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TARGET THERAPY
Staying on Target
TM
This workbook will help you learn new skills so that you can you live a
healthier life with your diabetes. What is Basal-Bolus? introduces
flexible insulin therapy, (also called intensive therapy) as a way to correct
your blood glucose levels. Terms to Learn First gives you the definitions
that you will need. Making Bolus Insulin Changes, outlines how to
make changes to rapid and short acting insulin doses. Putting it All
Together gives you a plan to get started. Adjusting for Basal Insulin,
explains changing long acting insulin doses. Trouble-Shooting, tells
what to do when you are having a hard time. Problem-Solving and
Exercises gives you a chance to practice what you learned. Use this guide
as you work with your diabetes health care team to help you avoid the
complications of diabetes.
BD provides this workbook for informational purposes only. It is not intended to be a substitute for professional
medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified healthcare
provider with any questions you may have regarding a medical condition. Never disregard professional medical advice
or delay in seeking it because of something you have read in this workbook
Target Glucose............................................5
Algorithm ..................................................5
Method I ............................................26
Basal Insulin................................................6
Method II ............................................26
Practice Problems......................................31
Option II..............................................38
Option I ..............................................37
WHAT IS BASAL-BOLUS?
WHAT IS BASAL-BOLUS?
When you have diabetes, it is important
to avoid high and low blood glucose
(sugar). This section reviews how outof-control blood glucose can lead to
diabetes complications. It also introduces
flexible/intensive therapy with basal-bolus
insulin adjustment1 as a way to help
keep you healthy.
Responsibilities / Rewards
of Basal-Bolus Before starting
flexible (basal-bolus) therapy, you
should think about its pros and cons.
Pros You will have more freedom
and other benefits, such as:
Ability to eat when and how
much you want
Freedom to skip a meal
Better diabetes control
Feeling of greater well-being
Reduced risk of complications
Cons You will have more work,
including:
Checking blood glucose four or more
times a day, and sometimes during
the night
Learning and practicing carbohydrate
(carb) counting
1 All glucose values used in this workbook are plasma values. If you use a blood glucose meter that reads whole
blood values, you should decrease them by about 10%.
High
Normal
Low
Blood Insulin
Blood Glucose
Bolus
Basal
Midnight
3
AM
6
AM
9
AM
Noon
3
PM
6
PM
9
PM
Midnight
SAMPLE ALGORITHM
Pre-Breakfast Algorithm For Rapid Or Short
Acting Insulin
If your Blood
Glucose is:
Your Rapid-Acting
Insulin Dose should be:
0-100:
2 units
101-150
3 units
151-200
4 units
201-250
6 units
251-300
8 units
Over 300
12 units
Dinner
98 mg/dl
129 mg/dl
89 mg/dl
105 mg/dl
Bedtime
EXAMPLE:
Calculating Lauries Correction Dose
Lauries ISF is 1 unit of rapid or short
acting insulin for every 50 mg/dl of
blood glucose.
Her target pre-meal blood glucose is
100 mg/dl, but her pre-dinner blood
glucose reading is 250 mg/dl.
She is 150 mg/dl over her target level.
Current blood glucose target blood
glucose = amount of glucose over target
[250 mg/dl 100 mg/dl = 150 mg/dl]
150 = 3
50
Name of
Insulin
Type of
Insulin
Peak Action
Humalog,
Novolog,
Apidra
Rapid
30 min. to
1 1/2 hours
Lantus
Long
No peak action
*Regular
Short
2 to 4 hours
*UltraLente
Long
8 to 30 hours
*NPH
Intermediate
4 to 12 hours
*Lente
Intermediate
7 to 15 hours
Understanding How
Insulin Works
Different types of insulin work at
different speeds. Their action can be
described as basal (steady and longacting), bolus (rapid burst of action) or
somewhere in between. They also act
differently in how fast they start working,
Onset of Action
Peak Action
Duration
RAPID ACTING
(Used for bolus
insulin taken
before eating
and to correct
for a high blood
sugar)
Insulin lispro
(Humalog),
Insulin aspart
(Novolog),
Insulin glulisine
(Apidra)
15 minutes
1/2 to 1-1/2
hours
3 to 5 hours
SHORT ACTING
Regular
1/2 hour
2 to 4 hours
6 to 8 hours
Insulin Action
6AM
9AM
Noon
3PM
6PM
9PM
MidN
3AM
6AM
9AM
10
Insulin Action
Type of Insulin
Onset of Action
Peak Action
Duration
LONG ACTING
(Use for basal
insulin taken
in injection or
in a pump to act
through day and
night to keep
blood glucose
levels stable)
Ultralente
Approx.
