Insulin Initiation & Titration Guide & Record
Contents
Page
Introduction……………….......................................1
Adjusting dosages……………………………………3
Sick day rules…………………………………………5
Hypoglycaemia……………………………………….6
Adjustment record …………………………………...8 & 9
Introduction
For many years there have been conflicting opinions over whether or not insulin titration is
prescribing. The purpose of this document is to clarify how insulin is prescribed and what is
meant by a ‘prescribed range’. This document is for intended for use by all registered nurses in
St Georges NHS Trust involved in insulin dosage titration. However, all health professionals
using this guide, or who have undertaken additional training must still act within their
clinical competencies, NMC standards and scope of practice, and where uncertain must
seek further guidance.
It is recommended that all health professionals involved in prescribing or administering insulin in
the Trust should undertake the e-learning course for insulin use which can be found through the
following link: http://www.diabetes.nhs.uk/safe_use_of_insulin/elearning_course/
The Nursing and Midwifery Council (NMC) “Standards for Medicine management” (2008) states
the following in relation to assessing and titrating medication:
Standard 9: Assessment
As a registrant, you are responsible for the initial and continued assessment of patients who are
self-administering and have continuing responsibility for recognising and acting upon changes in
a patient’s condition with regards to safety of the patient and others.
Standard 13: Titration
Where medication has been prescribed within a range of dosages, it is acceptable for registrants
to titrate dosages according to patient response and symptom control and to administer within
the prescribed range.
It is also stated that nurses or midwifes who have successfully completed a non medical
prescribing course …”must only prescribe drugs that are within their area of expertise and level
of competence….”
Using this record
This record should be given to each patient who may require the assistance from a health care
professional for administration of insulin when commenced on insulin. It is for the initial
prescriber to ensure this is done. The insulin titration record can be photocopied, attached to
the booklet and kept in the patient’s notes.
1
Insulin Commencement Dosage Guidelines: (please refer to Insulin Start
Group for further information)
The starting dose can be calculated according to body weight, most
commonly 0.3 to 0.5 units of insulin per Kg of body weight. However,
Individual assessment to the person’s circumstances must always be
considered when prescribing insulin dosages.
The term ‘units’ should be used in all contexts. Abbreviations, such as ‘U’ or
‘IU’ must not be used.
Bisphasic (Premixed) Insulin – usually two thirds of the calculated dose is
administered in the morning and one third in the evening, e.g. for a patient
weighing 60kgs the calculated initial starting dose will be a total daily dose
of 20 units with 12 units with breakfast and 8 units with the evening meal.
Basal Bolus – usually 50% of the calculated dose is the basal and 50% is
the bolus divided up between the meals, e.g. for a patient weighing 60kgs
you would usually start on 20 units a day with 10 units given as the basal
and the remaining 10 units is for the bolus doses with the meals (e.g. 4
units with breakfast, 2 units at lunch and 4 units with the evening meal).
Once daily intermediate/long acting insulin with Oral Hypoglycaemics (OHA)
The starting dosage is usually 6 to 10 units of insulin at bedtime, depending
on the Fasting Blood glucose (BG) level. However the timing and dosages
may also vary depending on the individual assessment and insulin type
used.
Insulin delivery devices;




Various delivery devices are available depending on the type of insulin
prescribed, and presented as 3ml prefilled pens, 3ml pen cartridges,
10ml vials, along with respective needles or syringes required. Each
brand has a registered name for their device.
Counsel patient on use prior to commencing insulin, ensuring they are
comfortable and familiar with the device.
Appropriate needle length and make should be advised
Patients should be advised on the safe disposal of syringes, needles.
Storage of insulin;
Check individual manufacturer’s storage recommendations. Usually;
 Unused/unopened insulin should be stored in a refrigerator (2–8°C)
 After opening and during use, insulin can be kept for 4-6 weeks at room
temperature.
2
Adjusting insulin – considerations
The aim of insulin therapy is for patient, where possible, to be able to self
administer and dose titrate in order to achieve the patient’s target blood
glucose levels.
Various factors can affect glucose levels. Review the following as indicated
before adjusting the dosage:

Blood glucose monitoring –check accuracy, review profile & symptoms to
identify any problem areas.











