International Diabetes Center International Diabetes Center Adjusting Insulin International Diabetes Center International Diabetes Center Adjusting Insulin Using Pattern Control A process of A process of • recognizing BG patterns • determining reasons why BG out of target • taking steps to bring BG back into target To correct a pattern, you can change To correct a pattern, you can change • food intake • activity • insulin International Diabetes Center International Diabetes Center Self Management – Pattern Control © 2003 International Diabetes Center. All rights reserved. © 2003 International Diabetes Center. All rights reserved. Monitor & Record Monitor & Record Monitor & Record Monitor & Record Assess Assess Influencing Influencing Factors Factors Assess Assess Influencing Influencing Factors Factors Evaluate Current Evaluate Current Dose Dose Evaluate Current Evaluate Current Dose Dose Identify Patterns Identify Patterns Identify Patterns Identify Patterns Take Action Take Action Take Action Take Action • Consistency is essential • % in target range • Frequency of monitoring • Consistency is essential • % in target range • Frequency of monitoring • Consistency of CHO • Timing of meals • Activity – Stress • Other medication • Consistency of CHO • Timing of meals • Activity – Stress • Other medication • Assess units/kg • Insulin distribution by time of day • Assess units/kg • Insulin distribution by time of day • AM Fasting • Pre-meal • Post-meal with rapid acting Lows-2 days Highs-3 days • AM Fasting • Pre-meal • Post-meal with rapid acting Lows-2 days Highs-3 days • Insulin • Food • Activity • Insulin • Food • Activity Pattern Control Pattern Control International Diabetes Center International Diabetes Center Record Blood Glucose Values Date Breakfast Lunch Dinner Bedtime 8AM BG Med BG 1 PM BG BG 7PM BG Med BG 11PM BG Med 1/25 257 (14.3) (14.3) 8R 16N 119 (6.6) (6.6) 105 (5.8) (5.8) 12R 14N 104 (5.8) (5.8) 1/26 368 (20.4) (20.4) 8R 16N 112 (6.2) (6.2) 84 (4.7) (4.7) 12R 14N 86 (4.8) (4.8) 1/27 226 (12.6) (12.6) 8R 16N 79 (4.4) (4.4) 114 (6.3) (6.3) 12R 14N 94 (5.2) (5.2) 1/28 Pre-meal Target: 70-140 mg/dL (3.9-7.8 mmol/L) (mmol/L) Treat to Target HbA1c HbA1c < 7% < 7% Fasting and Pre meal glucose Fasting and Pre meal glucose 70-140 mg/dL (3.9-7.8 mmol/L) 70-140 mg/dL (3.9-7.8 mmol/L) Postprandial glucose Postprandial glucose <160 mg/dL (8.8 mmol/L) <160 mg/dL (8.8 mmol/L) ( ( Two hours after the start of a meal the BG should Two hours after the start of a meal the BG should be no more than 20 to 40 mg/dL or 1.1 to 2.2 mmol/L be no more than 20 to 40 mg/dL or 1.1 to 2.2 mmol/L above the pre-meal BG above the pre-meal BG ) ) Bedtime glucose Bedtime glucose 100-160 mg/dL (5.5-8.9 mmol/L) 100-160 mg/dL (5.5-8.9 mmol/L) International Diabetes Center International Diabetes Center International Diabetes Center International Diabetes Center Testing Frequency Patients on Insulin • Four times/day recommended Four times/day recommended • Testing before each meal and before bedtime Testing before each meal and before bedtime • May also test pre-meal and 2 hours post meal to evaluate effect of May also test pre-meal and 2 hours post meal to evaluate effect of insulin on post-meal glucose insulin on post-meal glucose • Modify frequency of monitoring if necessary Modify frequency of monitoring if necessary • Encourage patients to record values in a record book Encourage patients to record values in a record book International Diabetes Center International Diabetes Center RA RA RA Times to Test Blood Glucose Serum insulin (mU/L) Hours RA RA RA Glargine Glargine 0 10 20 30 40 50 0 2 4 6 8 10 12 14 16 18 20 22 24 SMBG SMBG SMBG SMBG SMBG SMBGSMBG SMBG Meal Meal Meal Meal Meal Meal International Diabetes Center International Diabetes Center Testing Guidelines Lispro (Humalog) or Aspart (Novolog) Test Test before before meal and two hours meal and two hours after after meal meal • compare the before and after meal glucose compare the before and after meal glucose • adjust adjust Lispro or Aspart Lispro or Aspart insulin if insulin if difference > 40 mg/dL (2.2 mmol/L) difference > 40 mg/dL (2.2 mmol/L) • adjust basal insulin if fasting or adjust basal insulin if fasting or pre-evening meal glucoses out of target pre-evening meal glucoses out of target International Diabetes Center International Diabetes Center Self Management – Pattern Control © 2004 International Diabetes Center. All rights reserved. © 2004 International Diabetes Center. All rights reserved. Pattern Control Pattern Control Monitor & Record Monitor & Record Monitor & Record Monitor & Record Assess Assess Influencing Influencing Factors Factors Assess Assess Influencing Influencing Factors Factors Evaluate Current Evaluate Current Dose Dose Evaluate Current Evaluate Current Dose Dose Identify Patterns Identify Patterns Identify Patterns Identify Patterns Take Action Take Action Take Action Take Action • Consistency is essential • % in target range • Frequency of monitoring • Consistency is essential • % in target range • Frequency of