It is the patient who injects the insulin, not the doctor
The doctor prescribing the insulin is not the person who has to inject it and live with what happens thereafter. The insulin regimen must be tailored to the needs of the each person with diabetes. If the patient cannot control their blood glucose on a particular regimen, finds it hard to use, or loses confidence in it, it should be changed. Clearly, it is worth giving each new regimen a few months' proper trial with full education and continued support. If a patient moves to your clinic from elsewhere on a bizarre insulin regimen which seems totally illogical but appears to satisfy them, do not change it until you have had a chance to assess how it works for that person.
(a) Theory Does the patient know which insulins and how much of each he is taking? What is the insulin for? When is each insulin likely to act? Does he know how to adjust the dose according to blood glucose levels, diet, and activity? What should he do if he becomes ill? What precautions should he take? Is he aware of the risk and symptoms of hypoglycaemia?
(b) Practical Does the patient know how to check, store, and draw up his insulin? Does he know how to inject it? Does he know what to do with unused and used sharps and syringes? Have you watched him draw up and inject insulin? Does he know how to use his insulin pen, including changing cartridges? Have you watched him do this?
MONITORING OF PEOPLE ON INSULIN THERAPY 93
Table 9.3 Information for patients on insulin injections
1. Insulin name Dose injected before: breakfast/lunch/evening meal/bed
2. Your insulin type is human/porcine/beef.
3. Inject your insulin using a syringe/pen.
4. Inject your insulin subcutaneously—this means into the fatty tissue under the skin of the thighs, abdomen, buttocks, or upper arms.
5. Inject your pre-meal insulin minutes before food. Eat three meals a day with mid-morning, mid-afternoon and pre-bed snack unless otherwise advised.
6. Insulin lowers the blood glucose level and will help to control your blood glucose level.
7. Sometimes the blood glucose may fall too low (i.e. below 4mmol/1). This is called hypoglycaemia and may happen if you are taking too big a dose, eat too little or exercise more than you expect. If you feel muddled, slow-thinking, tingly, unduly emotional or cross, sweaty, shaky, or notice your heart thumping fast, eat some glucose, then have a big snack. Contact your doctor or diabetes nurse. You may need to reduce your dose of insulin.
8. Insulin will work only if you inject it regularly as prescribed!
9. If you are unable to take your insulin for any reason contact your doctor or diabetic nurse immediately.
10. Never stop your insulin. If you cannot eat, or are vomiting, contact your doctor immediately or follow the sick day rules he has given you.
11. Always carry a diabetic card and some glucose with you.
This table may be photocopied for use by patients only. © Dr Rowan Hillson, 2002. From Practical diabetes care, Oxford University Press, 2002.
2 Diabetes card? Ask the patient to show it to you.
3 Carrying glucose? Ask to see it.
4 Glucagon Has the patient's partner or relative an up-to-date supply and does he/she know how to use it? (See p. 101)
5 Hypoglycaemia Has the patient experienced this? Does he have warning symptoms? Does he have nocturnal hypoglycaemia?
6 Blood glucose balance (Table 9.1) If the blood glucose is persistently outside your targets for that patient, the patient's treatment needs adjusting.
7 Clinical state Apart from usual tissue damage monitoring, have any conditions arisen which would alter the insulin regimen? Is there any evidence of side-effects of treatment? Have you examined the injection sites?
8 Laboratory monitoring Consider checking renal function as this will alter insulin clearance.
9 Driving Has the patient told the DVLA he is on insulin? Does he know how to drive safely on insulin?
10 Take home message What does should the patient be taking now? When should it be taken? Write it down. Remember that the patient knows his or her diabetes far better than you do. Listen to their observations carefully and do not contradict them without due thought. For example, they are usually right in their belief that the pharmacist has given them the wrong insulin—this happens occasionally. They are usually correct in saying that a particular insulin does not suit them. And even if they do harbour misconceptions, correct them gently with an appropriate explanation.
The whole principle of insulin treatment is that the insulin is adjusted to the patient's lifestyle and not the other way around. People should not have to eat to keep up with their insulin—lower the dose to suit what they want to eat. People should not be prevented from doing particular things because they have to go home and inject their insulin—give them an insulin pen to carry with them. They should not be afraid that hypoglycaemia will ruin their work or a day out. Learn about your patient as a person and fit the diabetes treatment around his or her needs.
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All you need is a proper diet of fresh fruits and vegetables and get plenty of exercise and you'll be fine. Ever heard those words from your doctor? If that's all heshe recommends then you're missing out an important ingredient for health that he's not telling you. Fact is that you can adhere to the strictest diet, watch everything you eat and get the exercise of amarathon runner and still come down with diabetic complications. Diet, exercise and standard drug treatments simply aren't enough to help keep your diabetes under control.