and the possibility of overlapping insulin peaks later in the day, use the following formula to recommend an insulin dose. Formula: Number of hours injection delayed divided by 24 (number of hours in a day) and then multiplied by 100 = the percent to reduce the usual dose. Example: Usual morning dose of Humalog Mix 25, 20 units is delayed by 4 hours. 4/24 = 0.167 x 100 = 16.7% 20 units x 16.7% = 3.34 rounded to 3 Reduce dose from 20 to 17 units As there is less flexibility to fine-tune the insulin dose to correct a high blood glucose, the client needs to understand that blood glucose levels may be higher for a couple of days. Management of Hypoglycemia While Fasting The possibility of hypoglycemia during fasting needs to be discussed with the client. Encourage the client to test to confirm hypoglycemia if signs/symptoms are experienced. Glucose tablets are the preferred treatment method as they are quickly absorbed and are not liquid. The treatment needs to be reported prior to the start of the procedure and it is possible the procedure may be delayed.

Saskatchewan Insulin Adjustment Module Page 64 Managing Diabetes on a Clear Fluid Diet 37 What is a clear fluid diet? The clear fluid diet is used short-term to prepare the bowel for certain procedures, such as surgery or a colonoscopy. It may also be used for a short time during illness if you are not able to eat solid foods due to nausea and/or vomiting. How do I manage my blood sugars when I am not eating solid food? Speak to your doctor or diabetes educator about the need to change your diabetes pills or insulin dosage. You will still need to take some diabetes medication during this time. Drink plenty of sugar-free fluids throughout the day to prevent dehydration and relieve your thirst. Sugar-Free Choices: Water Clear tea + coffee Crystal Light Sugar-Free Soft Drinks Sugar-Free Gelatin Clear Chicken or Beef Broth Test your blood sugar level every 2 to 4 hours, testing more often if your blood sugar is low. Your blood sugar level will help you decide how much carbohydrate (sugar) containing fluid you need over the next few hours If Your Blood Sugar Level is 4-10 mmol/l Number of Portions of Sugar Containing Fluids Needed (see list on next page) 1 portion each hour until next testing time Above 10 You may not need sugar containing fluids. Drink sugar-free choices and check your blood sugar in 1 to 2 hours time. 37 Developed by MEDEC, Regina Qu Appelle Health Region (2007) and reproduced with permission.

Saskatchewan Insulin Adjustment Module Page 65 Sugar Containing Choices Juice: Grape, Cranberry, Apple or Orange Regular Soft Drinks: Meal Replacement Drinks Boost and Ensure (Do not use before surgery) Regular Popsicles Regular Gelatin One Portion (Contain 15 g carbohydrate) 1/3 cup (75 ml) to 1/2 cup (125 ml) 1/2 cup (125 ml) to 3/4 cup (200 ml) 1/3 cup (75 ml) 2 sticks 1/3 cup (75 ml) Note: if you are preparing for a test such as a colonoscopy, your doctor may provide instruction about specific colors of fluids to avoid, for example: red colored gelatin. Follow these instructions. Hypoglycemia (Low Blood Sugar) If your blood sugar level is below 4.0 or you feel weak, shaky or dizzy: Take: - ½ cup of juice (eg. apple juice) OR - 1 tablespoon of sugar or honey OR - 3-4 glucose tablets Wait 10 to 15 minutes and retest your blood sugar. If your blood sugar is still below 4.0, repeat the treatment Follow up - Once your blood sugar is above 4.0, have 1 portion of sugar containing fluids to carry you through until your next testing time. Before Going to Bed: Test your blood sugar level If bedtime blood sugar is 4.0 to 7.0, have 2 to 3 portions of sugar containing fluids If bedtime blood sugar is above 7.0, have 1 to 2 portions of sugar containing fluids You may wish to set an alarm and check your blood sugar once through the night Seek medical help if: blood sugar levels have been higher than 17 for more than 12 hours you have moderate to large amounts of ketones in your urine or blood (ketones are greater than 1.5) *Note: Ketones appear in people with Type 1 diabetes only

Saskatchewan Insulin Adjustment Module Page 66 Client Assessment for Insulin Adjustment for Fasting for a Test/Procedure 38 NAME: PHN Requirements of the test/procedure for diet changes/fasting: Support person(s) available to assist with care: Insulin: TIME Morning Noon Supper Evening Other BRAND AMOUNT Comments: Usual Blood Glucose Pattern: Morning pc meal Noon pc meal Supper pc meal Evening Night Client willing to do monitoring pre and post test/procedure: no yes Current Frequency/Timing of Hypoglycemia: None Other, provide relevant details Client is independent in insulin adjustment yes no who will assist if needed? Can client convert CHO to fluids? yes no Clear Fluid Diet given: yes no Referral made to dietitian: yes no 38 This is a sample form which can be used or adapted by a Health Region.

Saskatchewan Insulin Adjustment Module Page 67 Relevant past experience with fasting: None Instructions given by another care provider none yes, comment Advice given (diet, insulin adjustment pre and post test/procedure, contact for assistance): 1. 2. 3. Date: Signature: PRINT NAME SIGNED

Saskatchewan Insulin Adjustment Module Page 68 Managing Your Diet and Insulin for a Test or Procedure 39 Client s Name: PHN: Type of diabetes: Name of test: Date/time: MEAL PLAN No change is needed in your meal plan Use the clear fluid diet provided Make the following changes in your insulin doses: DATE TIME INSULIN Continued on next page 39 This is a suggested client handout which can be used or adapted by a Health Region.

Saskatchewan Insulin Adjustment Module Page 69 LOW BLOOD SUGARS If you think your blood sugar is low, try to do a test and write down the result. Treat the low sugar with glucose tablets. If you do not have them, use your usual treatment. You MUST tell the staff at the test/procedure you had a low sugar and how you treated it. PROBLEMS_NOT SURE WHAT TO DO WITH FOOD OR INSULIN Who to call ON THE DAY OF THE TEST or PROCEDURE: Take this sheet with you to the test/procedure Test your blood glucose when you first get up in the morning and write the result here Write down the dose of insulin which you took this morning. o I did not take any insulin o This morning I took the following insulin:

Saskatchewan Insulin Adjustment Module Page 70 Teaching Procedure For Self-Adjustment Of Insulin Learning Objectives Upon completion of this chapter you will be able to: Teach clients to self-adjust their insulin taking into consideration their age, concurrent medical conditions and lifestyle. Principles 1. Assessment of the client on insulin should include their willingness and ability to learn SMBG, interpretation of results, and to self-adjust medication when indicated. Potential barriers to the learning process may preclude the client being able to effectively adjust their own insulin dosages. These could include but are not limited to: a. unable to afford SMBG b. unable to understand necessary concepts, e.g. insulin action times, target blood glucose range, etc. c. unable to analyze abstract data, e.g. relationship of SMBG results to specific insulin action, identification of blood glucose trends, etc. d. unable to take action to make necessary IDA due to insecurity or unwillingness to take over perceived medical function. 2. Self-adjustment of insulin can be taught in a group setting or on an individual basis. 3. The 2008 Clinical Practice Guidelines should be used for target ranges for blood glucose control and IDA subject to individual needs. These guidelines are subject to individual variation related to factors such as the client s age, concurrent medical conditions, long-term complications of diabetes, and ability to perceive early warning signs of hypoglycemia. 4. Principles for IDA teaching must take into account the individual client s response to their insulin. General guidelines based on the usual or mean response pattern are useful for group instruction and for individuals until specific variation in insulin response is determined. Review the time actions the client s own insulins and present these in relation to his or her own lifestyle. Consider usual meal times and insulin injection times. Examples of resources are in the reference section. 5. General guidelines that can be provided to clients for self-adjustment include: a. Before making insulin adjustments, review consistency of carbohydrate intake at meals and snacks and/or accuracy of carbohydrate counting b. Look for patterns of high/low blood glucose results at specific times of the day. If the patterns are explainable, make the appropriate change in diet, activity, etc. If the patterns are unexplainable adjust the appropriate insulin by a factor of 10%.

