If your blood glucose targets are not being achieved, first find out if there are any errors in following your doctor's orders. Is the insulin injection technique followed, is the drug expired, are injections given on time and food taken, are doses drawn into the syringe correctly?

Or maybe you had some additional problems, for example there was a stressful situation? Have you ever had acute respiratory infections? Has your physical activity decreased sharply or, conversely, increased? Maybe you have lost control of your diet?

It even happens that the patient (this is especially typical for adolescents) deliberately administers insulin in inadequate doses in order to worsen his condition in order to achieve some of his goals from loved ones. These questions must be answered, and only after eliminating all possible errors should we begin to change insulin doses.

Rule two

Once you are sure that you are doing everything correctly, but the desired result is not there, decide which type of insulin is responsible for the increased or decreased sugar. If there is an increase or decrease in fasting blood glucose, the problem is in the “extended” insulin, which was administered the night before, if the readings after meals are changed- require revision, first of all, of the dose of “short” insulin.

Rule three

If there are no severe episodes of hypoglycemia, there is no need to rush to change the dose of “extended” insulin. It takes 2-3 days to understand why the sugar level does not stay at the desired level. Therefore, it is customary to adjust the dose of “extended” insulin once every 3 days.

Rule four

If the cause of decompensation is “short” insulin, their dose can be changed more often (even every day) - based on the results of self-monitoring of glycemia. If the sugar before meals is high, increase the dose on the basis that 1 unit of insulin reduces the glucose level by about 2 units mmol/l - this means you have worked off today’s dose (made an emergency adjustment). To prevent hyperglycemia from reoccurring at the same time tomorrow, routinely titrate the dose, provided, of course, that the corresponding meal contains the same number of carbohydrate units.

Rule five

Change the dose very carefully- no more than 1-2, maximum 3-4 units, followed by careful monitoring of blood glucose. If hyperglycemia remains high, it is better to repeat the administration of 2-4 units of “short” insulin after 2 hours. You should not rush to increase doses, because you already know that a sharp decrease in sugar levels is much more dangerous than high but stable levels (of course, if there is no ketosis, but we already discussed this when we talked about the complications of diabetes).
Some articles contain recommendations for hyperglycemia above 18 mmol/l to add another 12 units (!) to the planned dose of “short” insulin.

Let's do the math. 1 unit of insulin reduces blood glucose levels by 2 mmol/L. Let's multiply 2 by 12 and get 24 mmol/l But there is also a planned dose of “short” insulin. What will we get in the end? Severe hypoglycemia, without a doubt. If the sugar is so high - more than 18 mmol/l, it is better to add 2-4 units to the planned dose, check the sugar after 1.5-2 hours and, if the indicator remains at the same level, make an additional “trick” of 3-4 units of the same "short" insulin. After 1-1.5 hours you will need to check your sugar again.

If nothing has changed again, the best thing to do is consult a doctor as soon as possible. Only if medical help is unavailable (the patient is in some very remote place from the hospital), you can try to independently make additional injections of “short” insulin in the future at the rate of 0.05 units per 1 kg of weight per hour.

For example, the patient's weight is 80 kg. We multiply 0.05 by 80 and get the result - 4 units. This dose can be administered subcutaneously once an hour, provided that the blood sugar level is also determined every hour. If the rate of decrease in glycemia becomes more than 4 mmol/l per hour, you need to stop “teasing” and continue to determine blood sugar every hour. In any case, the total single dose of “short” insulin should not be more than 14-16 units (planned plus correction). If necessary, an additional injection of “short” insulin can be given at 5-6 o’clock in the morning.

Rule six

Until insulin doses are adjusted, the number of bread units received for breakfast, lunch and dinner should remain constant from day to day.
You can afford a more free diet and daily routine only after the doses have been worked out and the target glycemic values ​​have been achieved.

Rule seven

If your sugar is not very high (no more than 15-17 mmol/l), change the dose of only one insulin at a time, for example, “extended-release”. Wait three days during which to check your sugar levels; if it gradually decreases, approaching the target, it may not be necessary to change the dose of “short” insulin. If during the day, including after meals, sugar still goes off scale, you still need to add 1-2 units of “short” insulin. Or vice versa, leave the dose of “long-term” insulin the same, but adjust the “short” insulin, but again little by little - 1-2 units, maximum 3 (this depends on the level of glucose in the blood before meals).

Be sure to check it after eating (after 1-2 hours, depending on the time of the highest activity - the peak of action - of this type of “short” insulin).

Rule eight

First of all, normalize the doses that cause hypoglycemia.

Rule nine

If your sugar levels are high around the clock, try to remove the highest value first. The difference in readings during the day is small - no higher than 2.8 mmol/l? Then normalize the morning numbers first. For example, if your fasting blood sugar is 7.2 mmol/l, and 2 hours after a meal it is 13.3 mmol/l, first change the dose of “short” insulin. Fasting sugar is 7.2 mmol/l, and after a meal it is 8. 9 mmol/l? Slowly adjust the dose of “long-acting” insulin, and only then, if necessary, take up “short” insulin.

Rule ten

If the total dose of insulin during the day is more than 1 unit per 1 kg of body weight, most likely there is an insulin overdose. With a chronic excess of administered insulin, chronic overdose syndrome develops; frequent episodes of hypoglycemia are replaced by a sharp rise in sugar to high values, appetite is increased and, despite decompensation of diabetes, weight does not decrease, but rather increases.

