Selected References For More In
- Graudins et al. Calcium channel and beta-blocker overdose: antagonist antidotes and adjunct therapies. Br J Clin Pharmacol, doi: 10.1111/bcp.12763.
- St-Onge M, et al. Treatment for calcium channel blocker poisoning: A systematic review. Clin Toxicol 2014 52: 926-944.
- Levine M, et al. Critical care management of verapamil and diltiazem overdose with a focus on vasopressors: A 25-year experience at a single center. Ann Emerg Med 2013 62: 252-258.
- Engebretsen KM, et al. High-dose insulin therapy in beta-blocker and calcium channel-blocker poisoning. Clin Toxicol 2011 49: 277-283
: Nov. 1, 2015
How To Manage Type 1 Diabetes
Before the discovery of insulin, diabetes was a death sentence. People couldnt use the nutrients in their food and would become thin and malnourished. Managing the condition required a strict diets and reduced carbohydrate intake. Still, these measures werent enough to reduce mortality.
In the early 1920s, Canadian surgeon Dr. Frederick Banting and medical student Charles Best discovered that insulin could help normalize blood sugar levels. Their discovery garnered them the Nobel Prize and allowed people with diabetes to live a much longer and healthier life.
According to the Centers for Disease Control and Prevention , 12 percent of adults with diabetes take insulin only, and 14 percent take both insulin and an oral medication. Taken as prescribed, insulin is a lifesaver. However, too much of it can cause significant side effects and sometimes death.
While some people may use excessive amounts of insulin intentionally, many others take too much insulin by accident. No matter the reason for the overdose, an insulin overdose needs to be treated immediately. Even with proper treatment, it can become a medical emergency.
High Dose Insulin Therapy
Take Home Points:
- High dose insulin is indicated in cardiogenic shock due to calcium channel blocker or beta blocker overdose
- HDI improves cardiac myocyte function by enhancing carbohydrate utilization within the myocyte and via other direct inotropic effects
- HDI is more effective than vasopressors/inotropes alone
- The starting dose for HDI is 0.5-1 units/kg bolus then 0.5-1 unit/kg/hr drip. Note this is 10 times the usual dosing for DKA
Cardiovascular drugs cause many poisoning deaths each year, primarily from acute overdose. In 2016, cardiovascular drugs as a class were the second leading cause of poisoning deaths reported to the National Poison Data System , the majority of which were beta-blockers and calcium channel-blockers1 . This trend has continued through 2018, where calcium channel blockers and beta blockers were each listed in the top 10 substances associated with the largest number of fatalities 2.
High dose insulin therapy – How does it work?
While the efficacy of HDI has not been established with controlled clinical trials, there is substantial evidence from animal models and human case series. For instance, in a swine model of propranolol toxicity, pigs treated with vasopressors alone died within 20 minutes while those treated with HDI survived for 2-3 hours6.
So how do I do this?
Protocols vary by institution, so a consultation with a medical toxicologist and local poison center is recommended.
- Insulin bolus:
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How To Prevent Insulin Overdoses
- Take care when calculating meal time insulin. Taking an extra couple of minutes to be sure of your dose will save the time and hassle of an overdose.
- Never be tempted to delay your meal or snack if you have injected.
- Dont inject whilst doing other tasks, such as watching the TV, holding a conversation or performing another task as this raises the chance that you may forget your injection has been done. Concentrate solely on giving the injection
- Be careful of injecting insulin when you are hypo as mistakes are more likely to be made. Ideally, ensure your blood glucose has risen to safe levels and then put in your scheduled insulin dose.
- Ask for help if you have difficulty seeing the numbers or gradations on your insulin pen or syringe. See also our page on diabetes and visual impairment which lists a number of injection aids for people that have visual impairments
A Guide To Novolin Insulin
indications for Novolin Novolinis a man made form of insulin designed to help control diabetes mellitus. It is structurally identical to the insulin produced by the human pancreas, but is still quite effective in cats and dogs. Helping to bring down high blood sugar, Novolin assists pets with diabetes mellitus in controlling their hyperglycemia. Novolin, like all insulins, is only offered as an injection. Precautions Patients on Novolin should monitor their blood sugar closely, as an overdose of this drug will cause the blood sugar to drop dangerously low. The safety of using Novolin with pregnant or nursing pets has not been tested, so caution should be used. Pets taking anabolic steroids, beta adrenergic blockers, diuretics, estrogen agents, glucocorticoids, MAOIs, progestin, thyroid hormones, aspirin, digoxin, dobutamine, epinephrine, furosemide, phenylbutazone, or tetracycline should tell their vet before taking Novolin, as they may decrease its effectiveness. Dosage A U100 type insulin, make sure you have the proper syringe, otherwise your dosage will be off. The dosage in both cats and dogs is 0.2 units/kg, but you should consult with your veterinarian before administering any injections.Continue reading > >
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The High Blood Sugar Correction Factor:
Correction Factor = 1800 ÷Total Daily Insulin Dose = 1 unit of insulin will reduce the blood sugar so many mg/dl
This can be calculated using the Rule of 1800.
