Patient Name: ________________________________________ Date:___________

Symlin or Byetta

Breakfast dose: ______ units/ micrograms
Lunch dose: ______ units/ micrograms
Dinner dose: ______ units/ micrograms

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Mealtime/Bolus Insulin at Breakfast, Lunch, and Dinner.

Breakfast dose: ____ units Apidra (Glulisine), Novolog (Aspart), Humalog (Lispro), Regular
Lunch dose: _______ units Apidra (Glulisine), Novolog (Aspart), Humalog (Lispro), Regular
Dinner dose: ______ units Apidra (Glulisine), Novolog (Aspart), Humalog (Lispro), Regular

Correction (add to Mealtime/Bolus Dose if Blood Glucose in the following range):
Blood glucose = 0-59: 1/2 can non-diet soda or 4 oz of orange juice
Blood glucose = 60-119: give nothing
Blood glucose = 120-159: give ___ units
Blood glucose = 160-199: give ___ units
Blood glucose = 200-239: give ___ units
Blood glucose >=240:       give ___ units

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Basal Dose at the same time _______ time(s) daily. (Either every morning and every night)

Once a day either Nighttime or Morning: _____ units Lantus (glargine) or Levemir (Detemir)

Or two times a day (12 hours apart) _______ units Lantus (glargine) or Levemir (Detemir)

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Instructions:

Increase Basal dose (Lantus/Levemir) by _______ units every 3 days until the Fasting or morning sugar is less than 110 mg/dl.

After this is acheived, if blood sugars are still high at meal times (greater than 120 mg/dl), increase the meal dose (Apidra, Novolog, Humalog) by ______ units every 2 days.