Insulin Tutorial 2-13

We have now looked at six examples. What have we learnt?

1. When the diabetes has existed for a long time; whenever insulin requirements are high; whenever diabetes control is difficult to achieve - in all these circumstances blood glucose determinations are vital.

Many health-care professionals do not recommend patients to rely on urine glucose testing. However in some parts of the world urine tests are still used.

Nevertheless it is important to recognise that as the disease progresses urine sugar measurements become less and less useful and need to be replaced by blood glucose determinations.

2. Nowadays we draw a distinction between two forms of insulin therapy:

conventional insulin therapy
(Examples 1, 2, 3 and 4)

and

intensive conventional insulin therapy
(Examples 5 and 6).

3. The simplest form of conventional insulin therapy is a single daily injection of long-acting insulin (Examples 1 and 2) [Simulate This]. This is sometimes feasible during the remission phase ('Honeymoon period'). That is the period during which the pancreas is still producing some insulin (usually for a short while after diagnosis).

4. When insulin requirements rise and the pancreas is no longer producing any insulin, it can become necessary to give injections of premixed insulin twice a day (Example 3) [Simulate These A - B - C].

5. The most complicated mode of conventional therapy is to give a mixture of regular and long-acting insulin, mixed in the syringe immediately before giving the injection (Example 4) [Simulate This].

6. In intensive conventional insulin therapy insulin injections are given four times a day (Examples 5 [Simulate This] and 6 [Simulate This]). At the times of the three main meals regular insulin is injected, the dose depending on the blood glucose reading before the meal and the size of the meal (booster rate injection). Before going to bed long-acting insulin is injected as the basal rate. It is often necessary to give basal rate injections of NPH insulin in the morning and at midday as well.

For the proper management of intensive conventional therapy regular blood glucose determinations are essential, because the prompt decision whether to increase or decrease the regular insulin dose of the morning, midday or evening injection depends on the blood glucose reading determined in the morning, at midday and in the evening, and on the size of the meal.

The following general 'rules' may prove useful for deciding the booster rate injections:

1. Per 12 grams of carbohydrate 2 units regular insulin (in the morning rather more, at midday rather less, in the evening usually 2 units).

2. If the blood glucose reading is below 80 mg/dl (4.4 mmol/l), 2 units regular insulin less, if it is above 160 mg/dl (8.9 mmol/l), 2 units more; if it is above 240 mg/dl (13.3 mmol/l), as much as 4 units more.