= 1800 ÷ TDI = 1 unit insulin will drop reduce the blood sugar level by 45 mg/dl
While the calculation is 1 unit will drop the blood sugar 45 mg/dl, to make it easier most people will round up or round down the number so the suggested correction factor may be 1 unit of rapid acting insulin will drop the blood sugar 40-50 mg/dl.
Please keep in mind, the estimated insulin regimen is an initial best guess and the dose may need to be modified to keep your blood sugar on target.
Also, there are many variations of insulin therapy. You will need to work out your specific insulin requirements and dose regimen with your medical provider and diabetes team.
Insulin Doses Need To Be Raised Or Lowered:
- Throughout life as you grow
- For different activities
- For foods that may affect your blood sugar differently
- When you are sick
The information on the following pages may be hard to learn. Learning to change insulin doses can take time. It is important to learn this because changing insulin doses at home when needed and between diabetes appointments will help to control your blood sugar.
It is better to prevent high blood sugars than to chase them with extra insulin at the time of the high. It is better to prevent low blood sugars than to chase them with extra quick-acting carbohydrate.
Your certified diabetes educator will teach you how to change your insulin doses to prevent high or low blood sugar. We will help you by phone or email for several months after you find out you have diabetes. After you learn to change insulin doses without our help, we are still here to help you when you need.
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Treating An Overdose Of Long
If you have given too high a dose of long-acting insulin, this could affect you for up to 24 hours.
How you prevent a hypo will depend on how big the overdose was. If the overdose was large, such as a double dose, take carbohydrate to raise your sugar levels and call your health team or out-of-hours service for advice.
If the overdose was smaller, such as up to 5 units too much, take more carbohydrate than usual and aim to keep your sugar levels higher than normal over the next 24 hours to prevent a hypo occurring.
Test regularly through the day and at any time you think you may feel hypo
Take plenty of carbohydrate before sleeping. It is better to wake up with higher sugar levels than risking a hypo overnight. Dont risk going low. If you cannot be certain that hypos will be avoided, call your health team or out-of-hours service.
What Are The Different Kinds Of Insulin
There are two different ways in which insulin can be classified.
Origin: Is the insulin derived from animal sources, such as beef and/or pork, or human sources in a laboratory? This can be important, as a drug order may specify the origin of the prescribed insulin, because some patients respond more effectively to insulin from one source rather than another.
Action: How quickly does the insulin take effect? There are now four basic action speeds of insulin:
Rapid Action: The most rapidly-acting insulins are relatively new of the two brands available, one has been around for 5 years and the other, 10 years . These insulins begin to work in 5-10 minutes, peak in 1-1.5 hours, and end in 3-5 hours. These rapid-acting insulins are taken at the beginning of a meal to counteract the rise in blood sugar due to eating, or they are used to lower blood sugar levels quickly when they are too high. The names lispro and insulin aspart both indicate rapid-action insulins.
Fast Action: Fast-acting insulin begins to work in about half an hour, peak in 2.5 to 5 hours, and then end in about 8 hours. Fast action insulins are often taken about a half hour before a meal, to counteract the rise in blood sugar that follows. The names Regular and Semilente both indicate fast-action insulins. To see a visual illustration of the difference in action between rapid and fast-acting insulins, see the charts below which show insulin levels over time in hours after an insulin injection:
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Example #: Carbohydrate Coverage At A Meal
First, you have to calculate the carbohydrate coverage insulin dose using this formula:
CHO insulin dose = Total grams of CHO in the meal ÷ grams of CHO disposed by 1 unit of insulin .
For Example #1, assume:
- You are going to eat 60 grams of carbohydrate for lunch
- Your Insulin: CHO ratio is 1:10
To get the CHO insulin dose, plug the numbers into the formula:
CHO insulin dose =
- The carbohydrate coverage dose is 6 units of rapid acting insulin.
- The high blood sugar correction dose is 2 units of rapid acting insulin.
Now, add the two doses together to calculate your total meal dose.
Carbohydrate coverage dose + high sugar correction dose = 8 units total meal dose!
The total lunch insulin dose is 8 units of rapid acting insulin.
What To Do If You Miss A Dose Of Insulin
For people with insulin-dependent diabetes, the near-constant attention to detail can sometimes be taxing on our mental health.
While perfection is impossible, diabetes demands a lot of precise measuring, counting, and dosing of food, exercise, and especially insulin.
But were human. We are bound to forget to take a dose of insulin from time to time. This article will detail exactly what you should and shouldnt do if you miss a dose of insulin.
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Example #: Formulas Commonly Used To Create Insulin Dose Recommendations
This example illustrates a method for calculating of your background/basal and bolus doses and estimated daily insulin dose when you need full insulin replacement. Bear in mind, this may be too much insulin if you are newly diagnosed or still making a lot of insulin on your own. And it may be too little if you are very resistant to the action of insulin. Talk to your provider about the best insulin dose for you as this is a general formula and may not meet your individual needs.
