Adjusting diabetes regimens in Diabetes

Adjusting diabetes regimens in Diabetes

Self-measurement of blood glucose offers the diabetic patient and his or her doctor a unique opportunity to restore glucose levels to within, or at least near, the physiological range. What is clear is that both need to understand the various factors that influence glucose levels in the blood, i.e. food intake, physical activity and insulin supply. Self-measurement of blood glucose allows the individual to interpret these variables and learn, through experimentation, the effect of a change to one or more. The outcome of such a programme of self-experimentation in association with the careful review is almost always marked improvement of control.

This article details the approaches used by the Diabetes Unit, Princess Margaret Hospital, Christchurch, New Zealand in instructing patients in self-management of their insulin replacement regimens. The essential aspect underlying the basic programme is knowledge, not only knowledge by the patient but of the attending health professional.

It is essential that the reader is familiar with the pharmacokinetics of different insulins and the factors influencing absorption (Berger et al. 1982), as these are fundamental to the treatment of insulin-dependent diabetics. In addition, new advances and changes in treatment impose a need for regular updating.

1. 1 Understanding the Physiological Basis of Glucoregulation

In the past, many health professionals and their patients have accepted glycaemic control that today is considered not appropriate. One of the contributors to this problem has been the lack of awareness of non-diabetic individuals. Very often in the past patients have been reassured that their measured glucose levels, for example around 10 mmol/L, are nearly normal when in fact such a value is around 2 times normal. This Diabetes Unit has adopted a rigid policy of ensuring that its patients are well aware of the normal range of blood glucose at different times of the day. All results obtained from self-measurement of blood glucose are then interpreted with reference to this normal range. Because many health professionals do not have a good understanding of the variation of glucose throughout the 24-hour period

Table 1. The Basic requirements for good control in diabetes

Competent support from health professionals patient knowledge in all aspects of diabetes management good understanding of physiological mechanisms for glucoregulation, especially as they relate to insulin release and action understanding of nutrient requirements in diabetes and the importance of normal body weight awareness of the mechanisms of action and pharmacology of insulin and oral agents awareness of the effect of exercise on glucoregulation Clear identification of treatment goals.

It can be seen clearly that in the fasting state before breakfast, values are usually around 4 to 5 mmol/L. After ingestion of food, glucose levels rise slightly but seldom exceed 7.5 mmol/L.

In fact, many subjects show a rise in glucose of less than 1 mmol/L postprandially. These data highlight the effectiveness of the glucoregulatory process. A number of different factors are responsible for this glucoregulation, but insulin is clearly one of the most important.

This unit has found that once a diabetic patient understands this relationship between insulin, food and glucose control, he or she is in a position to choose an insulin replacement regimen that is rational and physiologically appropriate.

2. Choosing a physiological Insulin Replacement Regimen

There is a physiological requirement for greater amounts of insulin at times of good ingestion and also during the early hours of the morning-approximately after 4 am. This can be achieved by a multiple subcutaneous injection regimen or by insulin infusion associated with mealtime pulses.

2.1 Advantages of a Multiple-dose Regimen

Although such regimens may, on the surface, appear inconvenient, they do have distinct advantages in that they give flexibility of mealtimes, relatives simplicity in altering the insulin dosage in accordance with the requirements for that meal, and of course, there is the potential for excellent glycaemic control over the whole 24-hour period. Other factors, such as reduction of frequency of hypoglycaemia, inherent flexibility of lifestyle and greater ease in adjusting other variables, e.g. exercise, are reasons why many patients come to adopt such a regimen. One other distinct advantage is that it is easier for the patient to understand which insulin is working at any time of the day, and therefore which insulin needs adjustment. These patients very quickly learn to do their own adjustments, although initially, they do need the support of a health professional. We have found that algorithms for insulin adjustment (table II) and stylized diagrams of insulin action are very useful patient aids.