In addition, a manifestation of an overdose of evening insulin can be the Somogyi phenomenon, when in response to nocturnal hypoglycemia, hyperglycemia develops in the morning, which often entails an erroneous increase in the evening dose of insulin and only aggravates the severity of the condition. The increase in sugar during the Somogyi phenomenon can persist for 72 hours, and in rare cases even lead to ketoacidosis.

Rule eleven

If you are unable to recognize hypoglycemic conditions, your blood sugar target should be increased.

In addition to adjusting insulin doses, it is also necessary to reconsider nutrition and physical activity. If hypoglycemia is frequent, you need to adjust your carbohydrate intake: add an intermediate snack or increase their volume for breakfast, lunch or dinner (an additional afternoon snack is preferable).

As for physical activity, in this case it should be reduced somewhat. But if your sugar level is consistently high, you should, on the contrary, reduce the intake of carbohydrates during main meals and exercise more vigorously. It’s probably not worth completely canceling intermediate snacks or afternoon snacks - this can increase glycemic fluctuations.
Intensive insulin treatment regimen good for everyone, but may not be suitable for some patients. For example, people who are elderly or have limited self-care capabilities will not be able to independently determine the required dose change and administer the injection correctly. The same can be said for those who suffer from mental illness or have low levels of education.

This method is also impossible for those patients who do not have the ability to independently measure their blood glucose levels, although glucometers have now become so accessible that such problems are very rare. Nothing will work with the intensified method for undisciplined people. And, of course, it is impossible if a person categorically refuses frequent injections and taking a drop of blood from a finger. In such cases, a traditional insulin therapy regimen is used.
With the traditional regimen, 2 times a day at a strictly fixed time- before breakfast and before dinner - the same doses of “short” and “long-acting” insulin are administered. It is with this treatment regimen that it is possible to independently mix short- and medium-acting insulins in one syringe. At the same time, such “handicraft” mixtures have now been replaced by standard combinations of “short” and “medium” insulins. The method is convenient and simple (patients and their relatives easily understand what they should do), and in addition, it requires a small number of injections. And glycemic control can be carried out less frequently than with an intensified regimen - it will be enough to do it 2-3 times a week.

This is why it is good for lonely elderly people and patients with limited self-care capabilities.

Unfortunately, it is impossible to achieve a more or less complete imitation of natural insulin secretion and, therefore, good compensation for diabetes in this way. A person is forced to strictly adhere to the amount of carbohydrates that was determined for him in accordance with the selected dose of insulin, always eat food strictly at the same time, and strictly adhere to the daily routine and physical activity. The interval between breakfast and dinner should be no more than 10 hours. For people leading an active lifestyle, this therapy option is absolutely not suitable, but since it exists and is used, let’s talk about it in more detail.

You already know about the existence of standard combination drugs, which consist of a mixture of “short” and “long-acting” insulin.
note- almost every name of combined insulin contains the indication “mix,” which means a mixture, or “comb,” which is an abbreviation for the word “combined.” Could just be a capital letter "K" or "M". This is a special labeling of insulins, necessary in order not to confuse regular forms with mixtures.

Along with this, each bottle must have a digital designation corresponding to the proportions of “short” and “extended” insulin. Let’s take, for example, “Humalog Mix 25”: Humalog is the actual name of insulin, mix is ​​an indication that it is a mixture of “short” and “extended” humalog, 25 - the share of “short” insulin in this mixture is 25%, and the share of “extended” insulin, respectively, is the remaining 75%.

NovoMixe 30

In NovoMix 30 the share of “short” insulin will be 30%, and “long-acting” insulin will be 70%.
As always, the daily dose of insulin should be determined by your doctor. Next, 2/3 of the dose is administered before breakfast, and 1/3 before dinner. In this case, in the morning the share of “short” insulin will be 30-40%, and the share of “extended” insulin, respectively, will be 70-60%. In the evening, “long-acting” and “short” insulin are administered, as a rule, equally, so at least two mixture options should be available, for example, 30/70 and 50/50.

Of course, for each type of mixture you need separate syringe pens. The most popular are mixtures containing 30% short-acting insulin ( NovoMix 30, Mixtard NM30, Humulin M3, etc. .). In the evening, it is better to use mixtures in which the ratio of “short” and “long-term” insulin is close to one (NovoMix 50, Humalog Mix 50). Taking into account individual insulin needs, mixtures with a drug ratio of 25/75 or even 70/30 may be needed.
For patients with type 1 diabetes It is generally not recommended to use a traditional insulin therapy regimen, but if you have to do this, it is more convenient to use combinations with a large volume of “short-acting” insulin. For type 2 diabetes, on the contrary, mixtures with a predominance of “long-acting” insulin are optimal (it can be 70-90% ).
Onset, peak and duration of action of standard insulin mixtures depend not only on the administered dose (as with all other forms), but also on the percentage of “short” and “long-acting” insulin in them: the more of the first in the mixture, the earlier its action begins and ends, and vice versa. In the instructions for each bottle, these parameters - the concentration of insulin contained - are always indicated. You are guided by them.
As for action peaks, there are two of them: one refers to the maximum action of “short” insulin, the second - “long-acting”. They are also always indicated in the instructions. Currently, a mixed insulin NovoMix 30 penfill has been created, consisting of “ultra-short” aspart (30%) and “extended” crystalline aspart protamine (70%). Aspart is an analogue of human insulin. Its ultra-short part begins to act 10-20 minutes after administration, the peak of action develops after 1-4 hours, and the extended part “works” up to 24 hours.
NovoMix 30 can be administered once a day immediately before meals and even immediately after meals.
When using NovoMix 30, glycemia after meals is more effectively reduced and, what is very important, at the same time the frequency of hypoglycemic conditions decreases, and this allows for improved control of diabetes in general. This drug is especially good for type 2 diabetes, when nighttime glycemia can be controlled with tablets.
We have already said that the use of fixed insulin mixtures does not allow careful control of glycemia. Whenever possible, preference should be given to an intensified treatment regimen.
At the same time, in recent years, a special method of administering insulin has been increasingly used - a constant supply throughout the day - in small doses. This is done using an insulin pump.

