Guidelines For Dosing Correctionsupplemental Insulin

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Correction or supplemental doses of insulin (CDI) are administered to correct hyper-glycemia that results in spite of the patient having taken the usual prescribed basal and prandial insulin doses. CDI is taken in addition to the usual basal and/or bolus insulin dose(s) to be administered at the time when the FS BG is checked and found to be high. The CDI should not be large enough to cause, nor taken so frequently that overlapping peaks (insulin stacking) will result in hypoglycemia. Typically, approximately 1U of short-or rapid-acting insulin will lower BG by 40 to 50 mg/dL in the patient with DM1. The BG lowering response depends on the patient's insulin sensitivity and daily insulin requirements varying from 0.5 to 3 U of short- or rapid-acting insulin for every 50 mg/dL lowering of BG. If correction dose insulin is needed at bedtime, it should be administered at a reduced dose compared to other times of day in order to reduce risk of nocturnal hypoglycemia.

Several methods for determining CDI are in use; however, studies to determine their specific safety and efficacy are lacking. Each method will take into account the patient's relative sensitivity to insulin, either through an association with the known TDD of insulin being taken or the patient's body weight. A key point to make regarding any method whereby CDI of insulin are used is that the impact on BG for an individual must be carefully monitored and the CDI adjusted as necessary if it does not lower the BG as expected or if it leads to hypoglycemia. This will require monitoring before and after the initial CDI recommended is taken to allow determination of the most appropriate CDI for the individual patient.

One method for determining starting correction insulin doses is to determine the dose as a simple percentage of the total number of units of insulin (basal plus bolus) that makes up the patient's TDDI. Typically, the correction dose will be 10% of the TDDI. If marked hyperglycemia is present and/or urine ketones are positive, the correction dose will be 20% of the TDDI, rounded down to the nearest unit. For example, if the basal insulin dose is 14 U of glargine and the meal dose is 5 U of insulin aspart with breakfast, 3 U with lunch, and 4 U with dinner, the total daily dose of insulin is 26 U. A CDI for moderate elevation in BG would be 2 U of rapid-acting insulin and for more marked hyperglycemia, if urine ketones are present, would be 4 U of rapid-acting insulin. This correction dose will be taken in addition to a usual basal and/or bolus insulin dose to be taken whenever the FS BG is above a predesignated target value for that time of day.

A second method in widespread use was developed by Paul Davidson and applies an insulin correction factor. It is known as the rule of 1800 when a rapid-acting insulin analog is

Table 4 Sample Correction/Supplemental Dose Scale for Insulin Administration

Correction dose scale for insulin3

For blood glucose

Low doseb

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