Conducting intensive insulin treatment

Intensive insulin treatment is essential in type 1 diabetes if you hope to prevent the complications of the disease. This means measuring your blood glucose at least before each meal and at bedtime, plus using both short-acting and longer-acting insulin to keep the blood glucose between 80 and 100 before meals and less than 140 after eating. How you do this is the subject of this section.

In a person who doesn't have type 1 diabetes, a small amount of circulating insulin is always present in the bloodstream and, after eating, insulin increases temporarily to control the glucose in the meal. Intensive insulin treatment attempts to mirror the activity of the normal human pancreas as much as possible.

In intensive insulin treatment, you usually take a certain amount of longer-acting insulin at bedtime. I prefer insulin glargine because it produces a smooth basal level of glucose control over 24 hours. In addition, you take a dose of rapid-acting insulin before each meal. I prefer lispro because it is more convenient and less hypoglycemia occurs. The dose of lispro is determined by the expected grams of carbohydrates in the meal you're about to eat, as well as by your blood glucose at that moment. Your doctor should provide you with a list of how much insulin to take for a given situation. Each patient is different, and the dosage must be individualized.

Using the carbohydrates in a meal to determine your insulin dose is called carbohydrate counting. The key to this system is to know the carbohydrates in your food. Here is where you make use of your friendly dietitian, who can go over your food preferences and show you how many carbohydrates are in them. The dietitian can also show you where to find carbohydrate counts for any other foods that you might eat.

You also need to know how many grams of carbohydrate are controlled by each unit of insulin you take. This is determined by checking your blood glucose an hour after eating a known amount of carbohydrate. For example, one person may need 1 unit to control 20 grams of carbohydrate, while another person needs 1 unit to control 15 grams of carbohydrate. If both of them eat a breakfast of 75 grams of carbohydrate, the first person might take 4 units of lispro, while the second person takes 5 units of lispro. Then additional units are added for the amount that the blood glucose needs to be lowered. A typical schedule is to take 1 unit for every 50 mg/dl that the blood glucose is above 100 mg/dl. Insulin can also be subtracted if the blood glucose is too low. For every 50 mg/dl that the glucose is below 100, subtract 1 unit. (To see how carbohydrate counting works in practice, see the sidebar "Carbohydrate counting to maximum health.")

By measuring your blood glucose frequently, you can find out how different carbohydrates affect your blood glucose. By using the carbohydrate sources that have a low glycemic index, you will need to use less insulin to control them. (See Chapter 8 for more on carbohydrates.)

As you attempt to help your body mirror normal insulin and glucose dynamics, you often have to deal with a greater frequency of hypoglycemia. The best way to handle hypoglycemia is by eating slightly smaller meals and using the unused calories as between-meal snacks. This technique smoothes out the ups and downs.

At what point do you adjust your insulin glargine? If you find that several mornings in a row your fasting blood glucose is too high, you might add a unit or two to your bedtime glargine. If it's too low, you might reduce your insulin glargine by a unit or two or try eating a small bedtime snack. A high blood glucose level throughout the day is an indication to raise the glargine. Getting a lot of hypoglycemia at different times of day is a reason to lower the glargine. These adjustments are best done in consultation with your doctor. If, however, you're unable to see your doctor, you can put your knowledge to use and make these adjustments on your own.

Adjusting insulin when you travel

If you're traveling between time zones, you may wonder if you need to change your insulin routine while you're gone. Time changes of less than three hours require no modifications, but changes above three hours require progressively more. You should probably discuss these changes with your physician before you go.

Say that you're taking the red-eye flight at 10 p.m. from San Francisco, arriving at 6 a.m. at Kennedy Airport in New York. If you are taking insulin glargine, you do not have to change your dose. Just start using lispro at the beginning of your meals (which you'll be eating three hours earlier than usual because of the time change).

When you return to California, you add three hours to your day. In this case, you need to take an extra measurement of your blood glucose. If it's around 150, you need do nothing, but if it's 200 or more, take a couple of units of lispro insulin to bring it down. If your blood glucose is much below 100, eat a small snack. Again, you do not have to adjust your insulin glargine.

