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Intensive Insulin Management

Education

Education is the most important task of the physician who provides care to a diabetic patient. Education is necessary not only for patients with newly diagnosed diabetes and their families, but also for patients with diabetes of any duration or those who have have not been properly educated about their disorder or who may not he aware of the current advances in diabetes management. Depending on the patient's nature of diabetes mellitus, and their associated acute and chronic complications, and their willingness to manage blood sugars, intensive insulin management may be a good choice. The endocrinologists at Houston Thyroid and Endocrine will train a patient who requires insulin in self-management to use algorithm to adjust the timing and quantity of their insulin dose, food, and exercise in response to their recorded blood glucose values.

Concept of Intensive Insulin Management


A combination of rapid acting insulin analogs and long acting insulins allows for more physiologic insulin replacement. In clinical studies, combinations of rapid acting insulin analogs together with intermediate acting or longer acting insulins for basal coverage have now been shown to have improved hemoglobin A1c values with less hypoglycemia compared to a regimen of regular insulin with meals and NPH at night. If your physician at Houston Thyroid and Endocrine Specialists has recommended intensive insulin management please refer to the intensive insulin management worksheet. Self-monitoring is useful in educating patients about the glycemic effects of specific foods and glucose lowering effects of exercise. It also reduces the likelihood of unexpected episodes of severe hypoglycemia. Initially blood glucose levels should be checked at least 4 times per day in a patient taking multiple insulin injections. Generally, these measurements are taken before each meal and at bedtime. In addition patient's will be taught to check their blood glucose levels whenever they developed symptoms that could represent hypoglycemic episodes. All blood glucose levels and they're timing and corresponding insulin doses should be recorded in an organized way and must be brought with the patient for the endocrinologist to review/download during regularly scheduled checkups. Your doctor will work on achieving goal blood sugars. Ideally pre-meal blood sugars should be 70 to 140 mg/dl and 2 hours after a meal less than 180mg/dl. 


Potential Risks and Benefits

Which regimen and what blood sugar targets are appropriate for individual patient depend on many many factors. These factors include as stated disease, the presence of complications such as heart disease, the patient's age, patient's motivation, ability to perform required tasks, and history of frequent or severe low blood sugars.intensive insulin management may not be safe if you few struggle with frequent low blood sugar reactions, are a child, are an older adult, have coronary artery disease, have a history of stroke, or have severe diabetes related complications. Recent studies such as the ACCORD trial have challenged the benefits of intensive insulin management in patients attempt to achieve hemoglobin A1c levels lower than 6.5% and have had diabetes for more than 8-10 years, especially if cardiac complications are present. 
 Risks Hypoglycemia Weight Gain 
 Benefits Reduce eye retina damage by >75% Reduce risk of nerve damage by >60%Prevent or slow the progression of kidney disease by 50%


ID Bracelet
All patients receiving therapy that can cause hypoglycemia should wear a medic alert bracelet or necklace that clearly states that insulin or an oral sulfonylurea agent is being taken. A card in a wallet or in a purse is less useful, because legal problems may come up if a victim's person belongings are searched without permission. Information on how to obtain a medic alert identification device can be obtained from your local pharmacy or from the MedicAlert Foundation

Calculations

Your physician will adjust your insulin regimen for you and provide the appropriate insulin to carbohydrate ratio, correction factor and target blood glucose. There are some rules of of thumb that can help decide how much insulin will be required. To obtain a carbohydrate ratio, divide the average daily dose into 500. For example, if the average daily dose is 50 unit/day then the insulin to carbohydrate ratio would be 1:10.  To calculate the correction factor, a rule of thumb is to average three days of insulin requirement and 1700 by that number. For example, if the insulin requirement for 3 days is 100 units, then the correction factor is 17. In this example, the blood glucose would be reduced by 17 mg/dl for every 1 unit of insulin taken. 

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Medhavi Jogi,
Aug 13, 2010, 5:04 AM
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Medhavi Jogi,
Aug 13, 2010, 5:14 AM
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