Saskatchewan Insulin Adjustment Module Page 71 c. Monitor blood glucose before and 2 hours after meals while making IDA and evaluate the result of specific IDA over the following three to four days. d. Only make IDA every 3 to 4 days, except in unusual circumstances such as illness, pregnancy, travel, excessive hyperglycemia, or hypoglycemia. In such cases, consult your Registered Nurse or doctor. e. Compensate for high or low blood glucoses if your Registered Nurse or doctor has provided you with a correction factor for rapid or short-acting insulin. The extra insulin with the correction factor must be included in your evaluation of patterns of hypo/hyperglycemia. f. If self-adjustments do not improve the identified problem consult your Registered Nurse or doctor. 6. Sick Day Management. Contact your doctor in the event of illness for further specific IDA guidelines. 40 7. Principles for IDA for exercise include: Monitoring of blood glucose is essential in determining the need for insulin and/or food compensation for exercise. Insulin or food adjustments for exercise are best evaluated by SMBG before, during, and after exercise. Once a satisfactory pattern of glycemic response to exercise and insulin/food adjustment is obtained, less frequent monitoring is required. a. Exercise is not recommended if urine ketones are > 8 mmol/l or blood ketones >3 mmol/l. b. Decrease the insulin that will be working at the time you plan to exercise. Use the guide from your Registered Nurse or doctor when making changes 41. c. Revise IDA as required to optimize blood glucose control. d. Other information to give clients for exercise: When you exercise, always carry some form of sugar, such as glucose tablets, juice, lifesavers or hard candy. Never drink alcohol around the time you exercise as it can result in low blood sugar. Dehydration, especially in hot weather, can be very serious if your diabetes is in poor control. Prevent dehydration by drinking water before, during and after exercise. 40 The Registered Nurse receiving such a request will communicate with the physician to coordinate care relative to the illness and need for additional rapid or short-acting insulin. The additional insulin must take into account the presence or absence of ketones. Insulin adjustment for acute illness is not part of the basic Transfer of Medical Function. 41 Refer to information in the Learning/Procedure module which can be modified as a client handout. Also see Additional Resources at the end of Module

Saskatchewan Insulin Adjustment Module Page 72 If you reduce your insulin and are unable to exercise, your blood sugars will be high that day. 8. Taking extra rapid or short-acting insulin in anticipation of a special meal/food, e.g. birthday, special meal, etc. can prevent hyperglycemia post meal or later in the day. Blood glucose monitoring to evaluate effectiveness is recommended.

Saskatchewan Insulin Adjustment Module Page 73 PRACTICE CASES The following cases are to be completed after reviewing the Learning and Procedure Module. If there is a provincial workshop, there will be discussion of the cases at the workshop. Or, the diabetes educator can review the cases with a qualified physician and/or an experienced diabetes educator colleague. Answers are provided at the end of this section for each case. Review each of the following cases and provide an answer with rationale. Also consider what questions you might ask a client in each of these situations. CASE #1 Sarah is 60 years old with type 2 diabetes. She has been using insulin for about one year and has had diabetes for 8 years. Her eating and activity patterns were recently assessed and are relatively consistent from day to day. Her last A1C reading was 7.2%. She weighs 165 lbs (75 kg). INSULIN DOSE: N 15 units at bedtime Date Before Post Post Noon Post Bedtime Breakfast Breakfast Supper June 10 7.6 9.8 7.5 8.1 June 13 8.6 8.6 5.0 5.2 6.0 June 16 7.2 8.8 9.1 9.9 June 20 7.8 7.8 6.9 4.7 6.3 Eating pattern as assessed by a dietitian: Carbohydrate distribution - breakfast 50 grams - lunch- 60 grams - pm snack 15 grams - Supper 65 grams - hs snack 30 grams What variables would you consider in client assessment? What insulin dose adjustments would you consider?

Saskatchewan Insulin Adjustment Module Page 74 CASE #2 This continues the story with Sarah from Case #1, now 6 months later. She has increased her bedtime N to 22 units and her fasting blood glucose levels are consistently below 7 mmol/l. The following pattern has emerged in her blood glucose levels over the past four weeks. INSULIN DOSE: N 22 units at bedtime Date Before Breakfast Before Lunch Before Supper Bedtime Jan 10 6.7 5.0 4.5 8.5 Jan 13 6.8 5.0 5.2 9.0 Jan 16 5.2 5.3 6.0 9.2 Jan 20 5.8 6.9 4.7 9.3 Other What variables would you consider in client assessment? What insulin dose adjustments would you consider?

Saskatchewan Insulin Adjustment Module Page 75 CASE #3 Continuing with Sarah from cases 1 and 2, you have reviewed the variables suggested in the answer for Case 2 and found she will not be able to decrease the evening glucose level through changes in eating or activity. You have requested a physician order for pre-supper rapid-acting insulin. The physician agrees and asks you for your suggestion for an amount of insulin. You know that Sarah usually eats about 65 grams of carbohydrate at supper and works hard to be consistent with this amount. She is not physically active in the evening as she does not want to drive in the evening and has other interests to keep her occupied. What would you recommend and what would be your rationale for this recommendation? What follow-up plan would you make with Sarah for ongoing IDA to the presupper rapid-acting insulin?

Saskatchewan Insulin Adjustment Module Page 76 CASE #4 John is 50 years old, works as an accountant. He has been on insulin for 10 years and has had diabetes for 12 years. His BMI is 24. INSULIN DOSES: Breakfast Humalog 7 units Noon 0 Supper Humalog 10 units Breakfast Humulin N 28 units Bedtime Humulin N 8 units The following values represent typical log book entries Date Before Before Before Bedtime Other Breakfast Lunch Supper Oct 24 2.0 4.8 4.8 6.8 Oct 25 16.9 12.2 8.1 5.4 Low during the night Oct 26 7.1 7.6 5.9 6.2 His doctor would like to switch him to an extended long-acting insulin analogue (Lantus) and asks you to recommend a dose. John says he prefers taking the long-acting insulin at bedtime. State the dose you would recommend and your reasons. What advice will you give John in terms of what he might expect to see in his glucose readings when he makes the switch?

Saskatchewan Insulin Adjustment Module Page 77 CASE #5 This case continues with John from Case #4. He is now using Lantus 32 units at bedtime, no longer has night-time or fasting hypoglycemia and his fasting glucose levels are usually between 5-6 mmol/l. However, his pre-supper blood glucose levels are slowly rising. He has omitted his afternoon snack to help compensate, but the glucose readings at supper remain elevated. Prior to the insulin change, they were usually below the target of 7, now they are usually 8-9 mmol/l and occasionally higher. His noon carbohydrate varies from 60-80 grams. What advice would you give about the amount of H to use at noon? Explain your recommendation.

Saskatchewan Insulin Adjustment Module Page 78 CASE #6 John from Cases 4 and 5 has followed your advice and it has worked out well. His usual doses of insulin in a day are Breakfast Humalog 7 units Noon Humalog 8 units Supper Humalog 10 units Bedtime Lantus 32 units He occasionally changes his carbohydrate intake, but adjusts his insulin accordingly. He does not snack between meals. He now says he would like to be able to fix the high blood glucose levels which he gets from time to time. Usually he cannot explain them and he finds this frustrating. Use the rule method to calculate the correction factor. Create a grid for John s breakfast insulin dose. If John does not want to carry around a grid, write down the calculation he would use if his fasting blood glucose reading is 12.6 one morning. What would be different in this calculation if John was using a short-acting insulin rather than a rapid-acting insulin?

Saskatchewan Insulin Adjustment Module Page 79 CASE #7 Mike is 39 years old with type 2 diabetes. In the past two months Mike says that whatever he tries, he can t get his blood glucose levels under control. He has gone back to his meal plan and followed it fairly faithfully. This is confirmed by a visit to the dietitian. He walks in the evening 2-3 days per week. His weight is 165 lbs (75 kg); height is 71 inches (180.3 cm). His A1C one month ago was 10.5% INSULIN DOSES a.m. Humulin N 30 units supper Humulin N18 units Date Before Breakfast Before Lunch Before Supper Bedtime Monday 10.9 8.9 16.4 12.3 Tues 17.2 12.6 11.1 10.9 Wed 15.8 13.2 12.7 14.5 Other What insulin changes would you recommend to this gentleman?

Saskatchewan Insulin Adjustment Module Page 80 CASE #8 Milly Smith has had diabetes for 22 years. She has been on insulin for the past 15 years. She has had high fasting readings for a few weeks. In the last week she has been increasing her pre-supper N, but the high readings continue in the morning. She also has been having restless sleeps and morning headaches. INSULIN DOSES: pre-breakfast: Humulin R 6 units and Humulin N 24 units pre-supper: Humulin R 3 units and Humulin N12 units Does Milly need any insulin adjustment?