Insulin therapy is currently the only way to prolong life for people with type 1 diabetes and severe type 2 diabetes. Correct calculation of the required dose of insulin allows you to imitate as much as possible the natural production of this hormone in healthy people.

The dosage selection algorithm depends on the type of drug used, the chosen insulin therapy regimen, nutrition and physiological characteristics of the patient with diabetes. All patients with diabetes need to be able to calculate the initial dose, adjust the amount of the drug depending on carbohydrates in food, and eliminate occasional ones. Ultimately, this knowledge will help avoid multiple complications and give you decades of healthy life.

Types of insulin by duration of action

The vast majority of insulin in the world is produced in pharmaceutical factories using genetic engineering technologies. Compared to outdated drugs of animal origin, modern products are characterized by high purity, a minimum of side effects, and a stable, well-predictable effect. Currently, two types of hormones are used to treat diabetes: human and insulin analogues.

The human insulin molecule completely replicates the molecule of the hormone produced in the body. These are short-acting agents; their duration of operation does not exceed 6 hours. This group also includes intermediate-acting NPH insulins. Their action time is longer, about 12 hours, due to the addition of protamine protein to the drug.

Insulin analogs are structurally different from human insulin. Due to the peculiarities of the molecule, these drugs can be used to more effectively compensate for diabetes. These include ultra-short-acting agents that begin to reduce sugar 10 minutes after injection, long- and extra-long-acting agents that work from 24 hours to 42 hours.

Type of insulin	Working hours	Medicines	Purpose
Ultra-short	The onset of action is after 5-15 minutes, the maximum effect is after 1.5 hours.	, Apidra, NovoRapid Penfill.	Use before meals. They can quickly normalize blood glucose. The dosage calculation depends on the amount of carbohydrates supplied with food. Also used for rapid correction of hyperglycemia.
Short	The effect begins within half an hour, the peak occurs 3 hours after administration.	, Humulin Regular, Insuman Rapid.
Medium action	Works for 12-16 hours, peak 8 hours after injection.	, Protafan, Biosulin N, Gensulin N, Insuran NPH.	Used to normalize fasting sugar. Due to the duration of action, they can be injected 1-2 times a day. The dose is selected by the doctor depending on the patient’s weight, duration of diabetes mellitus and the level of hormone production in the body.
Long	The duration of action is 24 hours, there is no peak.	, Levemir FlexPen, Lantus.
Extra long lasting	Duration of work – 42 hours.	Tresiba Penfill	Only for type 2 diabetes. The best choice for patients who are unable to inject themselves.

Calculation of the required amount of long-acting insulin

Normally, the pancreas secretes insulin around the clock, approximately 1 unit per hour. This is the so-called basal insulin. It helps maintain blood sugar at night and on an empty stomach. To simulate background insulin production, a medium- and long-acting hormone is used.

For patients with type 1 diabetes, this insulin is not enough; they require injections of fast-acting drugs at least three times a day, before meals. But with type 2 of the disease, one or two injections of long-acting insulin are usually sufficient, since a certain amount of the hormone is additionally secreted by the pancreas.

The calculation of the dose of long-acting insulin is carried out first, since without fully meeting the basal needs of the body it is impossible to select the desired dosage of the short-acting drug, and periodic surges in sugar will occur after meals.

Algorithm for calculating insulin dose per day:

1. We determine the patient's weight.
2. We multiply the weight by a factor of 0.3 to 0.5 for type 2 diabetes, if the pancreas is still able to secrete insulin.
3. We use a coefficient of 0.5 for type 1 diabetes at the onset of the disease, and 0.7 – 10-15 years after the onset of the disease.
4. We take 30% of the received dose (usually up to 14 units) and distribute it into 2 injections - morning and evening.
5. We check the dosage over 3 days: on the first day we skip breakfast, on the second day we skip lunch, on the third day we skip dinner. During periods of fasting, glucose levels should remain close to normal.
6. If we use NPH insulin, we check glycemia before dinner: at this time, sugar may be reduced due to the peak effect of the drug.
7. Based on the data obtained, we adjust the calculation of the initial dose: reduce or increase by 2 units until glycemia is normalized.

The correct dosage of the hormone is assessed according to the following criteria:

• to maintain normal fasting glucose per day, no more than 2 injections are required;
• no night (measurement is carried out at night at 3 o’clock);
• before meals, the glucose level is close to the target;
• the dose of long-acting insulin does not exceed half of the total amount of the drug, usually from 30%.