4 to 8 hours
12 to 18 hours
Approx.
24 to 28 hours
Lantus
2 to 4 hours
No peak, stable
24 hours
6AM
9AM
Noon
3PM
6PM
9PM
MidN
3AM
6AM
9AM
Insulin Action
Type of Insulin
Onset of Action
Peak Action
Duration
INTERMEDIATE
NPH, Lente
1 to 3 hours
6 to 12 hours
18 to 24 hours
6AM
9AM
Noon
3PM
6PM
9PM
MidN
3AM
6AM
9AM
Fill in the chart/graph below to show the action of the types of insulin you are taking now:
My Bolus __________________ insulin:
My Basal__________________ insulin:
7AM
Noon
6PM
12MN
7AM
11
Figure 3
Effects of Previous Insulin Dose on
Blood Glucose Readings Tested at
Mealtimes and Bedtime
Insulin Dose
Blood Glucose
Breakfast Lispro
Breakfast BGM
Lunch Lispro
Lunch BGM
Supper Lispro
Supper BGM
Bedtime Lantus
Bedtime BGM
12
Breakfast
Pre
Lunch
Post
Pre
Dinner
Post
Pre
Bedtime
3 AM
Post
Day 1
Day 2
Day 3
2 American Diabetes Association, Standards of Medical Care for Patients With Diabetes Mellitus. American
13
Breakfast
Pre
Lunch
Post
Pre
Dinner
Post
Pre
Bedtime
Post
1 Mon
90
125
110
189
2 Tues
75
134
116
210
3 Wed
100
141
131
196
133
119
198
Average 88
3 AM
A Janes pre-breakfast, pre-lunch and pre-supper readings are in goal blood glucose
range, but her bedtime readings are all high and out of range.
Q Does Jane Need an Insulin
Adjustment?
A Maybe! But first she should think
about whether she had eaten too much
carb at dinner. Over the next few days,
she should decrease her portion sizes of
food at dinner she is eating (which will
decrease the amount of carb). If there
is no improvement in her blood glucose
readings, Jane should look for other
possible causes and solutions.
14
Breakfast
Pre
Lunch
Post
Pre
Dinner
Post
Pre
Bedtime
Post
1 Mon
90
125
110
239
2 Tues
75
134
116
73
3 Wed
100
141
131
266
133
119
193
Average 88
3 AM
15
Record Your Blood Glucose for the Past 3 Days and Pick Out the Patterns You See
Pre-meal blood glucose goals:________
Post-meal blood glucose goals:________
Day #
Breakfast
Pre
Lunch
Post
Pre
Dinner
Post
Pre
Bedtime
3 AM
Post
1 Mon
2 Tues
3 Wed
Average
16
17
Lunch
Supper
Bed
<50
50-69
10
11
70-89
11
12
90-130
10
12
13
131-160
11
13
14
161-190
12
14
15
191-220
13
15
16
221-250
14
16
17
251-280
15
17
18
281-310
16
18
19
Over 310
18
20
20
18
Subtract 3 units
60-90
Subtract 1 unit
90-130
130-200
Add 1 unit
200-250
Add 2 units
250-300
Add 3 units
300-350
Add 4 units
350-400
Add 6 units
Over 400
Add 8 units
PRACTICE PROBLEMS:
Blood glucose target: 100 mg/dl
Susans pre-lunch blood glucose
is 205 mg/dl.
Her reading shows that she is above
her target by 105 mg/dl
[205 mg/dl 100 mg/dl = 105 mg/dl]
Q How many extra units should
Susan take?
105 mg/dl = 2 units
50
A She should take 2 extra units. In this
case she should take a total of 14 units.
Bobs pre-lunch blood glucose
is 60 mg/dl.
His reading shows that he is below his
lower target by 40 mg/dl
[100 mg/dl 60 mg/dl = 40 mg/dl]
Using ISF Method I he would:
40 mg/dl = .8 units
50
Round .8 units to 1 unit
Decrease his insulin dose by 1 unit.
Take a total of 11 units.
Find Your Correction Dose for the
Highest Pre-Meal Blood Glucose you
had yesterday:
ISF = 50 mg/dl Target = _____ mg/dl
Pre-Breakfast
Pre-Lunch
Pre-Dinner
20
EXAMPLE:
Calculate Ritas ISF Using the Rule of
1500.
If Rita took 10 units of Regular insulin at
breakfast, 12 at lunch, 13 at supper, and
15 units of Lantus at bedtime, her total
would = 50 units a day.
