Myrissa Melinda L Alip, MD

Myrissa Melinda L.
Alip, MD
Diabetes Management Skills: Insulin Dosing, Adjusting and Monitoring
DI A B E T E S MA NA G E ME NT DI A B E T E S MA NA GE ME NT
Obj ec t i v e
IN SULIN IN ITIA TION ,
DOSIN G, A DJUSTIN G, A N D At the end of the session:
MON ITORIN G The participants will be able to know:
– When to start insulinization

– How to adjust insulin
– When to monitor blood glucose
Myri ssa Lacuna- Al i p, M

. D. Myri ssa Lacuna- Al i p, M
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In d i c a t i o n s f o r In su l i n In d i c a t i o n s f o r In s u l i n
Th er a py Th er a py
• Type 1
• If not at Target with combination OHAs, • Pre-conceptive women (chances of getting
diet, and exercise pregnant)
• Oral Medications contraindicated • Highly symptomatic with very high glucose
• Pregnancy if medical nutrition therapy levels (HHS)
alone does not adequately control blood
sugar Lancet 1998
Jovanavic- Peterson, JAMA 1991
Diabetes Care, 1992
N Engl J Med 2003
De Fronzo 1998
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In d i c a t i o n s f o r In su l i n Ba r r i er s t o st a r t i n g
Th er a py in su l in
• Starting insulin is too • Starting insulin is too
• Presence of Renal or Liver problems complex complex
• Secondary diabetes • Hypoglycaemia • Hypoglycaemia
• Acute injury, stress, infection, surgery, or • Weight gain • Weight gain
steroids • Injections will hurt • Lack of time/resources
• Patient’s choice • Injecting in public is • Referrals are necessary
embarrassing • Lack of evidence for the
best use of insulin
Adapted from: Korytkowski M. Int J Obes 2002;26(Suppl 3):S1-S7

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Myrissa Melinda L. Alip, MD
DI A B E T E S MA NA G E ME NT DI AB E T E S MA NA GE ME NT
St a r t i n g i n s u l i n is t o o St a r t i n g i n s u l i n is t o o
c o mpl ex c o mpl ex
Strategy
• Insulin can be initiated once or twice daily and Strategy
titrated gradually • Use available support services to train patients
• May use fixed starting dose without calculation • Trained nurses
• Use evidence-based titration guidelines • Patient organisations
• Use modern insulin injections available in the • Give patients take-home materials
market (injection device)

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In su l i n w i l l c a u s e
In j ec t i o n s w i l l hur t !
h y p o g l y c a emi a
• Encourage healthy diet and moderate • Reassure patients that injections are
exercise from the start relatively painless and are less painful
• Combine insulin with metformin than fingerstick glucose testing
• Explain that some insulins may cause less • Demonstrate injection injections
weight gain than others • Emphasize the benefits of improved
glycemic control

. D.
I d o n ’t w a n t t o i n j ec t i n
p u bl i c
Ho w d o I t h en s t a r t
in su l in ?
• Use pens rather than vials and syringes
• Highlight that rapid-acting analogues * Tailor it according to your patient’s
(alone or in premixed insulins) allow needs
discreet injections immediately before
eating

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8/12/2009
Ho w to i n i t i a t e In s u l i n ? W h y d o es i n s u l i n n eed
a d j u st in g ?
Use of Basal Insulin
• 10 U or 0.2 U/kg, whichever is greater • To meet target goal
• Dose at same time every day, at dinner or • Eliminate low blood sugar
bedtime • Overall goal is to improve blood
• Continue treatment and titrate dose glucose control.
accordingly

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8/12/2009
Ba si c Pr i n c i pl es o f In su l i n
Wh y d o es i n s u l i n n eed
A d j u s t men t
a d j u st in g ?
• Make adjustments to usual insulin dose
• To meet target goal based on blood glucose patterns.
• Eliminate low blood sugar • Adjust first to eliminate low blood sugars
• Overall goal is to improve blood • Adjust only one insulin at a time (unless
glucose control. this will cause a low blood sugar level at a
later time). Consider that when one
insulin is increased, another may need to
be decreased.
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8/12/2009
Ba s i c Pr i n c i pl es o f In su l i n SMBG c a n a i d i n d i a bet es
Ad j u s t men t c o n t r o l by :
Increase insulin when there is a pattern of • facilitating the development of an individualized
repeating high tests. DO NOT increase blood glucose profile, which can then guide
insulin on the basis of sporadic high tests. health care professionals in treatment planning
for an individualized diabetic regimen;
-Increasing the insulin dose will lower blood
sugar levels. • giving people with diabetes and their families
-Decreasing the insulin dose will raise blood the ability to make appropriate day-to-day
sugar levels. treatment choices in diet and physical activity as
Wait at least 3-4 test days between each insulin
well as in insulin or other agents;
Clinical Diabetes 20:45-47, 2002
adjustment to have sufficient data to © American Diabetes Association ®, Inc., 2002
determine a pattern.
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8/12/2009
SMBG c a n a i d i n d i a bet es Fr eq u en c y o f SMBG