Short term insulin requirement

To calculate short-term insulin, a special concept is used - a bread unit. It is equal to 12 grams of carbohydrates. One XE is about a slice of bread, half a bun, half a serving of pasta. You can find out how many units of bread are on a plate using scales, which indicate the amount of XE in 100 g of different products.

Over time, diabetic patients no longer need to constantly weigh food, but learn to determine the carbohydrate content in it by eye. As a rule, this approximate amount is sufficient to calculate the insulin dose and achieve normoglycemia.

Algorithm for calculating the dosage of short-acting insulin:

1. We set aside a portion of food, weigh it, and determine the amount of XE in it.
2. We calculate the required dose of insulin: multiply XE by the average amount of insulin produced by a healthy person at a given time of day (see table below).
3. We administer the drug. Short-acting - half an hour before meals, ultra-short - right before meals or immediately after.
4. After 2 hours we measure blood glucose, by this time it should be normalized.
5. If necessary, adjust the dose: to reduce sugar by 2 mmol/l you need one additional unit of insulin.

To facilitate the calculation of insulin, a food diary will help, which indicates glycemia before and after meals, the amount of XE consumed, the dose and type of drug administered. It will be easier to choose a dose if at first you eat the same type, consuming approximately the same portions of carbohydrates and proteins at a time. You can count XE and keep a diary online or in special programs for phones.

Insulin therapy regimens

There are two insulin therapy regimens: traditional and intensive. The first involves constant doses of insulin calculated by the doctor. The second includes 1-2 injections of a pre-selected amount of a long hormone and several short ones, which are calculated each time before meals. The choice of regimen depends on the severity of the disease and the patient’s readiness to independently control blood sugar.

Traditional mode

The calculated daily dose of the hormone is divided into 2 parts: morning (2/3 of the total) and evening (1/3). Short insulin is 30-40%. You can use ready-made mixtures in which short-term and basal insulin have a ratio of 30:70.

The advantages of the traditional regimen are the absence of the need to use daily dose calculation algorithms and rare glucose measurements once every 1-2 days. It can be used for patients who are unable or unwilling to constantly control their sugar.

The main disadvantage of the traditional regimen is that the volume and timing of insulin injections does not correspond at all to the synthesis of insulin in a healthy person. If a natural hormone is secreted to supply sugar, then everything happens the other way around: in order to achieve normal glycemia, you have to adjust your diet to the amount of insulin administered. As a result, patients are faced with a strict diet, each deviation from which can result in or.

Intensive mode

Intensive insulin therapy is generally recognized throughout the world as the most progressive insulin administration regimen. It is also called basal-bolus, as it is capable of simulating both constant, basal, hormone secretion and bolus insulin released in response to an increase in blood glucose.

The undoubted advantage of this regime is the absence of a diet. If a patient with diabetes has mastered the principles of correct dosage calculation and glycemic correction, he can eat like any healthy person.

Intensive insulin regimen:

Required injections	Type of hormone
	short	long
Before breakfast
Before lunch
Before dinner
Before bedtime

In this case, there is no specific daily dose of insulin; it changes daily depending on dietary habits, level of physical activity or exacerbation of concomitant diseases. There is no upper limit for the amount of insulin; the main criterion for the correct use of the drug is glycemic levels. Diabetic patients using an intensive regimen should use a glucometer several times during the day (about 7) and, based on the measurement data, change the subsequent dose of insulin.

Numerous studies have proven that achieving normoglycemia in diabetes mellitus is possible only with intensive use of insulin. In patients, the likelihood of nephropathy and heart problems decreases by 60% (7% versus 9% on the traditional regimen).

Correction of hyperglycemia

After starting to use insulin, it is necessary to adjust the amount of the drug by 1 XE depending on individual characteristics. To do this, take the average carbohydrate coefficient for a given meal, inject insulin, and measure glucose after 2 hours. Hyperglycemia indicates a deficiency of the hormone; the coefficient needs to be increased slightly. If sugar is low, we reduce the coefficient. By constantly keeping a diary, after a couple of weeks you will have data on your personal insulin needs at different times of the day.

Even with a properly selected carbohydrate ratio, hyperglycemia can sometimes occur in patients with diabetes. It can be caused by an infection, a stressful situation, unusually little physical activity, or hormonal changes. If hyperglycemia is detected, a corrective dose, the so-called boost, is added to the bolus insulin.

To more accurately calculate the injection dose, you can use an adjustment factor. For short-acting insulin it is equal to 83/daily insulin, for ultra-short insulin – 100/daily insulin. For example, to reduce sugar by 4 mmol/l, a patient with a daily dose of 40 units using Humalog as a bolus should make the following calculation: 4/(100/40) = 1.6 units. We round this value to 1.5, add insulin to the next dose and administer it before meals, as usual.

Hyperglycemia can also be caused by incorrect technique for administering the hormone:

• It is better to inject short insulin into the stomach, long insulin into the thigh or buttock.
• The exact interval from injection to meal is indicated in the instructions for the drug.
• The syringe is not removed for 10 seconds after the injection; all this time the skin fold is held.

If the injection is done correctly, there are no visible causes of hyperglycemia, and the sugar continues to rise regularly, you need to visit your doctor to increase the dose of basal insulin.