Delivering insulin with a pen

Several manufacturers, including Eli Lilly, Owen Mumford, Diesetronic, Novo Nordisk, Sanofi-Aventis, and Becton Dickinson, have sought ways to make delivering insulin easier. The insulin pen, shown in Figure 10-2, is one useful tool. The pen doesn't eliminate the need for needles, but it does change the way you measure your insulin. Either the pen comes with an insulin cartridge already inserted, or the cartridge is placed inside the pen just like ink cartridges used to be put in pens and replaced when it runs out.

Each cartridge contains 1.5 or 3.0 milliliters of insulin — either NPH, regular, lispro, aspart, a mixture of NPH-like lispro and lispro (such as 75 percent NPH-like lispro and 25 percent lispro), or a mixture of NPH-like aspart plus aspart. You can then dial the amount of insulin that you need to take. Each unit (sometimes two units) is accompanied by a clicking sound so the visually impaired can hear the number of units. The units also appear in a window on the pen. If you draw up too many units, one of the pens forces you to waste the insulin by pushing it out of the needle, while others allow you to reset the pen and start again. Depending on the pen, you can deliver from 30 to 70 units of insulin. You screw on a new needle as needed.

A number of different companies make pens for their own insulin. Available pens include the following:

1 Autopen, which is available in four different models. Two contain a 1.5-ml cartridge, and two contain a 3-ml cartridge. Within each size, one pen delivers insulin in 1-unit increments, and the other pen delivers insulin in 2-unit increments.

1 Humalog Mix 75/25, Humalog Mix 50/50, Humalog Pen, Humulin Mix 70/30, and Humulin N, all of which are prefilled, disposable pens containing 3 ml of the particular kind of insulin you use.

1 HumaPen Luxura HD, used for Humalog insulin when half-unit doses are needed, particularly in children.

1 HumaPen Memoir, a new pen that remembers the 16 most recent doses, their times, and dates; and is used with 3-ml lispro cartridges.

1 Levemir FlexPen, a prefilled disposable pen containing 3 ml of Levemir insulin.

1 NovoLog FlexPen and NovoLog 70/30 FlexPen, which are prefilled disposable insulin syringes containing 3 ml of insulin.

1 NovoPen Junior, which takes NovoLog cartridges containing 3 ml of insulin and can be measured in half-unit doses.

1 NovoPen 3, which holds NovoLog 3-ml cartridges.

1 SoloStar, a disposable pen that contains 3 ml of Lantus insulin.

1 Opticlix, which uses 3 ml glargine or glulisine cartridges.

Insulin pens require needles, and you must match the pen with the proper needle in order for the pen to work properly. If the needles don't come with the pen, the instructions with the pen tell you which needle to use.

Should you shift from your syringe and needle to a pen? If you're comfortable with the syringe and needle and feel your technique is accurate, you probably have no reason to do so. If you're new to insulin, have some visual impairment, or feel that you're not getting an accurate measurement of the insulin, a pen may be the solution for you.

Delivering insulin with a jet injection device

Jet injection devices (see Figure 10-3) are for the person who just can't stick a needle into his or her skin. At around $1,000 or more, they're expensive, but they last a long time and replace the syringe and needle.

Figure 10-3:

A jet injection device.

Jet injection devices are made by at least two different manufacturers:

1 Advanta Jet, which delivers K to 50 units of all types and mixes of insulin

1 Advanta Jet ES, which is useful when the skin is particularly tough

1 Adveanta Jet's Gentle Jet, which is a low-power version for children of the two Advanta Jet

1 Medi-Jector Vision, which delivers all types of insulin from 2 to 50 units in 1-unit increments

A large quantity of insulin is taken into the injection device, enough for multiple treatments. The amount of insulin to be delivered is measured, usually by rotating one part of the device while the number of units to be delivered appears in a window. The device is held against the skin. With the press of a button, a powerful jet of air forces the insulin through the skin into the subcutaneous tissue, usually with no pain perceived by the patient. The devices come in a lower power form for smaller children. These devices can deliver up to 50 units at one time.

Should you try an insulin jet injector? If you have no trouble with the syringe and needle or find the pen to be an easy substitute, you don't need a jet injector. If you hate needles or need to give frequent shots to a small child who is very resistant to them, a jet injector may solve your problems.

Supplements For Diabetics

Supplements For Diabetics

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.

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