Saskatchewan Insulin Adjustment Module Page 81 CASE # 9 Fred is a 58 year old lean male (70 kg.). He has a 6 year history of type 2 diabetes. He tests regularly and has regular contact with the dietitian who confirms that he has a consistent carbohydrate intake. It has been 1 year since initiation of insulin therapy. He hates insulin injections. He has several complaints when he comes to see you: morning hyperglycemia mid-afternoon hypoglycemia nocturia, decreased sleep INSULIN DOSE: single injection NPH 80 units before breakfast What changes would you consider?

Saskatchewan Insulin Adjustment Module Page 82 CASE # 10 Joe is a 36 year old sedentary Assistant Manager in a meat packing plant and has had diabetes since age 24. His sister with diabetes is developing retinopathy and he is anxious to learn more about his diabetes and improve his control. He has no complaints and feels well. He is 4 kg. above his healthy weight and would like to lose some weight. He is on no specific diet and can recall no dietitian contact, but he says that he eats regular meals and quantities. He is taking Humulin R10 units and Humulin N 35 units each morning Humulin N 25 units at supper. Glucose patterns on a three day per week before meal and bedtime snack testing routine are as follows: Date Before Breakfast Before Lunch Before Supper Bedtime 4.4 11.1 7.8 8.9 4.4 16.7 7.9 11.1 6.7 15.8 8.9 6.7 4.4 16.7 6.8 11.7 2.2 16.7 9.1 16.7 6.7 11.1 11.1 16.7 Other What would you discuss with him and what possible recommendations might you make regarding his insulin dose?

Saskatchewan Insulin Adjustment Module Page 83 CASE # 11 Joe has decided to do carbohydrate counting and has made some dietary changes to reduce his weight. Review his food records on the following page and calculate the total carbohydrate intake for each meal. As a reference use Beyond the Basics (2005). MEAL FOOD EATEN # grams of carbs Basal Insulin Breakfast Time: 0615 hrs BG: 4.4 Two hour BG: Activity Snack Time: BG Lunch Time: 1200 hrs BG: Snack Time: BG Supper Time: BG: 2 toast, whole wheat 2 tsp. jam (regular) 6 ounces unsweetened orange juice At work sitting Orange Sandwich: 2 slices of bread, whole grain 2 slices cheese or ½ cup salmon 2 tsp margarine lettuce and tomato slice Apple, orange or banana, medium 1 cup skim milk Oatmeal granola bar Meat or fish about 3 ounces 1 cup potatoes Broccoli, 1 cup 1 slice bread, whole grain yogurt, skim w artificial sweetener, ¾ cup ½ banana, small TOTAL CHO PER MEAL/SNACK

Saskatchewan Insulin Adjustment Module Page 84 CASE #12 Joe is now comfortable with carbohydrate counting and has started using some pre-meal rapidacting insulin based on the amount of carbohydrate he eats. He is now using Lantus at 10 pm as his basal insulin For each meal calculate the insulin to carbohydrate ratio using the food record below [see bottom] and then fill in the insulin to be taken at the meal. Comment on the appropriateness of the calculated ratio. Assume the single bg values given here represent the usual pattern of bg results. MEAL FOOD EATEN # grams of carbs INSULIN TAKEN Basal Insulin 0 Breakfast 2 toast, Rapid 12 units Time: 0615 hrs BG: 4.4 2 tsp. jam (regular) ½ grapefruit Two hour BG: 9.8 Activity Snack Time: BG Lunch Time: 1200 hrs BG: 5.3 Snack Time: BG 12.3 Supper Time: BG: 10.8 At work sitting 1 cup carrot & celery sticks 2 tbsp low fat dip Sandwich: 2 slices of bread 2 slices cheese or ½ cup salmon 2 tsp margarine lettuce and tomato Apple, orange or banana 1 cup chocolate milk Meat or fish about 3 ounces 1 cup potato salad corn, 1 cup 1 slice bread yogurt, skim w artificial sweetener, ¾ cup ½ banana, small Rapid 10 units Rapid 10 units 2 hour BG: 13.6 Basal Insulin Lantus 32 units Bedtime 1 apple Time: 10 p.m. BG: 6.7 Insulin:carbohydrate ratio is units for grams of carbohydrate or units (breakfast) Insulin:carbohydrate ratio is units for grams of carbohydrate or units (lunch) Insulin:carbohydrate ratio is units for grams of carbohydrate or units (supper) Insulin:carbohydrate ratio is units for grams of carbohydrate or units (bedtime)

Saskatchewan Insulin Adjustment Module Page 85 CASE #13 Joe is getting very good at counting CHO and deciding how much insulin to take. He is disappointed with some of his pre-meal glucose levels. He asks you what he can do to correct some of the high pre-meal levels. Assume his target glucose level is 7 insulin:cho ratio for supper is 1:10 TDD is usually ~ 70 units/day What is his correction factor? Write in any correction insulin doses you would recommend using the same chart below. MEAL FOOD EATEN # grams of carbs Supper Meat or fish about 3 ounces Time: 1 cup rice BG: 10.8 salad corn, ½ cup 1 slice bread yogurt, skim w artificial sweetener, ¾ cup ½ banana, small 2 hour BG: Basal Insulin Bedtime Time: 10 p.m. BG: 6.7 INSULIN TAKEN Meal Bolus: Correction: TOTAL Taken: Lantus 38 units

Saskatchewan Insulin Adjustment Module Page 86 CASE # 14 Jeff, a 30 year old salesman is fairly inactive and has type 1 diabetes of ten years duration. He is moderately obese, some 8 kg. overweight and slowing increasing. He would like to drop a few pounds. He typically eats three meals and three snacks. INSULIN DOSES: (Novolin) Breakfast: Novorapid 10 units Noon: Novorapid 6 units Supper: Novorapid 12 units Bedtime: Levemir 26 units 90% of his blood glucose tests are in the 4-8 range and exceptions are usually explained by food and activity variations. His last A1C was 6.9% He plans to take up his old school sport of basketball two hour practice on Monday from 7-9 p.m. and weekly game 2:30-4:30 p.m. on Saturdays. What advice does he need to leave him safe for the new exercise pattern?

Saskatchewan Insulin Adjustment Module Page 87 CASE # 15 Karen is 78 years old, lives alone and has had type 2 diabetes for 12 years. Her weight is ~151 lbs (68.5 kg) and height is 61 (155 cm). She has had no problems with hypoglycemia recently. In the past she has had mild hypoglycemia and 6 months ago she had an unrecognized low blood glucose level. Her neighbor called 911. She has seen a dietitian recently and her carbohydrate intake is usually consistent from day to day. A daily afternoon snack has been recommended. In addition to diabetes she has had a myocardial infarct 2 years ago, has hypertension (now controlled) and dyslipidemia (now controlled). Present Medications Metformin 1000 mg bid NovoMix 30, 28 units, pre-breakfast NovoMix 30, 16 units, pre-supper Recent blood glucose readings: Date Before Breakfast Before Lunch Before Supper Bedtime 10.5 7.8 3.4 8.0 9.2 8.3 4.0 7.2 11.1 7.1 2.8 6.9 Other Carbohydrate intake distribution (as assessed by the dietitian) Breakfast - 30 grams Lunch - 60 grams Snack 0 15 grams Supper - 45 grams HS - 30 grams What target glucose level would you set with Karen and her physician? What does the current dose of 28 units of NovoMix 30 represent in terms of types of insulins and how many units of each insulin does this dose represent? What changes, if any, would you recommend to her current medications? What might you consider if the first issue or problem you identify is resolved?

Saskatchewan Insulin Adjustment Module Page 88 CASE #16 Karen has taken care of the first problem you identified in Case #15. All her circumstances remain unchanged. Use the medication doses from the answer to case #15 here. See the current blood glucose pattern below. Date Before Breakfast Before Lunch Before Supper Bedtime 10.5 7.8 7.4 8.0 9.2 8.3 7.0 7.2 11.1 7.1 7.8 6.9 Other What suggestions do you have to help Karen achieve target glucose levels?