Modern methods allow achieving excellent results in the treatment of type 1 and type 2 diabetes. With the help of properly selected drugs, you can significantly improve the patient’s quality of life, slow down or even prevent the development of serious complications.

Correct calculation of insulin dosage for patients with diabetes mellitus (DM) is one of the main points in therapy. In our review and simple video instructions, we will learn how this injectable drug is dosed and how to use it correctly.

For diabetes mellitus, in addition to diet and taking oral hypoglycemic drugs, a very common treatment method is insulin therapy.

It consists of regular subcutaneous injection of insulin into the patient’s body and is indicated for:

• acute complications of diabetes - ketoacidosis, coma (hyperosmolar, diabetic, hyperlaccidemic);
• pregnancy and childbirth in patients with mellitus or difficult-to-treat gestational diabetes;
• significant decompensation or lack of effect from the standard;
• development of diabetic nephropathy.

The insulin therapy regimen is selected for each patient individually.

In this case, the doctor takes into account:

• fluctuations in the patient's blood sugar level;
• nature of nutrition;
• meal times;
• presence of concomitant diseases.

Traditional scheme

Traditional insulin therapy involves the administration of injections fixed in time and dose. Usually two injections (short and long-acting hormone) are given 2 times a day.

Despite the fact that this scheme is simple and understandable to the patient, it has many disadvantages. First of all, this is the lack of flexible adaptation of the hormone dose to the current glycemia.

Essentially, a diabetic becomes hostage to a strict diet and injection schedule. Any deviation from the usual lifestyle can lead to a sharp jump in glucose and deterioration in well-being.

Today, endocrinologists have practically abandoned this treatment regimen.

It is prescribed only in cases where it is impossible to administer insulin in accordance with its physiological secretion:

• in elderly patients with low life expectancy;
• in patients with a concomitant mental disorder;
• in individuals who cannot independently control glycemia;
• in diabetics who require outside care (if it is impossible to provide it qualitatively).

Basal-bolus scheme

Let's remember the basics of physiology: a healthy pancreas produces insulin constantly. Some of it provides the so-called basal concentration of the hormone in the blood, and the other is stored in pancreatic cells.

A person will need it during meals: from the moment the meal begins and for 4-5 hours after it, insulin is sharply, spasmodically released into the blood to quickly absorb nutrients and prevent glycemia.

The basal-bolus therapy regimen means that with the help of insulin injections, an imitation of the physiological secretion of the hormone is created. Its basal concentration is maintained by 1-2 injections of a long-acting drug. A bolus (peak) increase in the level of the hormone in the blood is created by “shots” of short-acting insulin before meals.

Important! When selecting effective doses of insulin, you need to constantly monitor your sugar levels. It is important for the patient to learn how to calculate drug dosages in order to adapt them to the current glucose concentration.

Basal Rate Calculation

We have already established that basal insulin is necessary to maintain normal fasting blood glucose. If there is a need for insulin therapy, its injections are prescribed to patients with both DM 1 and DM 2. Popular drugs today are Levemir, Lantus, Protafan, Toujeo, Tresiba.

Important! The effectiveness of the entire treatment depends on how correctly the dose of extended-release insulin is calculated.

There are several formulas for selecting long-acting insulin (RAI). It is most convenient to use the coefficient method.

According to it, the daily volume of total administered insulin (TSDI) should be (IU/kg):

• 0.4-0.5 – with newly diagnosed diabetes;
• 0.6 – for patients with diabetes (diagnosed a year or more ago) in satisfactory compensation;
• 0.7 – with unstable SD compensation;
• 0.8 – with decompensation of the disease;
• 0.9 – for patients with ketoacidosis;
• 1.0 – for patients during puberty or late pregnancy.

Of these, less than 50% (and usually 30-40%) is a prolonged form of the drug, divided into 2 injections. But these are only average values. When selecting the appropriate dosage, the patient must constantly determine the sugar level and enter it into a special table.

Self-monitoring chart for patients with diabetes:

In the Notes column you should indicate:

• nutritional features (what foods, how much was eaten, etc.);
• level of physical activity;
• taking medications;
• insulin injections (name of drug, dose);
• unusual situations, stress;
• drinking alcohol, etc.;
• weather changes;
• well-being.

Typically, the daily dose of IPD is divided into two injections: morning and evening. It is usually not immediately possible to select the required amount of hormone needed by the patient before going to bed. This can lead to episodes of both hypo- and hyperglycemia the next morning.

Glucometer - a simple device for self-monitoring

To calculate the starting evening dose of long-acting insulin, you need to know how much mmol/l 1 unit of the drug reduces blood sugar. This parameter is called the insulin sensitivity coefficient (ISI). It is calculated by the formula:

CFI (for extended ins.) = 63 kg / diabetic weight, kg × 4.4 mmol/l

This is interesting. The greater a person's body weight, the weaker the effect of insulin on him.

SD (at night) = Minimum difference between the sugar level before bed and in the morning (over the last 3-5 days) / CFI (for extended ins.)

Round the resulting value to the nearest 0.5 units and use. However, do not forget that over time, if glucose in the morning on an empty stomach is higher or lower than usual values, the dose of the drug can and should be adjusted.

