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Endocrine System

Insulin Dose Calculator

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INITIAL INSULIN DOSE ASSESSMENTMedical disclaimer: this calculator is not for any specific patient

1PERSON’S INFORMATION
2INITIAL INSULIN DOSE




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Reference article for the reasoning behind the dose calculation.

Medical Disclaimer:

This calculator is to help your provider calculate the initial insulin dose. This is not a prescription for any specific person. Insulin should only be administered with a provider’s prescription. This calculator does not establish a patient-doctor relationship between you and DrBeen or its affiliates/partners/associates/team members.

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Categories
Endocrine System

Calculating Daily Insulin Dose

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Medical Disclaimer: your physician/provider will give you the instructions and dosage needed for the insulin administration. The following information is for educational purposes and is not a prescription for any specific patient. Incorrect insulin dosage can cause severe hypoglycemia with dangerous outcomes.

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Understanding The Terms Related to The Insulin Administration

Basal Insulin

About 40-50% of the daily insulin dose is used during the intervals between meals and at night (fasting states.) This amount of insulin is usually constant.

Bolus Insulin

This dose of insulin is used for two purposes:

  • Reducing blood glucose levels that are higher than the goal/target level.
  • Disposing of the new blood glucose that will become available after eating carbohydrates/food.

High Blood Sugar Correction Amount

This is the amount of bolus insulin needed to correct high blood sugar. Generally, 1 unit of rapid-acting bolus insulin is needed to reduce the blood glucose level by 50 mg/dl. This drop can range from 15-100 mg/dl depending upon the individual, their state, time of the day, etc.

Insulin to Carbohydrate Ratio

This is the amount of carbohydrates that will be reduced by 1 unit of insulin. Generally, 1 unit of rapid-acting insulin will dispose of 12-15 grams of carbohydrates.

Keep in mind that the amount of carbohydrate disposed of by 1 unit of insulin can vary. Some reasons for this variation are the following:

  • Different individuals respond differently to insulin.
  • Person’s health. For example fever, infections, etc.
  • Time of day, for example early in the morning our bodies produce hormones that increase blood glucose levels. This is called the dawn phenomenon. Usually, our natural insulin counters this effect, however, in diabetics this correction may not occur leading to high fasting glucose levels.
  • Blood glucose rebound as a result of insulin administration that causes hypoglycemia. This can occur in the morning after the administered insulin has caused hypoglycemia leading to the release of stress hormones that in turn work to release more glucose in the blood. This is called the Somogyi phenomenon.

Worked-out Examples

Initial Insulin Dose Calculator

Calculate the amount of bolus insulin needed for the carbohydrates in the meal

This is the insulin needed to dispose of the carbohydrates that you will eat in your meal.

Assumption: your insulin sensitivity index is: 15gm per unit. Warning, this index is different for different people. You will have to determine your sensitivity index by repeatedly checking your blood glucose levels before meals, administering insulin, taking meals, and then checking the blood glucose levels. 

Let’s say you will eat 1 cup of white rice. It has 45 grams of carbohydrates. (Reference: If you eat a cup of cooked long grain rice, you will be eating 45 grams of carbohydrates.)

You will need 3 units (45/15) of bolus insulin (rapid-acting insulin) to dispose of this one cup of white rice.

Calculate the amount of bolus insulin needed to correct the excess blood sugar

Assumptions:

  • Your pre-meal goal/target blood glucose level is 120 mg/dl
  • The carbohydrate correction factor is 50 mg/dl

Formulae:

  • (Pre-meal blood glucose) – (target pre-meal blood glucose level) = excessive blood glucose levels
  • Additional bolus insulin units = (excess blood glucose levels)/(carbohydrate correction factor)

Before your meal, check your blood glucose level. Let’s say it is 270 mg/dl.

Thus, 270 mg/dl – 120 mg/dl = 150 mg/dl

This means your pre-meal blood glucose level is 150 mg/dl above the target level. We have to add bolus insulin (rapid-acting insulin) to correct this excessive blood glucose as well. The correction factor of 50 mg/dl means that we will have to administer 1 extra unit of bolus insulin for each 50 mg/dl of excess blood glucose.

(Excess glucose)/(insulin correction factor) = additional bolus insulin units needed

150/50 = 3 units of additional bolus insulin to correct for this excessive 150 mg/dl blood glucose

The total bolus insulin (rapid-acting insulin) needed is 3 units.

 

Summary

For this patient who is going to eat two chapatis (30 grams carbohydrates) and has pre-meal blood glucose level of 270 mg/dl the bolus insulin levels will be 2 units (for chapatis) + 3 units (for the excessive pre-meal blood glucose level) = 5 total units.