Rule of 1500
1) Add all insulin doses
10 units Insulin Regular
12 units Insulin Regular
13 units Insulin Regular
+ 15 units Insulin Lantus
50 units
PRACTICE PROBLEMS:
1. Calculate your ISF using the Rule
of 1500.
Fill in all the insulin doses you take in one
day and add them up:
# of units
Type of insulin
3) Answer = ISF
Insulin Sensitivity Factor =
1 unit of short or rapid acting insulin will lower
blood glucose 30 mg/dl
Total units/day
3 Klingensmith, GJ. American Diabetes Association, Intensive Diabetes Management, Third Edition, 2003.
p. 107. 2003.
21
Pre-Dinner
Adjusted
Insulin Dose
Pre-Breakfast
Pre-lunch
Pre-dinner
REMEMBER:
Guidelines for Taking Correction
Doses for Out-Of-Goal Blood Glucose:
1. Check your blood glucose about 2
hours later. Use your post-meal blood
glucose goal. In this booklet, the
ADA recommendation of less than
180 mg/dl is used.
2. If your blood glucose is still not within
your range of blood glucose goals,
lower your ISF number (try changing
by 5).
3. If you have hypoglycemia (low blood
sugar), increase your insulin sensitivity
number.
ISF Method III Using the Rule of
1700 Another way to get a good
first guess at your insulin sensitivity is
to divide the sum of all of your insulin
doses into 1700.4
22
EXAMPLE:
If you take 10 units of Humalog at
breakfast, 12 at lunch and 13 at dinner,
and you take 15 units of Lantus at
bedtime, your total would = 50 units a
Rule of 1700
1) Add all insulin doses
10 units Insulin Humalog
12 units Insulin Humalog
13 units Insulin Humalog
+ 15 units Insulin Lantus
50 units of insulin/day
3) Answer = ISF
Insulin Sensitivity Factor =
1 unit of short or acting
insulin will lower blood
glucose 34 mg/dl
Pre-Dinner
Type of insulin
= ________
(ISF)
Adjusted
Insulin Dose
Pre-Breakfast
Pre-lunch
Pre-dinner
24
25
5 Warshaw, H.S. and Kulkarni, K., Complete Guide to Carb Counting. P. 146. American Diabetes Association 2001.
26
AM Carb
PM goal:
gms
BG before
meal
Food Eaten
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
BG 2 hours
after meal
Insulin
Comments:
Amount
Grams Carb
____________________________ _______________________________________
____________________________ _______________________________________
____________________________ _______________________________________
____________________________ _______________________________________
Total: _____________________________
AM Carb
PM goal:
gms
BG before
meal
Food Eaten
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
BG 90 min
after meal
Insulin
Comments:
Amount
Grams Carb
____________________________ _______________________________________
____________________________ _______________________________________
____________________________ _______________________________________
____________________________ _______________________________________
Total: _____________________________
AM Carb
PM goal:
gms
BG before
meal
Food Eaten
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
BG 90 min
after meal
Insulin
Comments:
Amount
Grams Carb
____________________________ _______________________________________
____________________________ _______________________________________
____________________________ _______________________________________
____________________________ _______________________________________
Total: _____________________________
Snack
BG before snack_________
Time:
Food Eaten
Amount
Grams Carb
_______________ __________________________________ ____________________________ ______________________________________
_______________ __________________________________ ____________________________ ______________________________________
Total: ____________________________
27
Usual Grams of
Carbohydrate
Carb:Insulin Ratio: 10:1
Usual Dose of
Insulin
70 Grams Carb
7 Units Humalog
90 Grams Carb
9 Units Humalog
28
= 9 units of Humalog
29
30
Getting Started:
A Five-Step Plan
1. Define your target blood glucose
level.
2. Calculate your insulin sensitivity
factor (ISF).
3. Try starting a carb:insulin ratio of 10
or 15 grams of carb:1 unit of insulin.
4. Count the number of carbohydrates
you will be eating.
5. Reduce, if necessary for exercise.
PRACTICE PROBLEMS:
Toms Night Out
Lets look at how Tom uses the 5-step plan
above to calculate his insulin adjustment.
Tom has a fun evening planned. He is
going out to an Italian restaurant for dinner
with some friends after a game of singles
tennis. When he tests his blood glucose
before dinner, he finds it is 190 mg/dl.
Here is his information for the five steps.
Blood Glucose Goals: 90-130 mg/dl
Target blood glucose level is 100 mg/dl
The initial ISF is 1 unit for every
30 mg/dl of blood glucose. Toms
total insulin dose is 50 units/day.