Note! With a few exceptions (pregnancy, puberty, acute infection), endocrinologists do not recommend using a nightly dose of the drug higher than 8 units. If, according to calculations, a larger amount of the hormone is required, then something is wrong with the diet.

Bolus Dose Calculation

But most of all the questions patients have are related to how to correctly calculate the dose of short-acting insulin (RAI). The introduction of ICD is carried out in a dosage calculated by bread units (XU).

The drugs of choice are Rinsulin, Humulin, Actrapid, Biogulin. Soluble human insulin is currently practically not used: it has been completely replaced by synthetic analogues of equal quality (read more).

For reference. A bread unit is a conditional indicator that is used to approximate the carbohydrate content of a particular product. 1 XE is equal to 20 g of bread and, accordingly, 10 g of carbohydrates.

Table. XE content in some products:

Product	Unit	HE
White bread	1 piece	1
Rye bread	1 piece	1
Cracker	3 pcs.	1
Boiled pasta	1 plate (100 g)	2
Rice porrige	1 plate (100 g)	2
Oatmeal	1 plate (100 g)	2
Buckwheat	1 plate (100 g)	2
Milk 2.5%	1 glass	0,8
Kefir	1 glass	0,8
Cottage cheese	1 tbsp. l.	0,1
Hard cheese	1 slice	0
Butter	1 tsp.	0,01
Sunflower oil	1 tsp.	1
Boiled beef	1 serving (60 g)	0
Pork stew	1 serving (60 g)	0,2
Fried, boiled chicken	1 serving (60 g)	0
Doctor's sausage	1 slice	0,1
Fish	1 serving (60 g)	0
White cabbage	1 serving (100 g)	0,4
Potato	1 serving (100 g)	1,33
cucumbers	1 serving (100 g)	0,1
Tomatoes	1 serving (100 g)	0,16
Apple	1 PC.	0,8
Banana	1 PC.	1,6
Strawberries	1 glass	1,5
Grape	1 glass	3

In general, the daily need for carbohydrates varies for a particular patient from 70 to 300 g per day.

This value can be divided as follows:

• breakfast – 4-8 XE;
• lunch – 2-4 XE;
• dinner – 2-4 XE;
• snacks in total (second breakfast, afternoon snack) – 3-4 XE.

Typically, ICD injections are given three times a day - before main meals (snacks are not taken into account).

In this case, the dose of the drug can and should change in accordance with the patient’s diet and blood glucose levels, taking into account that:

• 1 XE increases blood glucose levels by 1.7-2.7 mmol/l;
• administration of 1 unit of ICD reduces glycemia by an average of 2.2 mmol/l.

Let's look at an example:

• Patient with type 1 diabetes, ill for 4 years, compensation is satisfactory. Weight – 60 kg.
• We calculate the SSDI: 0.6 × 60 kg = 36 UNITS.
• 50% of the SSDI is the IDI = 18 units, of which 12 units before breakfast and 6 units at night.
• 50% of the SSDI is ICD = 18 units, of which before breakfast – 6-8 units, lunch – 4-6 units, dinner – 4-6 units.

Since diabetes mellitus is a chronic disease with a long course, great attention must be paid to patient education. The doctor’s task is not only to prescribe a medicine, but also to explain the mechanism of its effect on the body, and also tell how to adjust the insulin dosage based on the glycemic level.

A theoretical algorithm for calculating the daily dose of insulin in patients with type 1 diabetes mellitus (DM) is carried out using different coefficients: the approximate amount of insulin in units is calculated per kilogram of actual body weight; if there is excess body weight, the coefficient decreases by 0.1, if there is a deficiency, it increases by 0.1:

0.4-0.5 U/kg body weight for patients with newly diagnosed type 1 diabetes;
0.6 U/kg body weight for patients with type 1 diabetes lasting more than a year in good compensation;
0.7 U/kg body weight for patients with type 1 diabetes lasting more than a year with unstable compensation;
0.8 U/kg body weight for patients with type 1 diabetes in a situation of decompensation;
0.9 U/kg body weight for patients with type 1 diabetes in a state of ketoacidosis;
1.0 U/kg body weight for patients with type 1 diabetes during puberty or in the third trimester of pregnancy.

As a rule, a daily dose of insulin of more than 1 unit/kg per day indicates an insulin overdose.
For newly diagnosed type 1 diabetes, the daily dose of insulin required is 0.5 units per kilogram of body weight. In the first year after the onset of diabetes, there may be a temporary decrease in the daily insulin requirement - this is the so-called “honeymoon” of diabetes. Subsequently, it increases slightly, averaging 0.6 units. With decompensation and especially in the presence of ketoacidosis, the dose of insulin due to insulin resistance (glucose toxicity) increases and usually amounts to 0.7-0.8 IU of insulin per kilogram of body weight.

Administration of long-acting insulin should mimic the normal basal insulin secretion of a healthy person. It is administered 2 times a day (before breakfast, before dinner or at night) at a rate of no more than 50% of the total daily dose of insulin. The administration of short-acting or ultra-short-acting insulin before main meals (breakfast, lunch, dinner) is carried out in a dosage calculated according to XE.

The daily requirement for carbohydrates is determined by the total number of calories needed by a particular patient, and can be from 70 to 300 g of carbohydrates, which is from 7 to 30 XE: for breakfast - 4-8 XE, for lunch - 2-4 XE, for dinner - 2-4 XE; 3-4 XE should be in total in the 2nd breakfast, afternoon snack and late dinner.