Is correct insulin being taken
Is the prescribed medication being taken (and at appropriate times)
Dosage – is the patient “dialling” up the correct amount?
Is the timing of insulin injections appropriate to that type of insulin
Is insulin dose distribution appropriate to patients needs
Injection sites – check for lipodystrophy / lipohypertrophy
Is the insulin delivery device working correctly?
Injection technique, needle size, injection sites
Is insulin being stored correctly/in date
Are there other medications affecting glucose levels eg Steroids
Dietary intake – any increase/decrease in appetite/type of foods/drinks in relation
to insulin type
Activity levels changed
Alcohol intake
Illness
Other issues eg stress/depression/patients understanding


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Key points:
 Never change the dose of insulin based on a ‘one-off’ reading, look for a
pattern of high or low readings over a period of 3-7 days, except where
hypoglycaemia is occurring on a regular basis.
 Ideally change one dose at a time to avoid confusion, and allow time
for results of adjustment to become apparent
 Adjust for low blood glucose levels first ~ never treat high blood glucose levels
if hypos are present or suspected.
 Consider the issue of rebound hyperglycaemia
3
Adjustments to insulin are usually made by either increasing the dose by
10% the problem is hyperglycaemia, or decreasing by 10% if there is
hypoglycaemia. NB: Insulin sensitivity can vary greatly from person to
person. Where the individual dose is >50 units, a 20% adjustment might be
necessary. If, through titration, insulin dose is likely to exceed an
increase of 50% of original dose, please discuss with the diabetes
nurse specialist.
IMPORTANT


All insulin doses must be measured and administered using an
insulin syringe or specific insulin pen device, with units clearly
marked. (Except if patient is using Continuous Subcutaneous
Insulin Infusion CSII)
Intravenous syringes must never be used for insulin
administration.
4
Adjusting BD pre-mixed insulin
(eg; Novomix 30, Humalog Mix 25, Humalog Mix 50, Humulin M3)

If period between breakfast and evening meal if outside target,
adjust morning insulin
 If period between evening meal and pre breakfast is outside
target evening insulin
Pre-breakfast
blood glucose
reading
Adjust evening
insulin by:
Pre evening
meal blood
glucose
reading
Adjust morning
insulin by:
Below patient
target
- 10%
Below patient
target
-10%
Above patient
target
+10%
Above patient
target
+10%
Adjusting basal insulin
(eg; Glargine, Levemir, Isophane)

If pre-breakfast blood glucose outside target ~ adjust Basal insulin as
shown below :Pre-breakfast
Blood Glucose
Adjust basal
insulin by:-
Below patient
target
- 10%
Above patient
target
+ 10%
Adjusting bolus insulin (short/rapid acting)
(eg; Actrapid, Humulin S, Novorapid (aspart),Humalog (lispro), Apidra (glulisine)

N.B: Blood glucose levels 2 hour reflects the pre-meal bolus insulin
Pre-meal Blood
Glucose:-
Adjust bolus
insulin by:-
Below patient target
- 10%
Above patient target
+ 10%
5
Sick Day Rules
During illness or infection blood glucose levels often rises even though
the patient is not eating.
 Never stop insulin or tablets
 Test blood glucose 2-4 hourly
 Test urine for ketones
 Seek further advice if unsure
If necessary substitute meals with simple foods like:
• Soup and bread
• Milk pudding, custard or small measure of ice cream
• Breakfast cereal and milk
• Fruit yoghurt
• Dietary supplement, e.g. Complan or Build-up
If unable to tolerate food, sip one of the following every two
hours
• 1/2 glass lucozade
• 1 glass ordinary lemonade
• 1 glass fruit juice
Drink plenty of fluids. Make this up with sugar free drinks or water.
During illness or infection blood glucose often rises. Continue usual insulin
dose, but give extra as below whilst illness is present:
Below 10mmol/l
Take usual dose of insulin
Between 10 and 15 mmol/l
Take 4 extra units of quick acting
insulin
Between 15 and 20 mmol/l
Take 6 extra units of quick
acting insulin
More than 20mmol/l
Take 8 extra units of quick acting
insulin
These figures are a guide only.
NB: the presence of moderate to large amounts of Ketones may
indicate the need for need for admission, particularly if the patient is
dehydrated, blood glucose levels continue to rise, or vomiting
continues. Always seek medical advice if unsure to avoid serious
emergencies developing.
6
HYPOGLYCAEMIA - TREATMENT GUIDE
Hypoglycaemia is a blood glucose level of less than 4mmol/l. Whenever possible, check blood
glucose level prior to treatment. If asymptomatic, treat but repeat test.
NB: lack of hypo awareness can develop in some people especially with longer duration
diabetes or repeated episodes of hypoglycaemia.
MILD
Patient conscious and
able to swallow.
Symptoms may include:
Trembling, sweating,
hungry, tingling,
headache, anxiety,
palpitations, nausea,
forgetfulness.
MODERATE
Patient conscious and able
to swallow, but in need of
assistance.
Difficulty concentrating,
confusion, weakness,
giddiness, drowsiness,
unsteady, headache,
dizziness, difficulty focusing
and speaking.
SEVERE
Patient unconscious and
unable to swallow.
Fitting
STEP 1
Give 10-20 g of glucose
orally
Ensure gag reflex is
present
Give 10-20 g of liquid
glucose orally
Consider use of Glucose
Gel
Call for emergency
assistance 999
-Check airway
-Place patient in
recovery position
-Patient will require IM
Glucagon or IV Dextrose
STEP 2
Wait 15 minutes and recheck glucose levels, and record.
If reading is still below 4 mmol/L, or if no physical
improvement, repeat STEP 1.







