Pediatric Endocrinology Insulin Dosing Guide
Comprehensive reference for insulin dosing in pediatric endocrinology, covering onset, peak, and duration of action of various insulin preparations, guidelines for twice-daily dosing, managing Dawn Phenomenon and rebound hyperglycemia, and tips for multiple daily injections. Includes information on insulin-to-carb ratios, Insulin Sensitivity Factor, and correction formulas.
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Quick insulin dosing reference for residents Dept of Pediatric Endocrinology Stony Brook Children s Hospital
Timing and Duration of Action of Insulin Preparations Onset Peak Duration Rapid Acting Lispro (Humalog) Aspart (Novolog) 15-30 15-30 min 30-90 min 1-3 hours 3-5 hours 3-5 hours Intermediate Acting NPH Long Acting Glargine (Lantus) 1-4 hours 5-10 hours 10-16 hours 1-2 hours None 20-24+ hours Detemir (Levemir) 1-2 hours None (?) 8-23 hours
Twice daily Insulin dosing For two times a day injections .. 2/3 of total daily dose in the am 1/3 rapid acting 2/3 NPH 1/3 of total daily dose in the pm 1/3 to rapid acting 1/3 to NPH
Dawn Phenomenon Elevated blood glucose in the morning due to normal nocturnal secretion of GH and cortisol Or waning of insulin action from the prior evening dose of NPH Correct by increasing evening dose of NPH, may be limited by hypoglycemia in middle of night: preventable by changing NPH to pre- bedtime
Rebound hyperglycemia Peak activity of NPH causes unrecognized hypoglycemia in middle of the night Counterregulatory hormones causes exaggerated rise in blood glucose resulting in hyperglycemia in the morning Solution: the evening dose of NPH should be decreased to eliminate hypoglycemia at night
Multiple Daily Injections of total daily dose given as glargine (Lantus) Rapid acting insulin to cover meals and correct high BGs Insulin to carb (I:C) ratio can be determined by dividing 450 by the total daily insulin dose Typical I:C for toddler 1:30 grams; teenager 1:5-8 grams Insulin Sensitivity Factor (ISF) : 1800 rule is used: divided by the total daily insulin dose If someone s TDD= 30 units 1800/30= a 60 point drop per unit of insulin Correction formula: (Current BG minus Target BG)/ISF
Adjusting Insulin Doses Example 1 7 year old who takes Humalog and NPH at breakfast and dinner has the following blood glucoses. Do you want to make any changes to the insulin plan? If so, at which injection time, which insulin, and do you want to give more or less? Breakfast 110 102 99 119 107 Lunch Dinner Bedtime 92 210 135 199 81 168 123 208 62 257 2am 78 121 101 132 125 129 132 117 165 137
Adjusting Insulin Doses Example 1 7 year old who takes Humalog and NPH at breakfast and dinner has the following blood glucoses. Do you want to make any changes to the insulin plan? If so, at which injection time, which insulin, and do you want to give more or less? Breakfast Lunch Dinner Bedtime 110 92 102 135 99 81 119 123 107 62 2am 78 121 101 132 125 210 199 168 208 257 129 132 117 165 137 ANSWER: The dinner time blood glucoses are all high; increase AM NPH
Adjusting Insulin Doses Example 2 5 year old who takes Humalog and NPH at breakfast and dinner has the following blood glucoses. Do you want to make any changes to the insulin plan? If so, at which injection time, which insulin, and do you want to give more or less? Breakfast 187 199 176 212 169 Lunch 123 134 103 152 108 Dinner 158 116 132 128 142 Bedtime 129 143 165 186 152 2am 65 (juice) 88 57 (milk) 72 (juice) 93
Adjusting Insulin Doses Example 2 5 year old who takes Humalog and NPH at breakfast and dinner has the following blood glucoses. Do you want to make any changes to the insulin plan? If so, at which injection time, which insulin, and do you want to give more or less? Breakfast 187 199 176 212 169 Lunch 123 134 103 152 108 Dinner 158 116 132 128 142 Bedtime 129 143 165 186 152 2am 65 (juice) 88 57 (milk) 72 (juice) 93 ANSWER: The majority of the overnight numbers are low so decrease the evening NPH
Adjusting Insulin Doses Example 3 15 year old who takes Novalog at meals breakfast and Lantus at bedtime has the following blood glucoses. Do you want to make any changes to the insulin plan? If so, at which injection time, which insulin, and do you want to give more or less? Breakfast 184 205 175 187 154 Lunch 113 124 73 95 136 Dinner 132 98 193 117 124 Bedtime 128 114 132 105 129 2am 192 188 201 177 215
Adjusting Insulin Doses Example 3 15 year old who takes Novalog at meals breakfast and Lantus at bedtime has the following blood glucoses. Do you want to make any changes to the insulin plan? If so, at which injection time, which insulin, and do you want to give more or less? Breakfast 184 205 175 187 154 Lunch 113 124 73 95 136 Dinner 132 98 193 117 124 Bedtime 128 114 132 105 129 2am 192 188 201 177 215 ANSWER: The overnight and first morning blood gluocoses are high. Increase Lantus