Insulin is usually not administered during additional meals. In this case, the daily need for short-acting or ultra-short-acting insulin should be in the range from 14 to 28 units. The dose of short-acting or ultra-short-acting insulin can and should vary depending on the situation and in accordance with blood glucose levels. This should be ensured by the results of self-control.

Example of insulin dose calculation 1:

Patient with type 1 diabetes mellitus, ill for 5 years, compensation. Weight 70 kg, height 168 cm.
IPD 50% of 42 units = 21 (rounded to 20 units): before breakfast - 12 units, at night 8 units.
ICD 42-20 = 22 units: before breakfast 8-10 units, before lunch 6-8 units, before dinner 6-8 units.

Further dose adjustment of IPD is based on the level of glycemia, ICD is based on glycemia and XE consumption. This calculation is indicative and requires individual correction, carried out under the control of glycemic levels and the consumption of carbohydrates in XE.

It should be noted that when correcting glycemia, it is necessary to take into account the dose of short-acting insulin to reduce elevated levels, based on the following data:
1 unit of short- or ultra-short-acting insulin reduces glycemia by 2.2 mmol/l;
1 XE (South of carbohydrates) increases the glycemic level from 1.7 to 2.7 mmol/l, depending on the glycemic index of foods.

Example of insulin dose calculation 2:

A patient with type 1 diabetes mellitus, ill for 5 years, subcompensation. Weight 70 kg, height 168 cm.
Calculation of insulin dose: daily requirement 0.6 units x 70 kg = 42 units of insulin.
IPD 50% of 42 units = 21 (rounded to 20 units): before breakfast -12 units, at night 8 units.
ICD 42 -20 = 22 units: before breakfast 8-10 units, before lunch 6-8 units, before dinner 6-8 units.

Further dose adjustment of IPD is based on the level of glycemia, ICD is based on glycemia and XE consumption. Morning glycemia is 10.6 mmol/l, it is assumed to consume 4 XE. The ICD dose should be 8 units for 4 XE and 2 units for “decrease” (10.6 - 6 = 4.6 mmol/l: 2.2 = 2 units of insulin). That is, the morning dose of ICD should be 10 units.

It is believed that proper use of the treatment recommendations presented and strict adherence to the desired blood glucose level will help patients live longer and healthier lives. They should still be convinced of the need to purchase personal glucometers and constantly monitor glycemia and glycated hemoglobin levels.

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For adequate insulin therapy for both type 1 diabetes and type 2 diabetic lesions, it is necessary to select the dosage of subcutaneously administered insulin. The article describes in detail the features of calculating short-acting, ultra-short-acting and long-acting insulin. The necessary formulas are given with examples of determination depending on the quality and quantity of food consumed.

Diabetes mellitus type 1 and 2, like an epidemic, is affecting an increasing number of patients, causing metabolic disorders and serious complications even in children. If earlier it was difficult to treat lesions in type 2 diabetes, and completely impossible in type 1 diabetes, since insulin, the basis of pathogenetic treatment, was not discovered, now this area is actively developing. Genetic engineering analogues of the hormone have been discovered. The pathogenetic mechanisms of the disease were studied, which made it possible to explain the use of long- and short-term insulin in insulin therapy for diabetes. All that remains is to correctly answer the questions: how to calculate the amount of hormone administered and how to determine how many of this number of units will be in the extended fraction and how many in the short fraction.

Why is it necessary to correctly calculate the insulin dose?

Any drug taken orally or administered parenterally must be taken in an adequate amount approved by doctors. This is especially true for hormonal drugs. Therefore, the amount of insulin, especially in children, needs strict control and selection, because if the dosage of insulin is greatly exceeded, the blood glucose level progressively decreases. If with hyperglycemia there is a threat of hyperosmolar and ketoacidotic coma, then hypoglycemic conditions are even more dangerous. This should be avoided especially carefully, because it is very difficult to bring the body out of a comatose state if blood serum sugar is critically low. This requires resuscitation measures and the conditions of a specialized department. Even if this is observed, it is not always possible to cure and put a patient with a diagnosed hypoglycemic coma back on his feet.

At the same time, selection of the insulin dose is necessary to adequately maintain glycemia at the proper level. The target for type 1 diabetes, as well as for type 2 diabetes, is glycosylated hemoglobin. It reflects the degree of glycemia over 3 months and is a reliable value that reflects compensation of the disease and the adequacy of the prescribed dose of long-acting insulin and its short-acting analogue. That is why the question of how to calculate the dose of the drug is relevant for patients with this endocrinopathy. In cases where the calculation process fails and the amount of hormone is insufficient, glucose levels rise. With hyperglycemia, especially if it occurs chronically, the risk of vascular accidents and other complications increases. This is why proper selection of insulin dosage for type 2 diabetes is important in terms of prognosis and development of unwanted and dangerous conditions.

Selecting the required amount of short-acting insulin

To explain how to calculate insulin dosage in general, it is necessary to introduce some necessary concepts. To ensure that the patient does not have to worry about calculating the amount of carbohydrates and the mass of consumed products, bread units were invented. Their use somewhat simplifies and facilitates determination of the insulin dose. 1 unit is considered equivalent to 10 g of carbohydrate food. Some people are more accustomed to using 12 g. However, you need to remember that when calculating the dose of insulin for type 2 diabetes or type 1 insulin-dependent lesions, the same value is always used.