Using the rule of 1500, 1500/50 = 30
The initial carb:insulin ratio is 10:1,
1 unit of Regular insulin for every
10 grams of carb. Using the rule
of 500, 500/50 = 10
Tom is planning on eating about
90 grams of carbohydrates
See below for step 5
Toms Calculations:
Insulin needed for carbohydrates
9 + 3 = 12 units
3 units
9 units
31
________ Carbs
________ mg/dl
________ mg/dl
________ mg/dl
________
________ U of insulin
________ U of insulin
________ Total Dose
60 Carbs
8 Carbs/U of Insulin
7.5 U of Insulin
180 mg/dl
180 100 = 80
Insulin Sensitivity
30
Current BG Target BG
_______________________
Insulin Sensitivity
80
__
30
+ 2.5 U of insulin
-3 U of Insulin
7 U TOTAL DOSE
32
6 American Diabetes Association, Position Statement: Physical Activity/Exercise and Diabetes. American Diabetes
Association: Clinical Practice Recommendations, Diabetes Care. 27:Sup1:1, S58-S62. January 2004.
33
34
3:00 AM
Pre-Breakfast
Figure 4
Graph for Adjusting Basal Insulin
400
300
Blood Glucose
200
100
0
Bed
3 AM
Time
Fasting
35
7. Your graph should look like one of the 6 patterns shown in the next graph
(Figure 5) and labeled A-F.
Figure 5
Patterns of Overnight Blood Glucose Values
Blood Glucose
400
300
200
100
0
Bed
3 AM
Time
Fasting Bed
3 AM
Time
Fasting Bed
3 AM
Time
Fasting Bed
3 AM
Time
Fasting Bed
3 AM
Time
Fasting Bed
3 AM
Time
Fasting
8. Select the example that looks the closest to the pattern of your Basal Insulin in
Figure 4.
9. Look up the change in Table 1 below. The table below will indicate the change to
your basal dose that is needed.
Table 1: Changes to Basal Insulin
Changes to Basal for an Insulin Pump
Pattern What to do...
Expected Pattern
Pattern A
Increase 10 PM - 3 AM
Pattern A
Increase 10 PM - 3 AM
Pattern A
Decrease 10 PM - 3 AM
Pattern A or E
Increase 3 AM - 7 AM
Pattern A
Decrease 3 AM - 7 AM
Pattern B or C
Expected Pattern
Pattern A
Pattern A
Pattern A
Pattern A or E
Pattern A
Pattern A
36
37
Day
Breakfast
Lunch
Bedtime
3 AM
38
TROUBLESHOOTING
39
TROUBLESHOOTING
Sometimes you may find your blood
glucose levels go up and down wildly,
without any pattern that you can figure
out. This might make you feel like giving
up at times. Getting caught up in the
frustration and anger just makes you feel
more upset and hopeless. This section
can help you cope with these feelings
and put you on the right track to finding
the answers you need.
I am doing everything right and my
blood sugars still arent in my goal
I just dont understand it anymore!
40
2. Absorption of Insulin
Are your injection sites lumpy
or scarred?
Do you have any redness around
your injection sites? Are you
having trouble with your insulin
pump infusion site or are you
injecting in a scarred area? (This
could affect how your body is
absorbing the insulin and can
lead to problems with control.)
Have you changed how you
give insulin?
Have you changed the brand of
syringe or size of insulin needle?
If you are using an insulin pump,
is the tubing clogged?
3. Stress
Are you experiencing unusual
stress?
Did you know both physical and
emotional stress could affect your
blood glucose levels?
4. Infection
Do you have an infection?
Did you know infections are
a stress to the body and can
increase blood glucose levels?
5. Illness
Are you ill? Do you have a fever,
a cold, or a virus?
Did you know illness could
increase blood glucose levels?
6. Physical Activity
Have you changed your physical
activity a lot?
Are you more or less active than
usual? (If so, this can increase or
decrease your blood glucose levels)
7. Food
Are you eating more carb and not
taking enough insulin?
Is it possible you are not counting
your carbohydrates accurately?
Are you eating at the same time
of day or does it vary?
Are you eating less and taking too
much insulin?
8. Self-Monitoring of Blood Glucose
and Test Strips
Are your test strips outdated or
have the strips been outside the
vial? (This will make your glucose
readings inaccurate.)
Are you checking at the right
time of day to understand the
effect of your insulin, food and
physical activity?
Did you clean your hands before
checking your blood glucose?
Even small amounts of food
residue can affect results.
If you answered YES to any of the above
questions, correct the problem, give
yourself a few days and see if your
blood glucose levels out.