2.2 Alternative Regimens

Nevertheless, many patients do not accept a 4 time-a-day injection regimen and therefore it is essential to provide alternative regimens of either 3 injections per day or, more commonly, a twice-daily regimen where each of the 2 injections comprises rapid and long-acting components. Single-injection regimens or twice daily insulin regimens not containing rapid action insulin are not used by this Diabetes Unit in any situation where good diabetic control is considered important. We are of course clearly drawing a distinction between the patient who is motivated and striving for physiological control, and the patient in whom this may be considered not possible or not essential, e.g. elderly persons with other health problems.

Adjusting insulin

Meal-timed injection of rapid-acting insulin

This handout is a guide only to help you adjust your own insulin and achieve more normal glucose levels.

This applies only if your insulin regimes consist of:

• Rapid-acting insulin (clear) before each major meal, and
• Long-acting insulin (cloudy) either before your evening meal or as a separate injection before going to bed.

Time of Day	Ideal glucose levels mmol/L	Your results	Other changes	Other changes
Pre-breakfast	4-5	Too high Too low	# Evening long-acting insulin $ Evening long-acting insulin	Check glucose 2-4am Check glucose 2-4am
Between 2-4h After meals	4-8	Too high Too low	Meal timed rapid-acting insulin $ Meal timed rapid-acting insulin	Check exercise the programme, check diet
Before bed	4-8	Too high Too low	# Meal timed (evening meal) rapid-acting insulin $ Meal timed rapid-acting insulin	Check exercise programme check diet
2-4 am	3-5	Too high Too low	# Evening long-acting insulin $ Evening long-acting insulin or shift long-acting insulin to just before going to bed	Check pre-breakfast levels

General advice

· Most patients using insulin need to blood test only about 3 days each week

· On each testing day at least 3, preferably 4 tests are needed

· Study the daily test profiles and work out ways of improving these

· Make one change at a time only

· Retest over several days and if necessary make another change

· See your doctor if you are unsure what to do

Remember:

If your tests are high, they will not get better by themselves – you need to do something positive

A guide to insulin adjustment for patients on twice-daily dose regimens

Adjusting insulin

Twice daily injection of rapid-acting/long-acting insulin mixes

This handout is a guide only to help you adjust your own insulin and achieve more normal glucose levels.

This applies only if your insulin regimes consist of:

• A pre-breakfast injection of a rapid-acting (clear) and a long-acting insulin (cloudy) [separate or mixed], and
• An injection before the evening meal of a rapid-acting and a long-acting insulin (separately mixed)

Time of Day	Ideal glucose levels mmol/L	Your results	Other changes	Other changes
Pre-breakfast	4-5	Too high Too low	# Evening long acting insulin $ Evening long acting insulin	Check glucose 2-4am ? Shift evening long acting insulin to before bed
Between 2-4h After meals	4-8	Too high Too low	# Meal timed (breakfast) rapid-acting insulin $ Meal timed (breakfast) rapid-acting insulin	Check diet Check exercise programme
Before bed	4-8	Too high Too low	# Meal timed (evening meal) rapid-acting insulin $ Meal timed rapid-acting insulin	Check exercise The programme, check diet
Before evening meal	4-6	Too high Too low	# Morning long acting insulin $ Morning long acting insulin	Check exercise Programme, check diet
2-4 am	3-5	Too high Too low	# Evening long acting insulin $ Evening long acting insulin	Check pre-breakfast glucose levels

General advice

· Most patients using insulin need to blood test only about 3 days each week

· On each testing day at least 3, preferably 4 tests are needed

· Study the daily test profiles and work out ways of improving these

· Make one change at a time only

· Retest over several days and if necessary make another change

· See your doctor if you are unsure what to do

Remember:

If your tests are high, they will not get better by themselves – you need to do something positive

Benefits of Multiple-dose Regimens

This Unit attempts to obtain the best possible con­trol in all newly diagnosed insulin-dependent diabet­ics, all young diabetics (less than 40 years), all those with complications, and all pregnant patients with elevation of blood sugar. If twice-daily or 3-times-daily regimens are used, they can result in excellent gly­caemic control provided patients are active partici­pants in the programme and understand their insulin regimens well.

