Nurses at Mann-Grandstaff VA Medical Center of Spokane, WA, shared their insulin adjustment protocol for RN case managers with Case Management Advisor. The protocol is as follows:

Guidelines for adjusting insulin

i. Assess patient for correct insulin administration, exercise, eating habits, symptoms of hypoglycemia or hyperglycemia, self-management knowledge (treating hypoglycemia, sick day management).

ii. Look at individual glycemic goal.

iii. Adjust one insulin type at a time, unless balancing basal-bolus ratio.

iv. If starting insulin for the first time, titrate basal insulin until fasting glucose is less than 150 mg/dl, insulin dose reaches the number of units equivalent to 50% of patient’s weight in kilograms, or if any hypoglycemic event occurs. At that time, consider the addition of bolus insulin.

v. Goal for total daily insulin is 50% basal and 50% bolus, per patient agreement.

• If basal dose of insulin is greater than 50% of total daily dose (TDD) of insulin, may lower basal dose by 10% and add this amount to daily bolus dose. Consult provider if a larger adjustment is indicated.

• If total bolus dose of insulin is greater than 50% of total daily dose (TDD) of insulin, may lower total bolus dose by 10% and add this amount to daily basal dose. Consult provider if a larger adjustment is indicated.

vi. Titrate insulin dose to correct low glucose readings first. Consult provider if insulin dose needs to be lowered more than protocol allows.

vii. Adjustment of bolus insulin is to take into account what the patient is currently taking, i.e., prescribed dose of bolus insulin plus any additional units taken per correction chart.

viii. When increasing dose of bolus insulin, may split amount over three meals.

ix. If average fasting glucose is lower than bedtime glucose by 40 points or more (without having had a bedtime snack), may lower the basal insulin dose by 10%.

x. Check A1c to determine if at individual glycemic goal as appropriate.

xi. If A1c does not correlate with blood glucose readings, get 2 hour post-meal readings.

Advice for adjusting basal insulin:

(if not explained by unusual diet, exercise, or misuse of insulin)

Adjusting basal insulin:

- If average glucose is greater than 300 for 3 days, may increase insulin by 10 units.

- If average glucose is 250 to 299 for 3 days, may increase insulin by 8 units.

- If average glucose is 200 to 249 for 3 days, may increase insulin by 6 units.

- If average glucose is 140 to 199 for 3 days, may increase insulin by 4 units.

- If average glucose is 120 to 139 for 3 days, may increase insulin by 2 units.

Hypoglycemia:

- If individual glucose reading between 60 and 70, may decrease insulin dose by 2 units daily;

- If individual glucose reading less than 60, may decrease insulin dose by 4 units daily;

- If patient has two or more glucose readings of less than 70, may decrease total dose of basal insulin by 10%.

Adjusting bolus (mealtime) insulin:

- If average glucose is greater than 300 for 3 days, may increase insulin by 10 units;

- If average glucose is 250 to 299 for 3 days, may increase insulin by 8 units;

- If average glucose is 200 to 249 for 3 days, may increase insulin by 6 units;

- If average glucose is 140 to 200, for 3 days, may increase insulin by 4 units;

- If average glucose is 120 to 139, for 3 days, may increase insulin by 2 units.

Hypoglycemia:

- If individual glucose reading between 60 and 70, may decrease insulin dose by 2 units daily;

- If individual glucose reading less than 60, may decrease insulin dose by 4 units daily;

- If patient has two or more glucose readings of less than 70, may decrease total dose of basal insulin by 10%.