To “neutralize” 1 unit of bread, a different number of administered units of the hormonal drug is required. It depends on the time of day, because the degree of activity of the body and the amount of secretion from the insular apparatus of the pancreas are subject to circadian changes. In the morning for 1 XE you need 2 units of insulin, in the afternoon - 1 unit, and in the evening - 1.5 units.

To select the required amount of short-acting insulin, a clear algorithm of actions is required. To begin with, you should remember a few facts and postulates.

• Daily caloric intake is the first thing to take into account. Its determination takes into account the nature of the activity and the level of physical activity. The average figure for a patient weighing 60 kg, whose physical activity is close to average, is 1800 kcal.
• The share of carbohydrate foods consumed during the day is 60%. On average - 1080 kcal.
• When consuming 1 g of carbohydrates, 4 kcal of energy is released.
• The dose of insulin in diabetics is usually determined taking into account body weight. Also an important parameter is the characteristics of the course of the disease and duration (experience). Below is a table showing indicators of how many units of the hormone should be administered per body weight. Multiplying this indicator with weight, we get daily insulin.
• First, for convenience, short-acting insulin is selected, and then long-acting;
• Protein foods or foods containing fat are not taken into account when determining the dose.

Let's analyze a specific clinical situation. A patient weighing 60 kg has been suffering from diabetes for 4 years. The level of physical activity is average (to make calculating the insulin dose more convenient). As has already been determined, 1080 kcal is the daily caloric intake for a patient with the specified parameters. Considering that 1 g of carbohydrates, when broken down, produces 4 kcal of energy, 270 g of carbohydrate food will be required to cover 1080 kcal. Taking as a basis that 1 bread unit is identical to 12 carbohydrates, we calculate that the number of bread units capable of providing the necessary energy exchange will be 22 (270/12 = 22.5, rounded - 22).

From a dietetics course we know that 30% of energy costs must be covered in the morning, 40% at lunch, and 30% at dinner. It is easy to determine that in this case in the morning you need to take 7 XE (neutralized by 1 XE with two units of insulin, which means: 7 XE x 2 units of insulin = 14 units) and inject 14 units of short-acting insulin. At lunchtime, 40% corresponds to approximately 8 XE (8 XE x 1 unit of insulin = 8 units) and the same amount of hormone. In the evening, the amount of recommended carbohydrate food for this patient will be 7 units, and taking into account the required 1.5 units of insulin, in order to utilize this amount of carbohydrates, 10 units of the drug must be administered subcutaneously.

Here's how to calculate the amount of short-acting insulin. Over a period of time, you should observe what the body’s reaction to the selected therapy will be. You need to undergo a blood glucose test at least three times in a month and examine the percentage of glycated hemoglobin after 3 months to understand whether insulin therapy is adequate to the characteristics of the changed carbohydrate metabolism.

Selecting long-acting insulin

We have sorted out the definition of short-acting hormone analogue units. All that remains is to find out how to calculate and what are the rules for selecting a drug that is long- and extra-long-acting. It must be remembered that the amount is administered once if the drug is effective for 24 hours, and divided into 2 administrations when the effect is limited to 12 hours.

How to choose a dose of long-acting insulin

• The daily amount of the hormone is determined regardless of the time of its effect (body weight is multiplied by the indicator from the table, in our clinical case 60x0.8 = 48 IU);
• from the resulting number of hormone units, the amount of the short analogue of the drug is subtracted and the determined value is obtained (48-14 (in the morning) - 8 (lunch) - 10 (in the evening) = 16 units).

Calculation of insulin showed that the long-acting drug must be administered in the amount of 16 units, and the short-acting hormone - 32 units, divided into three doses.

What to do if your blood glucose level is high?

This situation (hyperglycemia) will force the already selected treatment to be adjusted. To avoid incorrect administration of the drug, they should be recalled.

1. A long-acting hormonal drug is injected into the subcutaneous tissue of the crease of the shoulder or thigh.
2. When it is necessary to use short-acting insulin, the abdominal area is preferred as the injection site, since absorption of the drug there takes a little longer.
3. The short-acting drug is used 15-20 minutes before the intended meal. If the drug has an effect very quickly (ultra-short analogues), then it should be administered right before a meal.
4. Genetic engineering drugs that act for 12 hours are administered twice (it must be borne in mind that the amount of the calculated hormone is divided in half).
5. Ultra-long-lasting analogues are administered once.
6. The injection is carried out quickly, but the drug is injected slowly (slow count to 10), only after that the needle is removed.

If all points are met, the calculation was correct, and hyperglycemia is still detected during a glycemic profile study, additional administration of the hormone is necessary, which should be discussed with your doctor.

In addition, it is necessary to take into account physical activity for type 1 diabetes. Before the planned event, which is accompanied by energy expenditure, you need to consume 2 bread units (24 g) of carbohydrates. The same should be done after the load.

In type 2 diabetes mellitus, taking into account physical activity is not necessary. The same as fixing attention on the number of bread units eaten during the subcutaneous injection regimen using ready-made mixtures. But with basal-bolus administration, you need to monitor what you eat.

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