Saskatchewan Insulin Adjustment Module Page 89 CASE # 17 Mary is a 65 old female. Her weight is 176 lbs (80 kg) and her height is 63 (160 cm). She has had type 2 diabetes for 10 years and started insulin one year ago. Her most recent A1C = 9.4%. She has found blood glucose levels to be increasingly difficult to control and is gaining weight. Blood glucose readings are 10-12 across the day with little variation. She is already on a maximum dose of metformin. INSULIN DOSES: Novolin 30/70 using an insulin pen 40 units at breakfast 35 units at supper What changes can you suggest?

Saskatchewan Insulin Adjustment Module Page 90 CASE # 18 Stan is a 36 year old lean male, weight 147 lbs (67.0 kg), height 68½ (174 cm). He has had Type 1 diabetes for two years. His carbohydrate intake is consistent at each meal. He has seen a dietitian recently. Meal plan - 2500 calories with the following carbohydrate intake: Breakfast - 105 grams Lunch 90 grams Pm snack 30 grams Supper 75 grams HS - 45 grams Stan prefers not to have a mid morning snack, but likes having one in the afternoon and a more substantial one in the evening. Insulin regime: N 35 units at h.s. and Humalog at each meal using the following grid: Blood glucose a.m. Noon Supper < 5 10 6 12 5.1 7 11 7 13 7.1-9 12 8 14 9.1-11 13 9 15 11.1-13 14 10 16 13.1-15 15 11 17 >15 16 12 18 Stan s present blood glucose pattern is: High fasting blood glucose High blood glucose at 10 p.m. Lows in mid-morning to noon He monitors his blood glucose closely and frequently and makes insulin changes based on meal pattern and activity levels. He usually works long hours at a physically demanding job. What changes would you recommend?

Saskatchewan Insulin Adjustment Module Page 91 CASE #19 Ruth is 75 yr old homemaker. She has type 2 diabetes and has been on insulin for 5 years. She is having some health issues and requires a biopsy of her liver and pancreas. She has been advised to fast from midnight the night before the procedure and to report to the hospital at 6:30 am. The exact time of the procedure is unknown. In the last month with Ruth has had no hypoglycemia Present insulin dose is 32 units of Humulin 30/70 given with breakfast ~0730 0800 hrs 10 units of Humulin R at supper ~ 1700 1730 hrs 27 units of Humulin N at bedtime ~ 2200 hrs Ruth eats consistent carbohydrate at meals and at regular times, she has a bedtime snack routinely. Glucose Patterns on 3 days prior to seeing the educator: Date Before Breakfast Before Lunch Before Supper Bedtime 6.3 8.3 6.2 9.3 6.1 6.6 8.5 7.3 7.2 7.5 6.2 9 Other What would you advise Ruth to do with her insulin dosages in preparation for the test and the morning of the test?

Saskatchewan Insulin Adjustment Module Page 92 CASE # 20 John, who has type 1 diabetes, will be fasting overnight in order to have major dental work done under local anesthesia. His procedure is booked for 8 a.m. and is expected to last until 9:30 a.m. His usual blood glucose results are listed below. In the last two weeks he has had two early morning episodes of hypoglycemia with readings of 2.2 and 1.9. These were unexplained. He has not changed his insulin dose following these low readings. His present insulin types and doses are Levemir 12 units with breakfast, usually taken at 0630 hours and 16 units at bedtime Humalog with each meal using a ratio of 1:8 and a correction factor of 2 Fasting pc Noon pc Supper pc Bedtime Day 1 4.1 6.9 5.9 8.9 7.1 13.4 6.3 Day 2 4.2 7.5 5.9 7.8 6.9 12.5 5.9 Day 3 4.9 6.9 8.2 6.4 11.8 6.2 Given these results, what recommendations would make for IDA the day prior to the procedure? What recommendations would you make for the IDA for the morning of the procedure? He is booked for 0800 hrs and expects to be finished by 0930 hrs at the latest. John gets home at 1030, he feels good and wants to eat some breakfast. He estimates he will be eating 60 grams CHO. His current bg is 11.8, his usual target bg pre-meal is 6. What advice would you give? END of CASES

Saskatchewan Insulin Adjustment Module Page 93 ANSWERS TO PRACTICE CASES ANSWER CASE #1 As the case states her eating and activity patterns are consistent from day to day, you might also consider: Does she always have the snack at bedtime (30 grams)? Accuracy of blood glucose monitoring Accuracy in her use of her insulin measurement and delivery system IDA: increase the bedtime N by 10% or 2 units to reduce fasting glucose. Sarah could be taught to make changes every 3-4 test days until she finds her fasting blood glucose readings below 7 mmol/l It would also be important to review the symptoms, treatment and prevention of hypoglycemia with the anticipated improvement in control. ANSWER - CASE #2: Assuming there were no issues with her insulin measurement/injection technique or blood glucose monitoring, you might also review: Her usual food intake at supper is 65 grams of carbohydrate (from case #1) o Has anything changed recently? o Is the client accurate with her carbohydrate counting? o Is the amount consistent from day to day or variable? What is her evening activity level? Has this changed in the past month? Has she noticed that physical activity in the evening will improve her bedtime readings? What evening activity is she willing to consider, if any? IDA to consider if improvement in glucose levels at bedtime are not found in eating or activity strategies: addition of rapid acting insulin pre-supper. The Transfer of Function does not cover initiation of a new insulin regimen so the Registered Nurse would need a physician order to make this change.

Saskatchewan Insulin Adjustment Module Page 94 ANSWER - CASE #3 As Sarah has not taken rapid-acting insulin pre-meal before, her sensitivity to this insulin is not known. To get a ball park idea the amount of insulin you could use the Rule of 500 (see Chapter IV, Section D in module). At present her TDD is 22 units. 500 22 = 22.7, rounded to 23 Therefore, according to the calculation, Sarah would take 1 unit of insulin for every 23 grams of carbohydrate. Her supper carbohydrate is 65 grams 65 23 = 2.8 Therefore, you could recommend 2-3 units as the initial dose of rapid-acting insulin pre-supper. The follow-up plan with Sarah could include the following: Record food or grams of CHO eaten at supper for a few days on the new insulin dose Test 2 hours post supper and at bedtime to assess the new insulin s effectiveness If post meal glucose levels are not dropping to 10 or less, increase the dose of rapidacting insulin by 1 unit after 3 test days If evening glucose levels are too low or she has symptoms of hypoglycemia, reduce the pre-supper dose of rapid-acting insulin by 1 unit ANSWER - CASE #4 When switching from intermediate-acting insulin to Lantus, it is recommended that the total dose of intermediate-acting insulin be reduced by 20% and the Lantus be given as a single dose. John prefers to take this insulin at bedtime. An alternative could be a morning injection of long-acting as Lantus is usually a once a day injection as long as it is given daily at the same time. The following recommendations are based on the injection occurring at bedtime. Total dose of N per day = 36 units 20% of this dose = 7.2 units Recommended starting dose of Lantus = 29 units Advice to John 1. First avoid hypoglycemia. If he has night-time or early morning hypoglycemia symptoms, reduce the Lantus by 10% or 3 units. 2. Check a glucose level around 3 am to ensure he is not missing hypoglycemia. 3. If there is no hypoglycemia and after 3-4 days on the starting dose, the fasting glucose levels are high (>7 mmol/l), increase Lantus by 3 units. Wait 3-4 days between each insulin increase. He may wish to check another 3 a.m. glucose level before making further increases. 4. He may find his pre-supper glucose readings become elevated as he no longer has intermediate acting insulin in morning. He will likely need to start on a pre-noon dose of H. This change will require a physician s order. Ask John to do some 2 hr pc lunch and ac supper results, to determine whether he needs to start a pre-noon dose of H. This information will be valuable for the physician determine what he needs to order. 5. If he is presently taking an afternoon snack, keep it in for now, but the need for the snack should be reassessed. 6. Review the treatment and prevention of hypoglycemia with John.

