3. OnsetPeakDuration Rapid Acting Lispro (Humalog)15-3030-90 min3-5 hours Aspart (Novolog)15-30 min1-3 hours3-5 hours Intermediate Acting NPH1-4 hours5-10 hours10-16 hours Long Acting Glargine (Lantus)1-2 hoursNone20-24+ hours Detemir (Levemir)1-2 hoursNone (?)8-23 hours

4.  For two times a day injections….. › 2/3 of total daily dose in the am  1/3 rapid acting  2/3 NPH › 1/3 of total daily dose in the pm  1/3 to ½ rapid acting  1/3 to ½ NPH

5.  Elevated blood glucose in the morning due to normal nocturnal secretion of GH and cortisol  Or waning of insulin action from the prior evening dose of NPH  Correct by increasing evening dose of NPH, may be limited by hypoglycemia in middle of night: preventable by changing NPH to pre- bedtime

6.  Rebound hyperglycemia  Peak activity of NPH causes unrecognized hypoglycemia in middle of the night  Counterregulatory hormones causes exaggerated rise in blood glucose resulting in hyperglycemia in the morning  Solution: the evening dose of NPH should be decreased to eliminate hypoglycemia at night

7.  ½ of total daily dose given as glargine (Lantus)  Rapid acting insulin to cover meals and correct high BGs › Insulin to carb (I:C) ratio can be determined by dividing 450 by the total daily insulin dose › Typical I:C for toddler 1:30 grams; teenager 1:5-8 grams › Insulin Sensitivity Factor (ISF) : 1800 rule is used: divided by the total daily insulin dose › If someone’s TDD= 30 units  1800/30= a 60 point drop per unit of insulin › Correction formula: (Current BG minus Target BG)/ISF

8. BreakfastLunchDinnerBedtime2am 110 9221012978 102135199132121 9981168117101 119123208165132 10762257137125 7 year old who takes Humalog and NPH at breakfast and dinner has the following blood glucoses. Do you want to make any changes to the insulin plan? If so, at which injection time, which insulin, and do you want to give more or less?

9. BreakfastLunchDinnerBedtime2am 110 9221012978 102135199132121 9981168117101 119123208165132 10762257137125 7 year old who takes Humalog and NPH at breakfast and dinner has the following blood glucoses. Do you want to make any changes to the insulin plan? If so, at which injection time, which insulin, and do you want to give more or less? ANSWER: The dinner time blood glucoses are all high; increase AM NPH

10. BreakfastLunchDinnerBedtime2am 18712315812965 (juice) 19913411614388 17610313216557 (milk) 21215212818672 (juice) 16910814215293 5 year old who takes Humalog and NPH at breakfast and dinner has the following blood glucoses. Do you want to make any changes to the insulin plan? If so, at which injection time, which insulin, and do you want to give more or less?

11. BreakfastLunchDinnerBedtime2am 18712315812965 (juice) 19913411614388 17610313216557 (milk) 21215212818672 (juice) 16910814215293 5 year old who takes Humalog and NPH at breakfast and dinner has the following blood glucoses. Do you want to make any changes to the insulin plan? If so, at which injection time, which insulin, and do you want to give more or less? ANSWER: The majority of the overnight numbers are low so decrease the evening NPH

12. BreakfastLunchDinnerBedtime2am 184113132128192 20512498114188 17573193132201 18795117105177 154136124129215 15 year old who takes Novalog at meals breakfast and Lantus at bedtime has the following blood glucoses. Do you want to make any changes to the insulin plan? If so, at which injection time, which insulin, and do you want to give more or less?

13. BreakfastLunchDinnerBedtime2am 184113132128192 20512498114188 17573193132201 18795117105177 154136124129215 15 year old who takes Novalog at meals breakfast and Lantus at bedtime has the following blood glucoses. Do you want to make any changes to the insulin plan? If so, at which injection time, which insulin, and do you want to give more or less? ANSWER: The overnight and first morning blood gluocoses are high. Increase Lantus