Once patient is conscious,
give sips of
Glucose gel or Lucozade.
Recheck glucose level every
15 minutes to ensure
increase to at least 4
mmol/L.
Once glucose level is over 4mmol/ls, ALWAYS FOLLOW UP WITH A SNACK to help
prevent recurrence (Snack eg: bread, biscuits, glass of milk, banana, small carton of fruit
juice).
Review cause of hypoglycaemia to help prevent recurrence, or seek advice from
Diabetes Specialist Teams.
If 2 hypos within 48 hour period further investigation is required
NOTE: If Insulin is due, it should NOT be omitted following hypoglycaemia – ensure
blood glucose is over 4mmol/ls and the person is able to eat before administering the
insulin .
Avoid use of correction doses for 24 hours following hypoglycaemia
7
Examples of suitable food and fluid to treat hypos
Name of
drink
1
Picture
10-20g
2
carbohydrate
Lucozade
60-115 mls
380ml
(Up to 1/3 of
bottle)
Cola
500ml
bottle
Name 3
of
food
Picture
10-20g
carb
Jelly
Beans
8-16
90-180 mls
(Up to 1/3 of
bottle)
Liquorice
Allsorts
3-5
Water
with
added
sugar or
honey
2-4
Teaspoons of
sugar or
honey in ½
glass of water
Jelly
Babies
2-4
Ribena
288ml
carton
72-114ml (up
to1/2 carton)
Dextrosol
tablets
4-7
Follow this immediate acting food with something more substantial such as a sandwich
or meal.
8
INSULIN RECORD
Patient details
Patient Name:……………………………………………………………………..
DOB: ……………………………………………………………………………….
NHS Number……………………………………………………………………….
Health professional details
GP and telephone number:……………………………………………………….
DN and telephone number………………………………………………………….
Wandsworth Diabetes Specialist Team numbers:
St Georges Thomas Addison Unit: 0208 …….
Queen Mary’s Beta Cell Unit: 0208 487 6447
Community Diabetes Nurse Specialist: …………………………………………………………..
Starting Insulin details
Date
Type of insulin
insulin
started
Starting
dosage
Insulin
device
presentation
Needle
type and
length
Other
diabetes
medications
Blood
glucose
target
Pre and
post
meal
NB: For Insulin titration guide see pages 3 - 4 & document on the adjustment sheet
Is patient able to self administer insulin? …………………………………………………
………………………………………………………………………………………………………
9
INSULIN ADJUSTMENT RECORD
Date
Adjustment
Rationale
Advised by
10
Further reading:
NHS Clinical Knowledge Summaries - Clinical topic - Insulin therapy in type 2 diabetes...Principles
of dose titration:
www.cks.nhs.uk/insulin_therapy_in_type_2_diabetes
Trend Uk ‘An Integrated Career and Competency Framework for Diabetes’ 3rd Edition
www.trend-uk.org/TREND_3rd.pdf
22/8/11
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