Saskatchewan Insulin Adjustment Module Page 95 ANSWER - CASE #5 Using the Rule of 500 to determine how many grams CHO for each unit of insulin. TDD = 7 + 10 + 32 = 49 500 49 = 10.2 Therefore, for every 10 grams CHO he would use 1 unit of insulin. It will be easier to assess the effectiveness of this recommendation if he agrees to use close to the same amount of carbohydrate for a few days. So, if he agrees to say about 70 grams, then he would use 7 units of H pre-noon. Advise John to check his 2 hr pc noon meal blood glucose levels. If the results fall between the target of 7-10, then it will confirm to John that he is using the correct amount of insulin for CHO eaten. If he seems unsure about carbohydrate counting or needs more information/support, make a referral to the dietitian.. He has the option to add extra carbohydrate at his noon meal to compensate for the extra calories he has lost with the elimination his afternoon snack. ANSWER - CASE #6 First calculate John s total daily dose TDD = 7+10+8+32 = 57 units Use the rule of 100 as he is using rapid acting insulin. 100 57 = 1.75 This means 1 unit of insulin will drop his blood glucose approximately 1.75 mmol/l To create a grid the 1.75, could be rounded to up to 2 mmol/l. If John has a history of severe low glucose levels, hypoglycemia unawareness or is nervous about being too low you could use a larger range for the dose changes; for example, 3 mmol steps. Or, you could set the target glucose level higher; for example, to 8 mmol/l. Grid using 1 unit will yield a decrease of approximately 2 mmol/l for morning insulin; the grid would be as follows: Blood Glucose Range Insulin Dose < 4.0* 6 4.1 7.0 7 7.1 9.0 8 9.1 11.0 9 11.1 13.0 10 13.1 15.0 11 > 15.1 12 Note: As part of client education, advise treatment of hypoglycemia and stabilization of blood glucose level before taking insulin and before deciding on the dose. Some clients may need less than the lowest amount on the grid.

Saskatchewan Insulin Adjustment Module Page 96 If John does not want to use a written grid, he would proceed as follows: Blood glucose = 12.6 Target glucose = 7 Difference = 12.6-7 = 5.6 Divide the difference by his correction factor: 5.6/1.75 = 3.2, rounded to 3 Add 3 units to his base dose of 7 = 10 units Humalog to be taken pre-breakfast OR He could use the rounded correction factor of 2 mmol/l drop for 1 unit of insulin 5.6 2 = 2.8, round up to 3 additional units added to the base dose of Humalog. If John was using a short-acting insulin, the TDD would be divided into 85 instead of 100. So the calculation would be: 85/57 (total daily dose of insulin) = 1.5 The grid below for short-acting illustrates blood glucose ranges of 1.5 mmol and insulin dose increments of one unit. Blood Glucose Range Insulin Dose < 4.0 6 4.1 7.0 7 7.1 8.5 8 8.5-10.0 9 10.1-11.5 10 11.6-13.0 11 > 13.1 12 ANSWER - CASE #7 Mike is currently using a TDD of 48 units of insulin. This is about 0.6 units per kg and it is all basal insulin with no insulin for his meals. The usual expected insulin requirement is about 0.5 to 1.0 units/kg. His BMI is 23 so you would not expect insulin resistance and a higher dose needed related to his weight. He could increase his doses of N further, but considering his A1c and his only insulin is basal insulin, he would likely gain greater benefit from starting to use pre-meal insulin. Review current his current patterns in his blood glucose records. The overall picture is too high. Highest pattern is fasting with a bedtime to fasting rise. Breakfast to noon a decrease by noon although not to target. Noon to supper pattern remains similar (1 elevation by supper, could explore reason). Supper to bedtime general lowering, although not to target. For extra information to guide IDA, could also suggest Mike check blood glucose 2 hrs pc when pre-meal blood glucose levels come closer to target. Discuss with Mike his thoughts on the use of rapid/short-acting insulin with meals. As he has only used intermediate insulin, he may be anxious about using these insulins.

Saskatchewan Insulin Adjustment Module Page 97 Possible choices to manage patterns these may need to be done in steps, as Mike is ready. Increased fasting blood glucose level with an average 5 mmol/l rise overnight, if this was lowered, it may assist with noon and other times of the day as a domino effect occurs. Since N at supper is already fairly large, consider moving the N to bedtime. He may be more comfortable with decreasing it 10% initially until he gains experience with this move. Consider with this move the effect on the breakfast to noon blood glucose level pattern. With this move, some rapid or short-acting insulin will be required at supper. RNs need to keep current with EDS requirements of the Saskatchewan Drug Plan. You will need to determine how much of the short or rapid-acting insulin to start to cover the supper carbohydrate intake. A dietitian will be able to help you determine his usual intake. You could begin with a conservative estimate of 1 unit for 20 grams of carbohydrate and adjust as needed. To determine the correction dose of rapid or short-acting insulin, consider the rule of 100 for rapid or 85 for short: 100/48 = 2.08, round to 2. 1 unit of insulin will decrease the glucose level by 2 mmol/l. His insulin grid will change by 2 unit increments. See what this move does however it is likely that Mike will also need to consider using some meal insulin at other times of the day. ANSWER - CASE #8 Two things suggest that Milly may be having night-time hypoglycemia: the restlessness during the night and new higher fasting readings. Ideally it would be useful for Milly to test a few glucose readings at bedtime, 3 a.m. and fasting to see if there is a trend of lower blood glucose overnight. In your assessment also consider: What does Milly eat at bedtime if she does snack o Is the carbohydrate consistent? o How much carbohydrate does she eat? o Does she use a combination of protein and carbohydrate? o Does she sometimes miss an evening snack? o Do any of these variables correlate with the symptoms or high fasting readings? Is Milly physically active in the daytime (especially later afternoon) or evenings? Is anything different on the nights when Milly is active in the day/evenings lower prebedtime readings, different fasting glucose levels the following mornings, correlation between evening activity and night-time symptoms? Also, she could reduce her evening N to see if the night-time symptoms disappear. If the night-time symptoms disappear and the fastings remain elevated, she may need to move her N from supper to bedtime to prolong the action towards morning without risking hypoglycemia with the higher doses. Changing the timing of the insulin requires a physician s order. She may need to decrease her dose of N when the timing is changed. Also look at the impact of the potentially lower fasting reading on the daytime insulin doses. Milly and her doctor may also consider use of a long-acting insulin analogue as EDS status is now available in Saskatchewan for Lantus 42 42 See Saskatchewan Exception Drug Status Program for current information: http://formulary.drugplan.health.gov.sk.ca/ cited 26 march 2009

Saskatchewan Insulin Adjustment Module Page 98 ANSWER - CASE #9 Consider as you have your discussion with Fred: What is Fred willing to do? What are his goals for himself? Is he happy with what is happening? Does he have some ideas on what he could do? Explore his concerns around insulin injections as the options for improving control involving more injections what does he currently use syringes, pens? Injection sites? Technique? Fears he has? The large single morning injection of one insulin may be causing some/all of Fred s complaints. The N peaks in the afternoon and could cause mid-afternoon hypoglycemia. Review his usual food intake and activity habits. Even though the dose of N is large, it may not last long enough to control glucose levels through the night and early morning. This would be responsible for the nocturia and the high fasting glucose levels. It is likely that Fred would benefit from spreading out his insulin however this will all depend on Fred s readiness and will likely need to be done in a series of steps, as Fred is ready. Some options for him to consider: He currently uses 1.1 units/kg per day which is more than usual considering he is lean. All of his insulin is basal insulin and it is also being used to cover his meals. The first priority is to reduce the frequency of lows in the afternoon by: increasing the carbohydrate taken in the afternoon reducing activity decreasing insulin dose in the morning Assume Fred is happy with his carbohydrate intake and activity pattern. Lower the morning N by 10% every 3-4 days until unexplained low blood glucose levels are eliminated. It is likely that at the same time, some N will need to be added at supper. Split the morning N dose between morning (2/3 of the NPH dose) and at supper or bedtime (⅓ of the NPH dose). You may need to gradually add in pre-meal short or rapid-acting insulin If he needs short or rapid-acting insulin later, he could use a syringe to measure to keep the number of injections at 2 or 3 per day.

Saskatchewan Insulin Adjustment Module Page 99 ANSWER CASE - #10 The pattern of Joe s glucose readings shows the supper N lasts until the following morning with fasting glucose reading at or below the recommended target of 4-7 mmol/l. Glucose levels for the remainder of the day are usually above target and the blood glucose level does rise from supper to bedtime. Before he changes his insulin, it would be beneficial for Joe to see a dietitian. He can decide whether or not he wants to use an approach of consistent carbohydrate or learn carbohydrate counting. When he has a meal planning method, the pattern of the glucose levels can be reviewed again. Likely the best option for Joe to consider will be pre-meal rapid acting insulin to handle the meal time carbohydrate. He could consider moving his supper N to bedtime or using extended longacting insulin analogue. Remember he is used to taking insulin twice daily and you may need to approach change gradually. Depending on his response to proposed changes and options, one choice, initially, may be to added, one insulin at a time, such as adding R to his supper insulin dose. The N may need to be reduced as the HS blood glucose levels will likely improve.