 

Calculating The Basal Insulin Dose

Initial Insulin Dose Calculator

First, we need to calculate the total daily insulin dose needed by the body. Then we will take 40-50% of this amount as the basal insulin (long-acting) amount needed. The rest of the insulin will be given via the bolus (rapid-acting) dosages (as calculated above.)

Formulae:

  • Total daily insulin requirement = (total body weight in pounds) / 4
  • Total daily insulin requirement = (total body weight in kilograms) x 0.55

Let’s work out an example

Let’s say the patient’s weight is 216 pounds or 98 kilograms. Let’s calculate the total insulin required for this patient:

  • Calculating with pounds: Total daily insulin required = 217 lbs / 4 = 54.25 units
  • Calculating with kilograms: Total daily insulin required = 98 kg x 0.55 = 53.9 units

The total daily insulin required by this patient is 54 units. (Warning do not administer this amount. Only 40% of this amount is needed in basal insulin.)

Calculating the daily required basal (long-acting) insulin dose

Daily basal (long-acting) insulin dose required = 40-50% of the total daily insulin required.

  • 40% = 54 units x 0.4 = 21.6 units of the basal (long-acting) insulin is required.
  • 50% = 54 units x 0.5 = 27 units of the basal (long-acting) insulin is required.

 

Final Calculations for the whole day and one meal (mentioned above)

For the patient in the examples above, the required insulin dosages are as follows:

  • Basal (long-acting) insulin: 21 to 27 units
  • Bolus (rapid-acting) insulin: 5 units needed when he/she was planning to take 2 chapatis and had a pre-meal blood glucose level of 270 mg/dl with a goal/target level of 120 mg/dl

 Initial Insulin Dose Calculator

 

Reference: This UCSF article on the insulin dose calculation is excellent, though a little confusing to read.

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Categories
Endocrine System

Daily Insulin to Oral Hypoglycemic

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Disclaimer:

This is not a prescription. Using medicines without the guidance of a licensed provider can be lethal.

 

Adding once-daily insulin to  oral hypoglycemic  therapy in  T2DM patient

  • NPH or detemir at bedtime
  • Glargine or degludec in the  morning or at bedtime

 

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Categories
Endocrine System

Beginning Therapy Type Two Diabetes Mellitus (T2DM) Patient

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Disclaimer:

This is not a prescription. Using medicines without the guidance of a licensed provider can be lethal.

 

Asymptomatic patient with HbA1c < 7.6%  or close to HbA1c 0.5 to 1.5% above treatment goal

•Lifestyle changes

•Metformin-p starting with 500 mg at bedtime. Then 500 mg with breakfast. Dose increased slowly if needed.

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Categories
Endocrine System

Insulin Initial Dose

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Disclaimer:

This is not a prescription. Using medicines without the guidance of a licensed provider can be lethal.

 

Initial total insulin dose:

0.2 to 0.6 units/kg/day in  divided doses.

Conservative initial doses of 0.2 to 0.4 units/kg/day are often recommended to avoid the potential for hypoglycemia.

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Categories
Endocrine System

Bolus Insulin

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Disclaimer:

This is not a prescription. Using medicines without the guidance of a licensed provider  can be lethal.

 

Prandial or bolus insulin dose should be calculated  to dispose of the carbs that will be eaten, and also to correct the blood glucose levels above the target  levels.

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Categories
Endocrine System

Insulin Initial Dose Calculation For Type Two Diabetes Mellitus

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Disclaimer:

This is not a prescription. Using medicines without the guidance of a licensed provider  can be lethal.

 

Calculation For  Type Two Diabetes Mellitus  (T2DM)
4 units or
0.1 unit/kg or
10% of the basal insulin dose.

 

Note:

This is calculation only, not the one time administration recommendation. Dividing and administring doses is a separate discussion.

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Categories
Endocrine System

When to Consider Insulin for a Type Two Diabetes Mellitus (T2DM) Patient?

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Disclaimer:

This is not a prescription. Using medicines without the guidance of a licensed provider  can be lethal.

 

If the first line therapy fails. then consider the second linc of oral drugs. However, in case HbAlc is greater than 8.5% than consider insulin instead of another Oral agent. OR

Type 2 diabetes mellitus patients that fit the following criteria:

  1. HbAlc levels equal or greatcr than 9.5%.
  2. Fasting blood glucose levels equal or greatcr than 250 mg/dL.
  3. Random blood glucose levels greater than 300 mg/dL.
  4. Ketosis.
  5. Unexplained weight loss associated with hyperglycemia.
  6. A hyperglycemic patient whose status (type I diabetes mellitus vs. type 2 diabetes mellitus) is not known.

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Categories
Endocrine System

Common Diabetes Medications

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Note: the listing of the drugs below is not a prescription for anyone. Taking diabetes medication without a doctor’s prescription can be fatal.