monitoring • Consistency of CHO • Timing of meals • Activity – Stress • Other medication • Consistency of CHO • Timing of meals • Activity – Stress • Other medication • Insulin distribution by time of day • Assess units/kg • Insulin distribution by time of day • Assess units/kg • AM Fasting • Pre-meal • Post-meal with rapid acting Lows-2 days Highs-3 days • AM Fasting • Pre-meal • Post-meal with rapid acting Lows-2 days Highs-3 days • Insulin • Food • Activity • Insulin • Food • Activity International Diabetes Center International Diabetes Center Assessing Influencing Factors • Carbohydrate content of meals Carbohydrate content of meals – Counting correctly – Consistency • Timing of meals and snacks Timing of meals and snacks – Delayed meals and skipped snacks can cause hypoglycemia with conventional regimens – Delayed basal insulin can increase blood glucose [...]... International Diabetes Center Evaluate Current Insulin Dose Assess if overinsulinization • Calculate the current total daily insulin in units/kg Average total insulin/ day: Type 1- 0.7 units/kg Type 2 – 1 unit/kg • Bolus : basal distribution is usually 50:50 Remember: • consistent exercise needs less basal insulin • consistent high carbohydrate intake needs more bolus insulin International Diabetes Center Self... International Diabetes Center Changing from Conventional to Physiologic Insulin Therapy Using Glargine • Total all daily insulin and then subtract 20% = New total daily insulin • New total daily insulin dose split 50% bolus at meals (RA or Regular) and 50% Glargine Example: Current Insulin Dose: 5 RA/12 N & 6RA/8N = 33 units/day New Insulin Dose: 33 units – 20% = 26 units/day 4 RA – 4 RA – 4 RA – 13 G... of meals Timing of meals ••Assess units/kg Assess units/kg • Insulin Insulin distribution distribution ••Activity – Stress Activity – Stress ••Other medication Other medication by time of day by time of day ••AM Fasting AM Fasting ••Pre-meal Pre-meal ••Post-meal with Post-meal with rapid acting rapid acting Take Action Take Action • Insulin Insulin ••Food Food ••Activity Activity Lows-2 days Lows-2 days... of meals Timing of meals ••Assess units/kg Assess units/kg • Insulin Insulin distribution distribution ••Activity – Stress Activity – Stress ••Other medication Other medication by time of day by time of day ••AM Fasting AM Fasting ••Pre-meal Pre-meal ••Post-meal with Post-meal with rapid acting rapid acting Take Action Take Action • Insulin Insulin ••Food Food ••Activity Activity Lows-2 days Lows-2 days... of meals Timing of meals ••Assess units/kg Assess units/kg • Insulin Insulin distribution distribution ••Activity – Stress Activity – Stress ••Other medication Other medication by time of day by time of day ••AM Fasting AM Fasting ••Pre-meal Pre-meal ••Post-meal with Post-meal with rapid acting rapid acting Take Action Take Action • Insulin Insulin ••Food Food ••Activity Activity Lows-2 days Lows-2 days... days Change only one type of insulin and one dose at a time Date Breakfast BG 10/15 10/16 10/17 Lunch Med BG Met 1000 126 138 (7.0) (7.7) 194 162 (10.8) (9.0) 144 163 142 (7.9) (9.1) Ev Meal Med Bedtime BG BG Med Met 1000 138 (7.7) Note Med 10 G 143 (8.0) (7.9) 153 131 243 (8.5) (7.3) (13.5) 262 10/18 (14.6) (mmol/L) International Diabetes Center Adjusting Physiologic Insulin Stage 4 Wt: 75 kg (165... Dose: 5 RA/12 N & 6RA/8N = 33 units/day New Insulin Dose: 33 units – 20% = 26 units/day 4 RA – 4 RA – 4 RA – 13 G International Diabetes Center Changing from Conventional to Physiologic Insulin Therapy Comparison Current Insulin: AM 6RA/20 N PM 4RA/16 N Current recommended: 36 units total N minus 20% = 29 units of glargine New regimen: 3RA – 3RA – 3RA – 29 G SDM: Total daily dose 46 units minus 20% =...Assessing Influencing Factors • Increase in exercise – • Illness and Stress – • In type 2 diabetes, exercise lowers BG and decreases insulin resistance Blood glucose usually increases Steroids – Increases blood glucose International Diabetes Center Self Management – Pattern Control Pattern Control Monitor & Record Monitor & Record ••Consistency... meal BG BG After meal 136 BG (10.3) 126 Notes 186 (7.6) Bedtime 206 (7.6) (7.0) (11.4) 101 135 197 (5.6) (7.5) (10.9) 158 128 239 (8.8) (7.1) (mmol/L) (13.3) International Diabetes Center Guidelines for Insulin Adjustment Current Dose Pattern of Lows Pattern of Highs 10 units or less Decrease by 1 unit Increase by 1 unit More than 10 units Decrease by 2 units or 10% Increase by 2 units or 10% International . International Diabetes Center International Diabetes Center Adjusting Insulin International Diabetes Center International Diabetes Center Adjusting Insulin Using Pattern Control A process of A process. Lispro or Aspart insulin if insulin if difference > 40 mg/dL (2.2 mmol/L) difference > 40 mg/dL (2.2 mmol/L) • adjust basal insulin if fasting or adjust basal insulin if fasting. Highs-3 days • Insulin • Food • Activity • Insulin • Food • Activity International Diabetes Center International Diabetes Center Evaluate Current Insulin Dose Assess if overinsulinization • Calculate