Saskatchewan Insulin Adjustment Module Page 100 ANSWER CASE #11 Note answers are included in the table. MEAL FOOD EATEN # grams of carbs Basal Insulin Breakfast Time: 0615 hrs BG: 4.4 Two hour BG: Activity Snack Time: BG Lunch Time: 1200 hrs BG: Snack Time: BG Supper Time: BG: 2 toast, whole wheat 2 tsp. jam (regular) 6 ounces unsweetened orange juice At work sitting Orange Sandwich: 2 slices of bread, whole grain 2 slices cheese or ½ cup salmon 2 tsp margarine lettuce and tomato slice Apple, orange or banana, medium 1 cup skim milk 30 10 22.5 TOTAL CHO PER MEAL/SNACK 62.5 15 15 Oatmeal granola bar 28 28 Meat or fish about 3 ounces 1 cup potatoes Broccoli, 1 cup 1 slice bread, whole grain yogurt, skim w artificial sweetener, ¾ cup ½ banana, small 30 15 15 0g 30g 0g 15g 15g 7.5g 60 67.5

Saskatchewan Insulin Adjustment Module Page 101 ANSWER CASE #12 MEAL FOOD EATEN # grams of carbs Basal Insulin 0 Breakfast Time: 0615 hrs BG: 4.4 Two hour BG: 9.8 Activity Snack Time: BG Lunch Time: 1200 hrs BG: 5.3 Snack Time: BG 12.3 Supper Time: BG: 13.6 2 toast, 2 tsp. jam (regular) ½ grapefruit At work sitting 1 cup carrot & celery sticks 2 tbsp low fat dip Sandwich: 2 slices of bread 2 slices cheese or ½ cup salmon 2 tsp margarine lettuce and tomato Apple, orange or banana 1 cup chocolate milk Meat or fish about 3 ounces 1 cup potatoes corn, 1 cup 1 slice bread yogurt, skim w artificial sweetener, ¾ cup ½ banana, small 30 10 15 55 15 30 15 30 75 0 30 30 15 15 7.5 INSULIN TAKEN Meal Bolus: 12 Correction: TOTAL Taken: 12 Meal Bolus: 10 Correction: TOTAL Taken: 10 Meal Bolus: 10 Correction: TOTAL Taken: 10 2 hour BG: 13.6 Basal Insulin Bedtime Time: 10 p.m. BG: 6.7 97.5 1 apple 15 Lantus 32 units 0 Insulin:carbohydrate ratio is 12 units for 55 grams of carbohydrate or 1:_5 (breakfast) Insulin:carbohydrate ratio is 10 units for 75 grams of carbohydrate or 1:7.5 (lunch) Insulin:carbohydrate ratio is 10 units for 75 grams of carbohydrate or 1: 9.7 (supper) Insulin:carbohydrate ratio is _0 units for 15 grams of carbohydrate or 0:15 (bedtime) Answered continued on next page

Saskatchewan Insulin Adjustment Module Page 102 The insulin:cho ratio seems appropriate for breakfast as the pc reading is 9.8. The insulin:cho ratio seems too high for noon as his pc reading is 12.3. The ratio may need to be lowered to 1:5. The insulin:cho ratio cannot be accurately assessed at present as his pre-supper is already elevated. The ratio may be appropriate if his pre-supper readings were consistently at target. First he needs to lower the pc noon reading. If pc noon readings are at target and this does not improve the pre-supper reading, he may need some basal insulin fasting. If the pc noon and pre-supper readings are at target, but the pc supper bg remains above target, he may need to adjust the insulin:cho ratio to 1:8 or 1:5. ANSWER CASE #13 His TDD is 70 units. The rule of 100 applies to use of rapid-acting insulin. 100 70 = 1.4. This means that 1 unit of insulin will lower the blood glucose by 1.4 mmol/l For the pre-supper reading of 10.8 mmol/l, he would calculate the correction by subtracting his target glucose level (7) from his current reading and then dividing by the correction factor. 10.8 7 = 3.8 mmol above target 3.8 1.4 = 2.7 additional units this could be rounded to 3 units. Supper Time: BG: 10.8 MEAL FOOD EATEN # grams of carbs Meat or fish about 3 ounces 0 1 cup rice, brown, cooked 45 salad 0 corn, ½ cup 15 1 slice bread 15 yogurt, skim w artificial sweetener, 15 ¾ cup ½ banana, small 2 hour BG: Basal Insulin Bedtime Time: 10 p.m. BG: 7.5 97.5 1 apple 15 INSULIN TAKEN Meal Bolus: 10 Correction: 3 TOTAL Taken: 13 Lantus 38 units 0

Saskatchewan Insulin Adjustment Module Page 103 ANSWER CASE # 14 Monday evening practices: The practices will occur during the action time of supper dose of Novorapid. As he wants to lose weight, it would be preferable to decrease insulin instead of eating extra food. As the activity is 120 minutes, he could drop his pre-supper Novorapid by 50% or 6 units. It would be advisable for him to carry extra CHO such as juice and a choice from grains/starches food group. He could be advised to check his blood glucose levels: Pre-supper Pre-practice Mid point in the practice Post practice Bedtime Following morning As there is the possibility of a carry over effect of the evening physical activity, he should also consider reducing his bedtime Levemir, initially by 20% (mid-point in the suggested reduction range of 10-30%). Depending on his bedtime glucose reading, he may need additional carbohydrate at bedtime and he may need to consider also checking glucose at 3 a.m. until he learns more about the effects of the practice on his night-time glucose. Saturday afternoon game, 2:30 to 4:30 p.m. If Jeff takes his Novorapid at noon, he will be past the peak action time by game time. He could make a modest reduction in the pre-noon NR, about 20% or 2 units for the first game. He would check his glucose level at the same times as he did for practices, beginning at pre-noon. Depending on the pre-game level he may need extra CHO then and/or at the mid-point in the game.. If he needs extra carbohydrate pre or mid-game, he should take a fast acting carbohydrate choice. Post game he will need to consider reducing his pre-supper NR because of the carry over effect of the exercise. He could begin with a 20% reduction, assuming a pre-supper glucose of 4-7 mmol/l [see suggested reduction in the Saskatchewan Learning/Procedure Manual]. Depending on his experience with post-activity glucose levels, he many also need to reduce his bedtime Levemir. ANSWER CASE #15 What target glucose level would you set with Karen and her physician? Due to her age, living alone, experience with unrecognized hypoglycemia and previous medical history, the recommended target pre-meal glucose level could be raised from 4-7 mmol/l to, for example; 6-8 mmol/l or slightly higher depending on your assessment of her ability to manage diabetes and recognize hypoglycemia. What does the current dose of NovoMix 30 represent in terms of types of insulins and how many units of each insulin does this dose represent? NovoMix 30 insulin represents a mixture of 30% NovoRapid (Aspart) and 70% aspart protamine crystal. The aspart protamine crystal has an activity profile similar to NPH. 28 units of NovoMix 30 insulin is

