Adding Short Acting Insulin in Primary Care

Last week, we discussed starting basal insulin (if you haven't already, check it out here). Now let's dive into adding mealtime insulin AKA prandial insulin. If you have patient that starts basal insulin and you still need to get better control of glucose, it can be helpful to add in prandial insulin. For example, if you get the morning fasting glucose under control but the A1c is not at goal or the patient has elevated glucose throughout the day related to meals. 

1. Starting prandial insulin for the first time: 

  • Aspart, fast-acting aspart, glulisine, or lispro: 4-5 units OR 10% of basal insulin dose prior to meal 
  • Short-acting regular insulin: 4-6 units, 0.1 units/kg (max 10u), OR 10% of basal insulin dose prior to meal 

2. Adding prandial insulin prior to additional meal(s): 4 units prior to meal 

3. Increasing existing dose(s) of short-acting regular insulin: (Based on how much prandial insulin the patient is using)

  • <10 units: increase by 1 unit
  • 11-20 units: increase by 2 units 
  • >20 units: increase by 3 units 

 

Example 1: 

Patient is on 30u basal insulin BID. Morning fasting sugars are now well controlled <150 and no hypoglycemic events noted. A1c remains elevated at 9. Pt at home glucose log shows trends of spiked glucose after lunch. 

Possible solution: Add pre-meal fast acting insulin 4 units before lunch. 

 

Example 2: 

Same patient as above. You added the pre-lunch fast acting insulin 4 units. It helps for a while then 6 months later she comes in and notes her glucose is now spiking at dinner. 

Possible solution: Increase the pre-lunch fast acting insulin to 5 units OR add in a pre-dinner fast acting insulin dose.

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