I always feel some concern when a patient goes home from the hospital with orders to add insulin to his or her blood sugar management routine. Insulin is a powerful hormone, and used safely, it is an excellent way to manage blood sugar and prevent the complications that diabetes can sometimes cause. However, I fear that too many patients go home from the hospital without a clear understanding and respect for insulin and how to use it properly. The first thing to understand is that there are different types of insulin. In this post I will cover only long-acting and rapid-acting insulin and describe the most common insulin regimens.
Long-Acting or Basal Insulin
Lantus and Levemir are two brands of long-acting insulin. Long-acting insulin lasts up to 24 hours, and it is usually taken once a day. Sometimes it is taken twice a day, in the morning and in the evening. The important things to know about this type of insulin is that it must be taken at the same time every day, and it cannot be mixed with other types of insulin in the same syringe. Long-acting insulin provides a slow, even background dose of insulin, and it has little or no peak, so there is less risk of low blood sugar events, although low blood sugar is a possible side effect. This insulin should be taken faithfully even if the blood sugar is in the normal range. This insulin takes hours to start working, so it is not used to correct a blood sugar that is currently too high.
Rapid-Acting Insulin
Humalog, Novolog, and Apidra are all different brands of rapid-acting insulin. They start to work in 10-15 minutes, peak in about 2 hours, and they are gone from the body in about 4 hours. Rapid-acting insulin is used to correct a blood sugar that is currently too high, and it is also often used to cover food that you are about to eat in order to prevent a large spike in blood sugar after your meal.
Post-Hospital Insulin Orders
Not all patients who go home on insulin are given the same orders, and your physician may order a different insulin routine than your Aunt Susie or your neighbor Sam was given by their physicians. Your physician may order any of the following:
- Long-acting insulin only (Lantus or Levemir) once or twice a day
- Long-acting AND rapid-acting (Humalog, Novolog, or Apidra) with a set dose (mealtime or nutrition dose) of rapid-acting insulin before each meal. Again, the purpose is to cover food that is about to be eaten.
- Long-acting and rapid-acting insulin with a rapid-acting insulin correction dose in the form of a sliding scale. If you are sent home on this order, you MUST have the sliding scale detailed out for you. For example, the order may say something like "If blood sugar is 151 to 200, inject 1 unit of Humalog. If blood sugar is 201 to 250, inject 2 units of Humalog and so on." This is just an example, and the actual sliding scale may differ. The important thing is that you cannot guess how much insulin to give yourself. You must have a detailed order.
- Long-acting insulin AND a set mealtime dose AND correction dose of a rapid-acting insulin
The types of insulin described above are quite expensive, and if you do not have insurance, your physician may order a less expensive insulin that has a different start time, peak, and duration time. If that is the case, it is important to ask your nurse for clear instructions before you leave the hospital.
Important things to know
If you are to give yourself both a mealtime or nutrition dose and a correction dose of a rapid-acting insulin, you can add the two doses together in the same syringe to avoid two injections. Just remember that no other insulin can be combined with a long-acting insulin the same syringe. If the correction dose is ordered to be given four times a day at meals and at bedtime if needed, then you will give yourself a correction dose at bedtime only if your blood sugar is high and the correction dose is needed. Always check your blood sugar before injecting insulin. Write down the time, your blood sugar, and the insulin dose in a log book so you can look for trends and also so you can take the logbook to your doctor appointment.
Recognizing and Treating Low Blood Sugar
When you check your blood sugar before meals, it should be higher than 70. If it is lower than 70, it is too low and must be treated before you eat your meal. Low blood sugar is treated with about 15 grams of a fast-acting simple carbohydrate. In other words, the treatment should be something that is almost pure sugar and can digest quickly. Some examples are half a cup of juice or regular soda, a small handful of jelly beans or other sugary candy that does not contain fat, or a cup of fat-free or low fat milk. After eating or drinking the carbohydrate, wait 15 minutes and recheck your blood sugar. If it is still below 70, eat or drink some more. If your blood sugar does not come up after two treatments, continue to eat or drink more carbohydrate and also call your physician. If the blood sugar was below 50, eat or drink double the amount of carbohydrates. Once the blood sugar is higher than 70, eat your meal. If it isn't mealtime, eat a snack that contains fat, such as peanut butter and crackers, which will help stabilize blood sugar. Right after eating, I recommend checking your blood sugar again. If it is at least 90, you might give yourself half the mealtime dose of insulin when you finish eating. Do NOT give yourself a correction dose, also, even if blood sugar is now high. Half the mealtime dose may be sufficient. Check with your physician to make sure he or she wants you to take half the mealtime dose after you have eaten.
The signs of low blood sugar may include:
- Tremors
- Clammy sweat
- Blurred vision
- Headache
- Dizziness
- Confusion
- Weakness
- Lethargy
- Racing heart
Don't Assume Anything When it Comes to Insulin
Please don't guess or assume anything about your insulin, when to take it, how much to take, or anything else. If you are unsure of anything related to your insulin or insulin routine, always call your physician for clarification. If you can't reach your physician, you might try calling your pharmacist for general insulin questions. But make sure you get accurate answers from a professional!
If you have any questions, feel free to post them here. I'm happy to try to help you.
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