Saskatchewan Insulin Adjustment Module Page 104 8.4 units of rapid-acting insulin 19.6 units of intermediate-acting insulin 16 units of NovoMix 30 insulin is 5 units of rapid-acting insulin 11 units of intermediate-acting insulin What changes, if any, would you recommend to her current medications? Current glucose pattern shows: Fasting above target Noon at or close to target Supper too low Bedtime at target The first consideration is always prevention of hypoglycemia, so a 10% minimum reduction in the morning NovoMix 30 would be recommended. 10% is about 3 units or a reduction to 25 units. This would translate to 7.5 units rapid (previously 8.4) and 17.5 units intermediate-acting (previously 19.6). Reinforce the consistency of her afternoon snack. If the above change increases the pre-supper readings to target, then the pattern of glucose readings can be re-assessed. What might you consider if the first issue or problem you identify is not resolved? In some cases, consideration may need to be given to using a different pre-mix (for example, 20/80) or splitting the insulins into their individual components. In order to decide the best action you will need to consider the client s ability and willingness to manage the proposed changes, target blood glucose levels for her age, overall health and symptoms of hypo or hyperglycemia. ANSWER CASE #16 The only glucose levels which are above target now are the fasting ones. Before making any changes to insulin: Review the amount and type of food she is eating at bedtime. Ask her to test her blood glucose level at 0300 a few times to ensure hypoglycemia is not being missed. Assuming there are no issues with either of the above, you could consider the following IDA: 1. As bedtime glucose levels are at target continue with the amount of rapid-acting insulin from the NovoMix30 dose (30% of 16 units = 5 units pre-supper). Move the remainder of the dose, (70% of 16 units = 11 units intermediate-acting insulin; Novolin NPH) to bedtime. Ask Karen to check a couple of glucose levels at ~3 a.m. If the 3 a.m. glucose levels are not too low and the fasting glucose levels remain elevated, increase the bedtime NPH by 10%. NOTE: This would require 3 different insulins which may be confusing to the client.. 2. Change to Levemir or Lantus at HS with short-acting insulin (Novolin Toronto or Humulin R) at breakfast and supper. The long-acting basal insulin analogue would decrease the

Saskatchewan Insulin Adjustment Module Page 105 risk of nocturnal hypoglycemia but would provide minimal insulin coverage for meals. Short-acting insulin could provide insulin coverage for all 3 meals with a total of 3 injections per day and 2 types of insulin. Dose calculations would be as follows: Levemir or Lantus = total intermediate dose for the day 20% of total dose when moving from a BID to OD dose. Therefore 19.6 + 11.2 = 30.8 6.2 (20% reduction in total intermediate dose) = 24.6 = 25 units at HS Short-acting insulin dose could be the same as in the premix. Therefore, the morning dose would be 7 units and the supper dose would be 5 units, BUT Karen s blood glucose levels decrease from breakfast to lunch. Therefore to be cautious, the morning dose could be decreased by at 2 units to decrease the risk of mid morning hypoglycemia. This regimen would require 3 injections per day with 2 different insulins. Also the benefits of rapid-acting insulin on post-meal blood glucose levels in the pre-mix will be lost. 3. Change to Levemir or Lantus at HS (same calculation as above) with rapid-acting insulin (NovoRapid or Humalog) with all meals. Because Karen has a fairly consistent carbohydrate intake from day to day, a routine dose of insulin with each meal may be an option rather than counting carbohydrates for each meal. Initiate rapid-acting insulin with meals at 1 unit per 15 grams of carbohydrates. This regimen would require 4 injections per day with 2 different insulins. NOTE: a physician s order would be needed to implement any of these changes ANSWER CASE # 17 Mary is already using 0.93 units/kg body weight and although she may have insulin resistance, other variables than lack of insulin may be causing the recent elevation in glucose levels. Before making any IDA, consider the following with Mary: she is gaining weight what might be different (food intake and/or activity level, her emotions)? a general food intake review paying attention to recent changes, food portions, fat intake, cooking methods, using food to cope. You might suggest she log her food for about 3 days, as a food review can be 50% inaccurate, especially if she has poor food awareness or if she is depressed. You might suggest a dietitian consult if there are food issues to be addressed. review a typical day to assess activity level and routines and possible changes. assess her quality of sleep. screen for depression. ask Mary to demonstrate her technique with her insulin pen to ensure accuracy. ask Mary to demonstrate her blood glucose monitoring technique. ask questions to determine if Mary has any symptoms suggestive of hypoglycemia (even though it s unlikely). ask about recent infections If there are no clues to improve glucose control in any of the above, then consider an insulin dose increase. Often it is beneficial to try to improve the fasting blood glucose level first.

Saskatchewan Insulin Adjustment Module Page 106 ANSWER CASE #18 The first priority will be to eliminate the lows at noon. If these are not related to food or activity changes, then his pre-breakfast insulin grid could be reduced by 1-2 units. Consider that he may feel he cannot eat any more for breakfast and he does not want to add a mid-morning snack. If this change results in elimination of the lows, and high glucose levels persist at 10 p.m. and fasting, he could look at strategies to reduce his bedtime glucose levels, hoping this would also reduce his fasting glucose. He could check his blood glucose about 2 hours after supper to assist in determining the effectiveness of his pre-supper insulin. If levels are rising > 10 mmol/l (if the pre-supper level is at target), then he can increase his pre-supper insulin grid by 2 units. If the post supper glucose level is < 10 and the rise occurs between that time and 10 p.m. then his basal insulin is likely responsible. His bedtime NPH may not be lasting 24 hours. He could consider two options: Try moving the NPH injection to supper time this may still leave the fasting glucose levels high. Starting a small dose of NPH at breakfast to help later evening basal coverage. Make sure he understands how to use the insulin grid as less insulin may be needed prenoon and/or pre-supper insulin to prevent hypoglycemia. With improved fasting blood glucose levels, he may need a further reduction in his pre-breakfast grid to prevent mid-morning or pre-noon hypoglycemia. He may also need to look at the quantity of his evening snacking. If he needs or wants these calories, he may need a small dose of rapidacting insulin at bedtime. To make this change you would need to consult with his physician. ANSWER - CASE #19 First explain what fasting means. Also explain that she could still experience a low blood glucose during this time. Tell her about the proper treatment (glucose tabs) and to be sure, if she has to treat a low sugar, to inform the personnel doing the procedure about the episode and treatment taken. Monitor her blood sugars regularly and, if she is up at night, do a middle of the night test. Bedtime Insulin night prior to the test At her usual bedtime, 2200 hrs., have a snack containing at least 15 gms of carbohydrate and a protein source. Adjust insulin dose down as she is elderly and will not be eating in the morning for an unknown amount of time. Reduce the bedtime Humulin N dose by 10% Usual dose: 27units of N at 2200 hrs. 27 X 10%= 2.7 unit 27-2.7= 24.3 units, new dose round this down to 24 units.

Saskatchewan Insulin Adjustment Module Page 107 Morning Insulin Dose Day of the Test Her usual morning dose is 32 units of Humulin 30/70 insulin. This is a combination of fast and intermediate acting insulin. The specific timing of the procedure is unknown. As she will not be eating, the safest action will be to delay her insulin until the procedure is completed and she is able to eat. Ruth can be given a chart to follow, basing the insulin dose on the number of hours her breakfast meal has been delayed. Use the formula: number of hours injection delayed divided by 24 (number of hours in a day) and then multiplied by 100= the percentage to reduce the usual dose. Example: usual morning dose of Humulin 30/70, 32 units is delayed by 4 hours 4/24=.167 X100= 16.7% 32 units X16.7= 5.4, round down to 5 units Reduce the dose from 32 units to 27 units of Humulin 30/70 The following is a suggested guide which could be given to Ruth. Arrival time for procedure - 0630 hrs Monitor blood glucose, if test is completed within the next 2 hour and she is able to eat something, then take her usual dose of Humulin 30/70, 32 units. If test completed within 3 hrs of arrival and able to eat If test completed within 4 hrs of arrival and able to eat If test completed within 5 hrs of arrival and able to eat If test completed within 6 hrs of arrival and able to eat Take 28 units of Humulin 30/70 and eat carbohydrate Take 27 units of Humulin 30/70 and eat carbohydrate Take 25 units of Humulin 30/70 and eat carbohydrate Take 24 units of Humulin 30/70 and eat carbohydrate Although this chart could be extended, it is likely best to advise the client that if the delay is longer than 6 hours, consult the physician. Provide the client with written instructions for the insulin dose changes and treating low blood glucose Advise her to take the instructions with her to the test location Provide her with your contact information in case of questions and reinforce physician contact if she has concerns.