We have realised that less reliance must be placed upon long-acting insulins since these impose prob­lems with inflexibility of lifestyle, requirement for between-meal snacks, and sometimes restrictions on exercise. The Unit’s experience with such regimens of long- and short-acting mixes has therefore been to reduce the amounts of long-acting insulins used and increase relatively the amount of short-act­ing insulins, perhaps contributing to the trend to overall reduction in daily consumption of insulin by insulin-dependent diabetic patients in this region. The present mean daily consumption of insulin by insulin-treated patients in the Christchurch area (Christ­church population 335,000) is 38.2 units. Patients us­ing large amounts of insulin (greater than 50 units day) are almost always on poorly constructed insulin replacement regimens and inevitably undergo a dose reduction when these are altered.

Patients on twice-daily or 3-times-daily regimens are equipped with instruction sheets on how to adjust their own insulin. An example of the sheet available to patients for the twice-daily mixed insulin regimen is shown in table III.

3. Special Control Problems

3.1 Nocturnal Hypoglycaemia

Because patients are very sensitive to insulin at night and frequently receive a long acting insulin either before the evening meal or before supper, they are at risk of developing their lowest level of blood sugar during the early hours of the morning. We require most patients to test their blood sugar at 2am or 3am on some occasion to at least verify that this is not occurring. Patients taking high doses of long-acting insulin are especially at risk. The solution is relatively simple since all that may be required is reduction of the evening dose of long-acting insulin. Any deteri­oration of periprandial glycogenic control can best be prevented by the addition (or increase) of short-acting insulin prior to the evening meal. A further useful alternative, however, is the shifting of the evening long-acting insulin to a later time in the night, such as immediately before going to bed. This has the ef­fect of advancing the peak action of the long-acting of insulin some hours, thus reducing the tendency to nocturnal hypoglycaemia.

3.2 Early Morning Hyperglycaemia

One of the more difficult parts of the day to man­age is the time around breakfast. Blood sugar is often at its highest immediately after breakfast and reaches its peak at mid-morning. This apparent escape of blood sugar control is a reflection of the insulin de­ficiency and inherent insulin resistance at this time of the day. Although good results are not always ob­tained, the situation can be improved dramatically by efficient use of a fast-acting insulin before breakfast and by ensuring that the patient is not insulin defic­ient during the period from 4am to 7am. Rational use of a long-acting insulin the evening before prevents this insulin deficiency occurring.

3.3 Postprandial Hypoglycaemia

Although the fast-acting insulins are absorbed fairly rapidly they are often associated with post absorption hyperinsulinism which may contribute to hypogly­caemia some 3 to 4 hours following injection. Useful techniques that may assist are reduction in the amount of fast-acting insulin that is used, dietary manipula­tion with some emphasis being placed on mid-morn­ing snacks, and careful balance of the exercise pro­gramme. A factor often overlooked is the variability of the absorption of insulin from different injection sites. Much faster insulin absorption can be achieved by injection into the abdomen and this can be en­hanced even further by massage. Increased rapidity of absorption with the consequence of less post-absorptive hyperinsulinism should reduce postpran­dial hypoglycaemia and patients who are injecting in the leg or the arm should try changing the injection site to the abdomen.

Blood Glucose Chart

Date
Time
B L O O D G L U C O S E (mmol/L) 20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
Normal 5
4
3
2
1
0

Insulin/Tablet - type - Dose
Comments
Useful blood testing times			- before breakfast and lunch - before evening meal - 1 – 2 hours after meals
Do at least 4 tests on any testing day Suggested testing days are			-------------------------------------

An example of a flow sheet or patient recording of blood glucose tests in use at the Diabetes Unit, Princess Margaret Hospital, Christchurch.

3.4 Insulin Requirements during Exercise

Many diabetic patients are now becoming involved in vigorous exercise programmes such as marathon running, and the patient, the doctor and other health professionals are having to come to grips with the nutrient and insulin requirements associate with this physical stress. Our experience to date has been too limited to make any generalization apart from finding meal-timed rapid acting insulin injection regimens advantageous because of the reduction in frequency of hypoglycaemia during the exercise

3.5 Pregnancy

The requirement for the very best of diabetic con­trol during pregnancy requires the adoption of one of the more intensive regimens such as 3- or 4-times-a-day injection. These algorithms are as applicable to the pregnant as to the non-pregnant individual.

