Highs

Always consider dietary adjustments. If highs are one-off, consider exercising your blood sugar down or using a sliding-scale (see below).

• Breakfast highs: increase evening long-acting insulin (but check your 0300 hrs test before doing so)
• Lunchtime highs: increase breakfast short-acting insulin (or decrease breakfast or mid-morning snack)
• Dinner highs: increase morning long-acting insulin (or decrease lunch or med-afternoon snack)
• Bedtime highs: increase dinner short-acting insulin (or decrease dinner or evening snack)
• 0300 hrs highs: no action necessary if breakfast sugar OK (and HbA1c OK), otherwise talk to MD

Ultra-Short-Acting Insulin

Humalog (lispro) is a form of ultra-short-acting insulin that has been modified so that it is absorbed quicker in to the blood stream after subcutaneous injection. In general terms, one unit of Humalog has the same blood glucose lowering effect as one unit of regular (short acting) insulin. After subcutaneous injection it begins to be absorbed within 10 minutes. It reaches its peak effect between 1 and 2 hours and disappears by 4 to 5 hours. Because Humalog is very short acting, between meal snacks are usually not necessary. The likelihood of gaining weight with Humalog therapy is therefore smaller than with regular insulin in a multiple daily dosing schedule. Though I never encourage my patients to miss meals, the chances of severe hypoglycemia when you miss a meal (and of course don't take Humalog) is much lower than with conventional insulin schedules. This quicker onset and shorter duration of action has some major advantages. The first is that you need not wait after taking your injection to eat. In fact, if you delay eating you run the risk of severe hypoglycemia. If you are forgetful or if there is a chance that you will not eat as soon as expected, it is acceptable to take Humalog after you eat. For the average size meal most people require 2-6 units. You need to experiment to see how much you need based on your body size, how much carbohydrate/starch there is in the meal you are going to eat etc. You should always test before taking your Humalog and give yourself extra sliding scale Humalog if your sugar is higher than your pre-meal target (usually in the range of 5-8). The best way to tell whether you take the ideal amount of Humalog is to test your blood sugar 1-2 hours after you eat. A reasonable target for sugar at this time is 9-10. If your sugar is lower than this you took too much; if it is higher you took too little. The alternative of course is you either ate too little or too much or made poor food choices.

Although using Humalog according to the above recommendations means more testing, it will lead to fewer hypoglycemic reactions, particularly severe hypoglycemic reactions. It will lead to improved HbA1c and ultimately will lead to better quality of life in the short term and fewer complications in the long term.

All patients taking Humalog need to take 2 daily shots of long-acting insulin. The long-acting insulin will be either NPH (N), lente (L), or ultra-lente (U). The best times to take your long-acting insulin is at lunchtime and at bedtime. The advantage of this is that the long-acting insulin typically peaks between 6 and 8 hours - this will be around 5-6 am for the bedtime N and at dinner time for the lunchtime N. The body is resistant to hypoglycemia at 5-6 am and of course your eating at dinner time. The dose of long-acting insulin is adjusted according to the blood sugar before meals. Thus, if the pre-meal breakfast sugar is too high you should probably increase your bedtime long-acting. Before doing so it is wise to test at 3 am to rule out the possibility that your morning high is not due to an asymptomatic early morning low followed by a rebound high. By the same argument, a high blood sugar at lunchtime may mean you need to increase your bedtime long-acting, though if your 2 hour post breakfast is too high then the correct adjustment would be to increase your breakfast Humalog not to increase your bedtime N. Remember you judge your dose of Humalog based on the 2 hour post meal reading. Similarly, a good 2 hour post lunch reading accompanied by a high pre-dinner reading should mean you increase your lunchtime long-acting. Similarly, a good 2 hour post dinner reading accompanied by a high bedtime reading should lead to an increase in the lunchtime long-acting.

A typical insulin schedule using Humalog schedule therefore contains a shot of Humalog before each meal and two shots of long-acting insulin, usually at lunchtime and bed. Most patients following this schedule successfully take roughly 50% of their insulin as Humalog at 50% is long-acting.