Ambulatory Insulin Titration Form

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Each of the four pilot sites adapted the basic concepts underlying the planned visit approach to meet the unique needs of the team and patient population. The Hoxworth Internal Medicine team generated an important change with its Ambulatory Insulin Titration Form.

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	THE UNIVERSITY HOSPITAL Progress Notes Ambulatory Insulin Titration Form	Name _____________________________ MRN _____________________________ DOB _____________________________ Phone Number _____________________________
		TUH-00, Rev. 8/061

Primary Care Doctor ____________________________________________________________

Date	AM  Blood Sugar		Lunch Blood Sugar		PM Blood Sugar		HS Blood Sugar
	Fasting	Post	Pre	Post	Pre	Post
Total
Average

Glargine (Lantus) Titration

Glargine Dose/Titration		Units
Average Fasting Sugar
Current Glargine Dose	____ Units
Glargine Titration	____ Units
New Glargine Dose	____ Units

Aspart (Novolog) Titration

Aspart Dose/Titration		Units
Breakfast	Lunch	Dinner
Current Aspart Dose
Aspart Titration
New Aspart Dose

 

Fasting Blood Glucose average for at least 3 consecutive days (mg/dl)	Adjust dose of glargine (Lantus), units
>180	+8
160-180	+6
140-159	+4
120-139	+2
100-119	+1
80-99	maintain dose
60-79	-2
<60	-4

 

Preprandial or Bedtime Blood Glucose average for at least 3 consecutive days (mg/dl)	Adjust dose of aspart (Novolog) units
>180	+3
160-180	+2
140-159	+2
120-139	+1
100-119	maintain dose
80-99	-1
60-79	-2
<60	-4

Notes: _______________________________________________________________________________________________

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Adapted from: Ann Intern Med 2006;145:125-134.

Signature (RN/MD)_____________________________________Date___________Time___________

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1. White Medical Records   Yellow Clinic Record

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