4. Self-measurement of Blood Glucose

One of the factors essential to good glucose control is self-measurement of blood glucose. If adequate rec­ords of blood glucose measurement are not main­tained, decision-making is impaired. This Unit im­poses fairly rigid requirements on insulin-treated patients with respect to self-measurement of blood glucose and patients are required to test on any given testing day or 4 occasions over the waking period. Patients are then required to interpret these results and make changes in the interests of good control.

Comprehensive records are maintained in order to assess the decision-making skills of the individual.No urine testing for glucose is asked of patients who are doing self-measurement of blood glucose, but urinary ketones are still needed at times of illness or poor control.

5 Conclusions

An excellent understanding by patients and their health advisers is essential for good glycaemic control in diabetes mellitus. Self-measurement of blood glu­cose allows the patient to interpret his or her control and make changes with the support of a health professional. Insulin regimens need to be appropriate to the physiological situation if they are to result in good physical control.

Diabetes Diet and Tablets

Diabetes Diet and Tablets

Diabetes occurs when the pancreas, a gland behind the stomach, fails to produce sufficient insulin. Insulin is needed by the body to handle the food we call carbohydrates (sugar and starches). These foods are normally broken down to a sugar called glucose, and insulin is necessary to convert this glucose to energy. Without sufficient insulin, the level of glucose in the blood rises and spills over into the urine, causing large volumes of urine to be passed, and as the body is unable to convert glucose to energy, excessive tiredness can also result. When diabetes occurs in middle age or later, there is usually only a partial insulin deficiency. This is called maturity onset or type II diabetes (as distinct from insulin-dependent or type I diabetes), and it can be controlled by diet or a combination of diet and tablets. If the person is overweight, it is more difficult for the reduced amount of insulin produced to act on the cells of the body, and so achieving and maintaining a normal weight is the cornerstone of treatment.

GOOD FOOD FOR ALL

Eating the right food is important for the whole population's health but especially for those with diabetes.

Now that you have developed diabetes, your body is unable to break down and use carbohydrates as it should. To control your condition you need to follow a few simple rules, whether you take tablets or not. In fact these simple dietary rules are the principles of healthy eating for everybody, they are: —

1) To avoid sugar in all forms

2) To eat less fat

3) To eat more fiber

4) To eat regular meals

Sugar, and foods containing it, will make your blood and urine sugar level rise considerably. Foods to avoid include sugar, glucose, jams/marmalades, sweetened fizzy drinks, sweets and chocolates.

Sugar-free drinks and saccharin sweeteners are useful, but diabetic jams, biscuits and sweeteners are unnecessary. They are expensive, and most contain sorbitol, which is fattening and can cause diarrhea.

Fats are high in calories, and a large intake can lead to heart disease and circulatory problems, so try to avoid fried and fatty foods and cut down on butter and margarine.

Fiber is the part of the diet that is not digested. It makes your diet more satisfying and helps to keep your sugar levels under control in addition to encouraging healthy bowel action. It is found in unrefined foods such as whole meal bread, whole meal flour, jacket potatoes, peas and beans, Branflakcs, Weetabix and digestive biscuits. Choose these instead of refined foods such as white bread, Cornflakes/Rice Krispies and white flour.

Being overweight does affect your diabetes, and you should try to correct it. By eating less fat and more fibre and avoiding sugar, you should find this relatively easy.

By making these long-term changes in your eating habits you will improve your health.

URINE TESTS

Your Doctor will advise you at what time and how often you should test your urine for sugar. Read and follow carefully the instructions on the container of your test strips. It is important that you empty your bladder completely half an hour before you do a test. You should then still be able to pass sufficient urine to test for sugar.

Keep a record of your urine tests and take it with you each time you visit your Doctor. Record diaries should be available from your surgery or clinic.

If your urine tests persistently show 1% sugar or more, seek medical advice.