c o n t r o l by :
• improving patients’ recognition of When to monitor
hypoglycemia or severe hyperglycemia • There is no absolute recommendation
• varies from person to person
• enhancing patient education and
• frequency and timing of glucose
patient empowerment regarding the monitoring should be dictated by the
effects of lifestyle and pharmaceutical needs and goals of the individual patient
intervention on glycemic control.
Diabetes Care 25:S97-S99, 2002
Clinical Diabetes 20:45-47, 2002 © 2002 by the American Diabetes Association, Inc.
© American Diabetes Association ®, Inc., 2002

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Fr eq u en c y o f SMBG SMBG
• SMBG should be carried out three or more
Type 1DM: 3 or more times daily times daily for patients using mul- tiple
Insulin or SU treated patients: daily insulin injections or insulin pump therapy.
• patients whose diabetes is out of control (A)
• for those having medication initiated or • For patients using less frequent insulin i nj
being modified ect i ons, noni nsul i n t herapi es, or me d
i c a l n u t r i t i o n t h e r a p y ( MNT )
Diabetes Care 25:S97-S99, 2002 alone, SMBG may be useful in achiev- ing
© 2002 by the American Diabetes Association, Inc.
glycemic goals. (E)
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SM BG SMBG
• To achieve postprandial glucose targets, • Continuous glucose monitoring may be a
postprandial SMBG may be appropriate. supplemental tool to SMBG for selected
(E) patients with type 1 diabetes, especially
• When prescribing SMBG, ensure that those with hypoglycemia unawareness. (E)
patients receive initial instruction in, and
routine follow-up evaluation of, SMBG
technique and their ability to use data to
adjust therapy. (E)
. D.
Keepi n g a d i a r y
Ba r r i er s t o i n c r ea si n g u s e
o f SMBG • Explain how to keep a
blood glucose diary
• cost of testing,
• Give reasons for keeping
• inadequate understanding a diary
• patient psychological and physical • Emphasize importance of
entering ALL results
discomfort • Encourage comments
• inconvenience of testing when daily activity is
different than usual

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DI A B E T E S MA NA GE ME NT
DI AB E T ES MA NA GE ME NT
Bl o o d g l u c o s e t est i n g Po st - mea l g l u c o s e t es t i n g
When to test?
Details to be learned
• Suspected post-meal hyperglycaemia
• How well did the last medication work? • Monitoring treatment specifically aimed at
• When did each insulin dose or tablet have lowering post-meal glucose
the most or least effect? • Hypoglycaemia in post-meal state
• For information on glycaemic effect of meal
• How did the food eaten affect levels?
Post-meal hyperglycaemia may be associated
• What was the benefit of physical activity? with increased risk of cardiovascular disease
in type 2 diabetes.
Ceriello 2004

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Co mmo n pr o bl ems
• Blood glucose levels do not
coincide with how one feels Cl i n i c a l A s pec t o f
• Not enough blood on strip In s u l i n In i t i a t i o n ,
• Finger prick may be painful
Ad j u s t men t , a n d CBG
• Results do not reflect HbA1c
Mo n i t o r i n g

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Myrissa Melinda L Alip, MD

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Myrissa Melinda L Alip, MD

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Myrissa Melinda L.

– When to start insulinization

Myri ssa Lacuna- Al i p, M

Myri ssa Lacuna- Al i p, M

Myri ssa Lacuna- Al i p, M

Myri ssa Lacuna- Al i p, M

Myri ssa Lacuna- Al i p, M

Myri ssa Lacuna- Al i p, M

SMBG c a n a i d i n d i a bet es Fr eq u en c y o f SMBG

Myri ssa Lacuna- Al i p, M

Myri ssa Lacuna- Al i p, M

Myri ssa Lacuna- Al i p, M

Myri ssa Lacuna- Al i p, M

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