If you answered NO to all of the above
questions, your next step is to sort
through your insulin doses.
41
1. Basal Insulin
Am I taking enough or too much
basal insulin?
Are my blood glucose levels
always too high or too low?
2. Bolus Insulin
Is my bolus insulin dose correct?
Are my blood glucose levels
too high or too low 2 hours
after eating?
8 AM
12 noon
6 PM
10 PM
BG
Ins
BG
Ins
BG
Ins
BG
Ins
Day 1
94
10 L
104
8L
205
13 L
150
1 LP
19 G
Day 2
108
10 L
103
8L
197
13 L
155
1 LP
19 G
Day 3
97
10 L
112
8L
215
14 L
125
19 G
43
44
night is to test it at 3 AM. Choice A Increasing the basal rate overnight might
cause hypoglycemia in the middle of the
night. Choice B - Increasing her daytime
basal rate would do nothing to help the
overnight blood glucose levels. Choice D Giving a bolus at 10 PM could cause a
problem with hypoglycemia at midnight.
Q What should Sally do if she
checks her blood glucose at 3 AM
and discovers that it was 60 mg/dl?
A. Lower the 10 PM to 3 AM basal rate?
B. Eat a big snack at 10 PM?
C. Decrease the snack bolus?
D. Increase the 10 PM to 3 AM basal rate?
Figure 5
Patterns of Overnight Blood Glucose Values
Blood Glucose
400
300
200
100
0
Bed
3 AM
Time
Fasting Bed
3 AM
Time
Fasting Bed
3 AM
Time
Fasting Bed
3 AM
Time
Fasting Bed
3 AM
Time
Fasting Bed
3 AM
Time
Fasting
45
By lowering the 10 PM to 3 AM
basal rate, Sally can avoid becoming
hypoglycemic at 3 AM. By doing this,
she may find that her fasting blood
glucose level normalizes because she will
not get a rebound high blood glucose in
the morning. The other choices will not
result in preventing hypoglycemia at 3
AM. If her morning glucose rises higher,
she can increase her 3 AM to 7 AM bolus
dose.
Jack Needs Help Figuring Out His
Bolus Dose for Certain Meals
Jack takes a bedtime basal dose of insulin
glargine (Lantus) of 20 units and bolus
meal doses based on a carb:insulin ratio
of 12 grams of carbohydrate/unit and an
insulin sensitivity factor (ISF) of 1 unit for
every 40 mg/dl. His goal blood glucose
range is 90-130 mg/dl, with a target of
100. He exercises regularly and seems
to do well on his current basal dose of
insulin glargine.
Q What should Jacks bolus dose be
for the following breakfast meal?
His pre-meal blood glucose is 112
mg/dl.
He will have 2 slices of toast,
1 orange, 1 slice of cheese,
1 cup of milk and coffee.
A Jack needs 5 units of rapid- or shortacting insulin for his meal of 60 grams
of carb with a blood glucose within his
blood glucose goals.
Q Can you find Jacks bolus dose
for the following dinner?
Jacks pre-dinner meal blood glucose
is 212 mg/dl.
He is planning to eat 2 pieces of
bread, a salad with croutons and
dressing, steak; large baked potato,
side order of peas and broccoli. For
dessert he will have 1/2 cup of vanilla
ice cream with a small cookie.
Use this space to figure out Jacks
bolus dose before peeking at the
following answer!
Planned Food (Carbs) _____Carbs
Divided by Carb/Insulin Ratio _____Carbs/U of
Insulin = ___units of insulin
Current blood glucose _____mg/dl
What is Jacks target blood glucose? _____
mg/dl
Current blood glucose - target blood glucose
_____ mg/dl
What is Jack's Insulin sensitivity factor? _____
Divide Jack's blood glucose calculation by
Insulin sensitivity
_____ U of insulin
_____ Total Dose
46
=10 units]
70
89
72
85
100
88
65
68
87
92
60
90
68
66
80
83
77
62
79
47
48
49
Written by:
Marjorie Cypress, RN, MSN, C-ANP, CDE
Albuquerque, NM
We wish to acknowledge the following health professionals for reviewing this publication and providing their valuable insights:
Jean E. Betschart Roemer, CPNP, MSN, MN, CDE
Pittsburgh, PA
Linda Urso, APRN, BC-ADM
Warren, MI
Kathleen C. Arnold, CS-ANP, BC-ADM, CDE
Gulfport, MS
BD and BD Logo are trademarks of Becton, Dickinson and Company. 2005 BD.
All other brands are trademarks of their respective owners.
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