How are Insulin-to-Carbohydrate Ratio (ICR) and Insulin Sensitivity Factor (ISF) calculated in diabetes management?

Calculating Insulin-to-Carbohydrate Ratio (ICR) and Insulin Sensitivity Factor (ISF) in Diabetes Management

There is no universal consensus on calculating ICR and ISF in diabetes management, but standardized starting formulas can be used with subsequent adjustments based on individual glucose responses.

Starting Formulas for ICR and ISF Calculation

Insulin-to-Carbohydrate Ratio (ICR)

• ICR shows diurnal variation, with different requirements throughout the day 1:
  • Morning/Breakfast: ICR = 300 ÷ Total Daily Insulin Dose (TDD)
  • Lunch and Dinner: ICR = 400 ÷ TDD

Insulin Sensitivity Factor (ISF)

• ISF also demonstrates significant diurnal variation, with higher correction dose requirements in the morning compared to afternoon and evening 2
• Morning ISF can be estimated using the 1800 rule: ISF = 1800 ÷ TDD 2
• Afternoon and evening ISF values are typically higher than the 1800 rule calculation 2
• ISF can also be estimated as approximately 5.14 × ICR for the same time of day 2

Adjustment Process for ICR and ISF

ICR Adjustments

• If carbohydrate counting is accurate but post-meal glucose is consistently out of target range, adjust the ICR 3
• For insulin pump users, review and adjust ICR settings during regular diabetes clinic visits (typically every 3-6 months) 3
• For hybrid closed-loop systems, carbohydrate ratio may need adjustment depending on the activity of ultra-rapid/rapid-acting insulin bolus 3

ISF Adjustments

• Adjust ISF if correction doses do not consistently bring glucose into target range 3
• Monitor post-meal glucose levels to guide adjustments:
  • Pre-breakfast insulin: adjust based on post-breakfast or pre-lunch glucose 3
  • Pre-lunch insulin: adjust based on post-lunch or pre-dinner glucose 3
  • Pre-dinner insulin: adjust based on post-dinner or bedtime glucose 3

Factors Affecting ICR and ISF Calculations

• Multiple factors influence both ICR and ISF values 2:
  • Age
  • Body mass index
  • Pubertal stage
  • Duration of diabetes
  • Total daily insulin dose
  • Time of day (diurnal variation)

Special Considerations

Fat and Protein Content

• High-fat and high-protein meals can cause delayed postprandial hyperglycemia (3+ hours after eating) 3, 4
• Additional insulin may be needed for high-fat/high-protein meals, but no consensus exists on a specific algorithm 4
• For insulin pump users, a split bolus feature (part delivered immediately, remainder over time) may provide better coverage for high-fat/high-protein meals 3

Clinical Pitfalls to Avoid

• Avoid using the same ICR and ISF values throughout the day due to diurnal variations 2, 1
• Be cautious of overbasalization with insulin therapy (signals include basal dose >0.5 units/kg/day, high bedtime-morning glucose differential, hypoglycemia, and high glycemic variability) 3
• Avoid using carbohydrate sources high in protein (e.g., nuts) to treat hypoglycemia, as protein may enhance insulin response to carbohydrates 3
• Recognize that insulin sensitivity varies significantly between individuals (range 1.9 to 9.1 mg/kg/min in studies) 5

Advanced Optimization Methods

• For insulin pump users with continuous glucose monitoring (CGM), data from both systems can be used to calculate a more precise ICR 6
• Hyperinsulinemic-euglycemic clamp studies suggest a starting ICR of 1:9.3 as a reasonable first estimate, with post-prandial blood glucose measured at 70 minutes 5

Remember that while these formulas provide a starting point, regular monitoring and adjustment based on individual response patterns are essential for optimal glycemic control.