The initial calculation of the basal/background and bolus doses requires estimating your total daily insulin dose:
What Is The Correct Dosage
The correct dosing of insulin is very important:
Giving a patient too little insulin does not adequately lower blood sugar so that they are still left with too much sugar in the blood too much sugar the the blood can cause damage to blood vessels, leading to blindness, kidney failure, severe problems with limbs , stroke and heart disease.
Giving a patient too much insulin can lower blood sugar too much and lead to dangerously low levels of sugar in the blood, which can cause seizures and coma, because the brain depends primarily on glucose in the blood for fuel. Even before a person’s blood sugar level drops low enough to cause seizure or coma, low blood sugar levels can lead to mood swings, impaired mental function, blurred vision, nausea and vomiting, heart palipitations and shakiness.
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Types Of Basal Insulin
Most basal insulin is injected into the fat just under your skin. You can do that with a needle and syringe to draw the right amount of medication. You also can use prefilled disposable pens that many people find easier to use.
Basal insulin is delivered in three main types. They differ on how soon they start working , how long they last, and when the insulinâs effects peak in your body.
Your doctor may prescribe a mix of insulin types for use throughout the day, depending on how much your blood sugar rises and falls, and on your lifestyle.
NPH . This can start working as quickly as an hour or two. It reaches its maximum effect in 4-12 hours and stays in your body for up to 24 hours.
Detemir and glargine . These take about 2 hours to get into your bloodstream. Effects last about 24 hours. Long-acting basal insulin doesnât really hit a peak. That can help match how your body would release insulin if it were able to.
Degludec and glargine u-300 . These start to work in 1-6 hours. They can last 36 hours or more. Ultra-long-acting insulin doesnât peak. That means its effect stays even instead of rising and falling.
Take Insulin As Soon As Possible
As the heading suggests, its best to take your insulin as soon as possible, but there are some caveats.
If you simply forgot to pre-bolus for a meal, and youre still within a 30-minute window of eating, you should count carbohydrates and bolus for the meal like you would regularly do.
If youve eaten more than a half-hour ago, its best to treat the high blood sugar you have, instead of trying to count carbohydrates that are now being digested. This helps prevent unnecessary hypoglycemia if you take too much insulin.
If youve missed a dose of your long-acting insulin, its best to call your Endocrinologist right away to determine how much of the remaining dose you should take, based on how much time has passed since your typical time of administration, etc., unless its within a window of an hour or so of your normal dose.
If thats the case, you can most likely proceed as normal .
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Know That When You Check Your Blood Sugar The Number Tells Us How Well Your Last Dose Of Insulin Worked
For example, meal rapid-acting insulin peaks in 1 to 2 hours and lasts 3 to 4 hours. Your blood sugar taken 2 hours after the meal tells us how well the peak of the insulin covered the peak of the blood sugar after you ate. Your blood sugar taken before the next meal tells us how well the insulin worked during the time your carbohydrate was breaking down.
Total Daily Insulin Requirement:
= 500 ÷ TDI = 1unit insulin/ 12 g CHO
This example above assumes that you have a constant response to insulin throughout the day. In reality, individual insulin sensitivity varies. Someone who is resistant in the morning, but sensitive at mid-day, will need to adjust the insulin-to-carbohydrate ratio at different meal times. In such a case, the background insulin dose would still be approximately 20 units however, the breakfast insulin-to-carbohydrate ratio might be breakfast 1:8 grams, lunch 1:15 grams and dinner 1:12 grams.
The insulin to carbohydrate ratio may vary during the day.
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What’s The Most Insulin To Take
I am taking Humalog and Lantus insulins: 40 units of Lantus and 85 to 90 units of Humalog each day. My morning blood sugar is in the 180 to 200 range. I have had several bad bouts of hypoglycemia and am scared that they could occur while I sleep. Is there a maximum amount of insulin I should take? Should I take an additional dose of Humalog at bedtime? Would different brands of insulin be more effective?Continue reading > >
What Can Cause An Insulin Overdose
Insulin overdoses can occur for a number of reasons. Some common reasons are listed below:
- Miscalculating the carb content of a meal
- Missing out or delaying a scheduled meal or snack after having injected
- Accidentally injecting twice for the same meal or snack
- Accidentally injecting the dosage number of a different meal
- Accidentally injecting the wrong insulin for example injecting your rapid acting insulin instead of your long acting insulin
- Having difficulty seeing the numbers or gradation on an insulin pen or syringe
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What Are Normal Insulin Levels
Insulin levels in the blood can be interpreted using a simple blood test that is performed after eight hours of fasting. This test must be performed in individuals with suspected insulin resistance or as a part of a hormonal panel in metabolic syndrome evaluation.
The normal values of insulin are as follows.