Type 1 Diabetes Mellitus

 

  • Usually young patients. 40% are lesser than 10 years of age.
  • Polyuria, polydipsia, weight loss
  • Random blood glucose levels of 200 mg/dL (11.1 mmol/L) or more.
  • Fasting blood glucose levels of 126 mg/dL (7.0 mmol/L) or more. Documented more than once.
  • Ketonemia, ketonuria, or both.
  • Islet antibodies usually identified.

Type 2 Diabetes Mellitus

  • Fewer or no symptoms.
  • Usually 40 years of age or above. (Age for developing type 2 DM is reducing.)
  • Polyuria, polydipsia.
  • Many women will present with candida vaginitis. (Glucose in urine promotes candida growth.)
  • Fasting blood glucose levels of 126 mg/dL (7.0 mmol/L) or greater. Documented more than once.
  • 75 g oral glucose tolerance test giving 200 mg/dL (11.1 mmol/L) or more after two hours is diagnostic. (Most sensitive test.)
  • HbA1c is 6.5% or more.
  • Usually, the patient has associated diseases like hypertension, dyslipidemias, and atherosclerosis.

Medications

Drugs are broadly classified into the following categories:

  • Drugs that reduce glucose absorption (acarbose, miglitol)
  • Drugs that reduce internal glucose production (metformin)
  • Drugs that throw glucose out of the body using the kidneys (SGLT2 inhibitors, canagliflozin, dapagliflozin, empagliflozin)
  • Drugs that directly or indirectly increase the insulin levels (sulfonylureas, meglitinide analogs, D-Phenylalanine derivatives, DLP1 agonists, and DPP4 inhibitors.)
  • Drugs that make peripheral tissue insulin sensitive (rosiglitazone, pioglitazone)
  • Insulins

 

 

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Figure: drug names in various categories

 

List of Drugs

 

 

  • Medicines that Affect Glucose Absorption
    • Acarbose and Miglitol
      • Competitive inhibitors of the alpha-glucosidase enzyme in the gut. This enzyme digests starches. Hence, glucose digestion and absorption reduces.
      • Cause flatulence.
  • Glucose Lowering Agents (act on the liver, muscle, or adipose tissues.)
    • Metformin (first line)
      • Increases hepatic protein kinase (PK) activity by increasing adenosine monophosphate levels (AMP). This, in turn, reduces hepatic gluconeogenesis and lipogenesis.
      • 1.5h to 3h half-life. Excreted unchanged by the kidneys.
      • Improves hyperglycemia and hypertriglyceridemia in obese patients without weight gain.
      • In the US metformin is contraindicated at the creatinine levels of 1.4 mg/dL in women and 1.5 mg/dL in men.
      • Most common side effects are gastrointestinal (anorexia, nausea, vomiting, abdominal discomfort, and diarrhea.)
      • Therapeutic doses do not cause hypoglycemia. Hence this drug is called euglycemia or antihyperglycemic drugs instead of a hypoglycemic drug.
      • Can cause vitamin B12 deficiency by interfering with its absorption.
      • Lactic acidosis has been reported.
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      • Figure: metformin blocking B12 absorption. Keep in mind that vitamin B12 deficiency can occur with long-term metformin use.
  • Beta cell stimulants (to trigger insulin release)
    • Sulfonylureas (bind to sulfonylureas receptors on the surface of the beta cells.)
      • First generation: Tolbutamide, Tolazamide, Acetohexamide, Chlorpropamide.
      • Second generation: Glyburide, Glipizide, Gliclazide, Glimipiride. 
        • More potent than the first generation. Use with caution in patients in whom prolonged hypoglycemia can be dangerous e.g. elderly or heart patients.
      • Glyburide has the most affinity and Tolbutamide has the least affinity.
      •   Binding to the sulfonylureas receptors closes K+ channels resulting in the cell depolarization and insulin release.
      • Used in type 2 because these drugs need functioning beta cells.
    • Meglitinide Analogs
      • Repaglinide
        • Binds to the sulfonylureas receptors, closes the ATP sensitive K+ channels, depolarizing the beta cells and releasing insulin.
    • D-Phenylalanine Derivatives
      • Nateglinide
        • Binds to the sulfonylureas receptors, closes the ATP sensitive K+ channels, depolarizing the beta cells and releasing insulin.
  • Incretins (trigger insulin release)
    • GLP-1 receptor agonists
      • Exenatide, liraglutide, albiglutide, dulaglutide.
        • Rapidly proteolyzed by dipeptidyl peptidase 4 (DPP4) and other enzymes.
        • Oral glucose causes the release of gut hormones glucagon-like peptide 1 (GLP1) and glucose-dependent insulinotropic polypeptide 1 (GIP1).
        • These hormones increase glucose-induced insulin release.
        • In type 2 DM these hormones are reduced.
    • DPP4 Inhibitors
      • Sitagliptin, Saxagliptin, Linagliptin, Alogliptin
  • Thiazolidinediones
    • Sensitize peripheral tissue to insulin.
    • Rosiglitazone and pioglitazone.
      • Acts on the peroxisome proliferator-activated receptor gamma (PPAR-gamma) resulting in liponectin increase and resistin reduction.
      • Rosiglitazone is reported to increase the risk of angina pectoris and myocardial infarction (MI). Banned in Europe.
      • 3-4% patients get edema.
      • Contraindicated in NY Heart Association class III and IV cardiac status.
      • Increases risk of fractures in women is reported (not men.)
      • 4% patients developed anemia. (Maybe dilutional due to the fluid retention.)
      • Weight gain possibly fluid retention as one factor.
      • Long-term pioglitazone administration needs consideration for the risk of bladder cancer.
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Figure: A pious (pioglitazone) rose (rosiglitazone) met a former (metformin).