Saskatchewan Insulin Adjustment Module Page 108 ANSWER - CASE #20 Given these results, what recommendations would make for IDA the day prior to the procedure? As he has had recent hypoglycemia and fasting bg is a the lower end of target bg, reduce the HS Levemir by 20%. So 16 x 20% = 3.2, round to 3 units less Levemir or 13 units. He likely requires a permanent reduction in the evening dose of Levemir and this should be discussed with John, reviewing the insulin dose adjustment principles of reducing a dose with unexplained low blood glucose readings. If he had not had the unexplained low readings, after assessment, it may have been appropriate to leave the evening Levemir dose unchanged the evening prior to the dental procedure. What recommendations would you make for the IDA for the morning of the procedure? He is booked for 0800 hrs and expects to be finished by 0930 hrs at the latest. No Humalog at the time of his usual a.m. insulin Do not take the Humalog as he will not be eating breakfast at his usual time. As the procedure is short he has the option of taking or not taking his Levemir. As this is a basal insulin, it would be expected to sustain the fasting bg during the procedure. John gets home at 1030, he feels good and wants to eat some breakfast. He estimates he will be eating 60 grams CHO. His current bg is 11.8, his usual target bg pre-meal is 6. What advice would you give? For the Humalog he would use 1 unit for every 8 grams CHO = 60/8 = 7.5 units. To correct the high bg value he would need to use a correction dose: 11.8 6 (target) = 5.8 / 2 (correction factor) = 2.9 Dose of Humalog would be 7.5 + 2.9 = 10.4 = 10 units (rounded down) For the Levemir if he has elected to delay the dose, he is 4 hours late with this insulin injection so 4/24 = 1.67 or 16.7% 16 (usual dose) x 16.7% = 2.7 round up to 3 and he will reduce his usual a.m. Levemir dose from 16 3 = 13 units.

Saskatchewan Insulin Adjustment Module Page 109 REFERENCES Educators are strongly advised to use a core text or reference when learning about insulin and IDA to supplement the module. Two excellent Canadian resources are highlighted in the references. Insulin (2009). In Canadian Pharmaceutical Association, Compendium of Pharmaceuticals and Specialties Ottawa, Ontario. Beaser RS, editor. Joslin s Diabetes Deskbook: A Guide for Primary Care Providers 2 nd edition. 2007;Joslin Diabetes Center:Boston. www.joslin.org Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2008 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes. 2008;32(suppl 1):S1-S201. Chapman TM. Insulin Detemir: a review of its use in the management of type 1 and type 2 diabetes mellitus. Drugs 2004;64(22):2577-2595. Davison KM. Eating Disorders and Diabetes: Current Perspectives. Can J Diabetes. 2003;27;1:62-73. Insulin. A Clinical Journal for Health Care Professionals. Free online access. www.insulinjournal.com cited 25 February 2009 Jones H. editor. (2009). Building Competency in Diabetes Education: Advancing Practice. Diabetes Educator Section, Canadian Diabetes Association: Toronto, Ontario. (in press, March 2009) Jones H. editor. (2004). Building Competency in Diabetes Education: The Essentials. Diabetes Educator Section, Canadian Diabetes Association: Toronto, Ontario NOTE: an new edition will be available in 2010. Perkins BA, Riddell MC. Type 1 Diabetes and Exercise: Using the Insulin Pump to Maximum Advantage. Can J Diab. 2006;30(1):72-79 Riddell MC, Perkins BA. Type 1 Diabetes and Vigorous Exercise: Applications of Exercise Physiology to Patient Management. Can J. Diabetes 2006;30(1):63-71 RxFiles cited 25 February 2009. RxFiles is an academic detailing program to assist physicians, pharmacists and other health care professionals to get excellent and objective drug data. This reference relates to current insulins in Canada. If the resource has been updated since the module was printed, look at www.rxfiles.ca Saskatchewan Registered Nurses Association. The Registered Nurse Scope of Practice: Guidelines for Nurses Prescribing and/or Distributing Drugs by Transfer of Functions. 1999. To order: http://www.srna.org/practice/resources.php

Saskatchewan Insulin Adjustment Module Page 110 Saskatchewan Registered Nurses Association. The Registered Nurse Scope of Practice: Special Nursing Procedures and Nursing Procedures by Transfer of Medical Functions. 1993. To order: http://www.srna.org/practice/resources.php Sclater A. Diabetes in the Elderly: The Geriatrician s Perspective. Can J Diabetes. 2003;27(2):172-175. Swenson K, Brackenridge B. Lispro Insulin for Improved Glucose Control in Obese Patient with Type 2 Diabetes. Diabetes Spectrum. 1998;11(1):13-15. Tibaldi J. Initiating and Intensifying Insulin Therapy in Type 2 Diabetes Mellitus. Am J. Medicine. 2008;121(6A):S20-29. Tibaldi J. Intensifying Treatment in Poorly Controlled Type 2 Diabetes Mellitus: Case Reports. Am J. Medicine. 2008; 121(6A):S30-34. Thompson DM, Kozak SE, Sheps S. Insulin Adjustment by a diabetes nurse educator improves glucose control in insulin-requiring diabetic patients: a randomized trial. CMAJ. 1999;161(8):959-962. White JR, Davis SN, Cooppan R, Davidson MB, Mulcahy K, Manko GA, Nelinson D. Clarifying the Role of Insulin in Type 2 Diabetes Management. Clinical Diabetes. 2001;21(1):14-21.

Saskatchewan Insulin Adjustment Module Page 111 ADDITIONAL RESOURCES 1.0 CLIENT HANDOUTS ON INSULIN/INSULIN ADJUSTMENT Husband A. (2008). Juggling for Control. Eli Lilly Canada, Inc. B.C. Children s Hospital, Insulin Dose Adjustment: An Online Education Program for Parents of Children with Diabetes 16 february 2007. Although this resource is for pediatrics, it demonstrates useful ways to explain IDA to anyone. http://www.bcchildrens.ca/services/specializedpediatrics/endocrinologydiabetesunit/forf amilies/insulindoseadjustment.htm cited 26 march 2009 BD Diabetes.com (USA) a patient insulin adjustment workbook which may be helpful in explaining concepts of IDA. NOTE: all the examples are in mg% for blood glucose values and it would not be appropriate as a Canadian handout as it may cause confusion. The content may assist care providers to develop explanations and client guidelines. http://www.bddiabetes.com/us/hcp/main.aspx?cat=3066&id=3120 cited 26 march 2009 2.0 DIABETES AND PREGNANCY NOTE: The Saskatchewan template for Transfer of Medical Function does not include management of diabetes during pregnancy. Registered Nurses may refer clients for pre-pregnancy support and management during pregnancy to one of the clinics below. Saskatoon Pregnancy Clinic Linda Bachiu, Diabetes Nurse Educator Diabetes Education Centre Royal University Hospital 103 Hospital Drive Saskatoon, Sk S7N 0W8 P 655-1571 F 655-6758 E linda.bachiu@saskatoonhealthregion.ca Regina Pregnancy Clinic Marion Boyd Metabolic and Diabetes Education Centre 2 nd floor, Medical Office Wing 1440-14 th Avenue Regina, Sk. S4P 0W5 P 766-4540 F 766-4178 E Marion.Boyd@rqhealth.ca

Saskatchewan Insulin Adjustment Module Page 112 ACKNOWLEDGEMENTS Saskatchewan Health would like to thank the following individuals who were involved as either committee members or others who were involved in the design, development, review or implementation of the Transfer of Medical Function for Insulin Dose Adjustment. Karen Butler, RD, Regina Qu Appelle Health Region, reviewer 2005, Working Group 2009 and Provincial Diabetes Advisory Body Gideon Dala, MD, Diabetologist, LiveWell Diabetes Program, Saskatoon Health Region Betty Deschamps, RN, Kelsey Trail Health Region, 2001,2005, 2009 Working Group Bev Kernohan, RN, Heartland Health Region, 2001, 2005, 2009 Working Group Nola Kornder, RN, Saskatoon Health Region, 2001, 2005, 2009 Working Group Arlene Kuntz, BSP, Drug Plan and Extended Benefits Branch, Saskatchewan Health, 2009 Working Group Tessa Laubscher, MD, Family Physician, Academic Family Medicine, University of Saskatchewan Heather Nichol, RN, Chair, British Columbia Registered Nurses Insulin Dose Adjustment Working Group Loren Regier, BSP, Program Coordinator, RxFiles Greg Riehl, RN, Nursing Practice Advisor, Saskatchewan Registered Nurses Association Carlene Schmaltz, RN, Kelsey Trail Health Region, 2005, 2009 Working Group Carol Straub, RN, Five Hills Health Region, 2001 and 2005 Working Group Judi Whiting, RN, Saskatoon Health Region, 2001, 2005, 2009 Working Group Karie Witte, RD, Saskatoon Health Region, 2005 Working Group