Remember metformin by the character on the left. He is nauseated, bloated, and has a lactic acid box. Some of the side effects of metformin.

For pioglitazone and rosiglitazone see how the rose is on a broken bone (stem) this is to help you remember that fractures can occur. See the broken heart to help you remember that angina pectoris and myocardial infarction risk increases. The boat filled with fluids is for water retention which in turn is causing dilutional edema – see the RBCs swimming in this extra fluid.

The yellow fat cells attached to the stem should help you remember that these drugs work on PPAR-gamma receptors to help increase liponectic and reduce resistin.

 

  • Na+/Glucose Co-Transport Inhibitors (SGLT2 Inhibitors)
    • Canagliflozin, Dapagliflozin, Empagliflozin
    • Canagliflozin reduces glucose threshold from ~180 mg/dL to 70-90 mg/dL.
      • Causes glycosuria.
      • Modest weight loss.
      • Reduces HbA1c by 0.6% to 1%.
  • Insulins
    • Rapid-acting
      • Apidra, Novolog, Humalog
    • Short-acting
      • Regular Insulins (Novolin, Humulin)
    • Intermediate-acting
      • NPH Insulins
    • Long-acting
      • Detemir, Glargin
    • We will discuss these in detail in another post
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Categories
Endocrine System

A Life with Diabetes: Changes You Can Make at Home

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Diabetes is a condition that affects the way your body processes sugar and can cause considerable health problems. There are two main types: type 1 is developed at a young age, while type 2 is more preventable. Risk factors include “a family history of diabetes, unhealthy diet, physical inactivity and high blood pressure,” states Care 2.  If you are one of the millions affected by this disease, it’s crucial that you take the time to properly care for yourself.

Here are some tips on making changes from the comfort of your own home.

 

Get in some workouts

Exercising regularly can vastly improve your blood sugar levels, help you lose weight, lower cholesterol, and avoid long-term complications that can accompany diabetes. According to Diabetes.co.uk, working out can even help reduce insulin sensitivity in type 1 diabetics.

However, if exercising is something that is new to you, it’s important that you start slow. Instead of going to the gym, consider investing in a home gym by finding a room in your living area where you have plenty of space. Even if you don’t plan on having big machines, you’ll want a room to move your body and store any equipment. A yoga mat, for example, is a good way to stretch and or practice yoga which is a more low impact workout. You’ll also want to get some dumbbells and resistance bands to increase weight when practicing strength training. Life Fitness stresses the importance of utilizing a jump rope as well as it is a “workout that burns around 10 calories a minute, and it works many of your major muscle groups, including your legs, shoulders, and arms.” Overall, try and create a fun, entertaining space with good lighting, a tv, or music. Make it a place you want to be and spend time in, even if it’s for just 15 minutes a day

 

Adjust your diet

Being diabetic also means keeping an ever watchful eye on your diet. Stay away from processed foods, excess sugar, and consider a low carb diet. Also, try and eat smaller portions of food throughout the day. Portion control means not depriving yourself of all your favorite foods, but instead only giving into your cravings and indulgences within reason. Balanced, colorful meals should include fibrous veggies, lean meats, and healthy fats commonly found in nuts, olive oil, and avocados.

Be aware of the hidden (although natural) sugars in fruits and use substitutes like vanilla, cinnamon, and honey to sweeten things. Make sure you also read the labels and try to stay clear of alcohol as it is often packed with sugar. In order to reduce your cravings, slowly cut back on things like soda and make trade-offs with yourself. If you want dessert, perhaps have a carb free dinner.

It can be easy to feel overwhelmed by having to manage your diabetes. Therefore, you should set reasonable goals in achieving a healthy lifestyle. Take any medications prescribed to you and check your blood sugar often in order to monitor your health. It’s also important that you stay hydrated and get plenty of sleep when trying to control your diabetes as it will help you feel more energized.  If you take enough action now, you may be able to reduce your symptoms or even reverse your diagnosis.

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