BLOOD TESTS

Your Doctor may ask you to do finger prick blood sugar tests instead of urine tests. These are more accurate and some people find them more convenient. The Doctor

TABLET TREATMENT

If dieting fails to control your diabetic symptoms and your blood and urine sugar levels, your doctor will most probably prescribe a diabetic tablet. There are 2 groups of diabetic tablets for which there are different medical indications.

The first group includes the following drugs:

(Company or Proprietary name in brackets)

Acetohexamide Chlorpropamide Glibenclamide Glibornuride Gliclazide Glipizide Gliquidone Glymidine Tolazamide Tolbutamide

(Dimelor) (Diabinese Glymese Melitase) (Daonil Euglucon Libanil Malix) (Glutril) (Diamicron) (Glibenese Minodiab) (Glurenorm) (Gondafon) (Tolanase) (Glyconon Pramidex Rastinon)

These drugs are all very similar and they work by stimulating the pancreas to produce more insulin. They are safe but they can occasionally cause mild indigestion or skin rashes, and very rarely jaundice or anaemia. As they act by causing the pancreas to produce more insulin they can cause low blood sugar levels and symptoms of what is called a “hypoglycaemic reaction”. These reactions are extremely rare and are more likely to occur in elderly people, or when alcohol is taken on an empty stomach, or when strenuous exercise is taken after missing a meal. The symptoms of hypoglycaemia include weakness, drowsiness, confusion, difficulty in focusing, tingling especially around the lips and unsteadiness, and can be corrected by a sweetened drink, of sugar lumps in water, repeated if necessary. If it is left untreated it can progress to unconsciousness necessitating a hospital admission.

Chlorpropamide and to a lesser extent some of the other tablets in this group can cause an unpleasant flushing when alcohol is taken. If this is a problem a different tablet can be substituted.

There is only one tablet in the second group and this is called Metformin (Glucophage). This tablet is usually used to treat very overweight people whose diabetes is poorly controlled on diet alone. It does not stimulate the pancreas to produce more insulin and cannot therefore cause a hypoglycaemic reaction. It acts by altering the way the body deals with sugar. Side effects include mild indigestion or diarrhea or a metallic taste in the mouth.

REMEMBER WHEN TAKING TABLETS TO FOLLOW CAREFULLY THE DOSAGE INSTRUCTION ON THE BOTTLE AND KEEP ALL TABLETS OUT OF THE REACH OF CHILDREN.

Very occasionally these tablets fail to control maturity onset diabetes and then insulin treatment is advised.

OTHER TABLETS AND MEDICINES

Whenever your Doctor prescribes a new tablet or medicine remind him that you have diabetes or that you are taking a diabetic tablet. Some medicines can aggravate diabetes and result in high blood sugar levels whereas others can increase the effect of diabetic tablets and cause too low a blood sugar level.

Steroids and to a lesser extent, certain diuretics (‘Water’ tablets) can aggravate diabetes. Certain anti-angina and blood pressure tablets, some anti-depressants, some antibiotics, an anti-fungal tablet, some tablets used to treat joint conditions and some tablets used in the treatment of high cholesterol levels may increase the effect of diabetic tablets. Remember also that some cough medicines have a high sugar content.

HEALTH CARE

As there is an increased risk of heart attacks and strokes among people with diabetes it is important for your diabetes to be well controlled and for you to achieve and maintain your normal weight and to take regular exercise. Brisk walking is a very good way to exercise, If you wish to undertake a more vigorous exercise programme ask your doctor’s advice first.

Smoking and high blood pressure also increase the risk of heart attacks and strokes so it is vital for you to STOP SMOKING and advisable for you to have your blood pressure checked once a year by your clinic or family doctor.

You should also have your eyes checked once a year by your doctor or an Optician. Diabetes can affect the blood vessels at the back of the eyes and although it is rare for such changes to cause any deterioration of vision in people with your kind of diabetes it is obviously best for serious changes to be recognised and treated before they can do any harm.

FOOT CARE

People who have diabetes are more likely to be troubled with corns; blisters or infections and they need to take special care of their feet. Wash your feet regularly and dry carefully between the toes. Cut your toe nails straight across preferably after a bath when the nails are soft. Do not cut them too close to the skin. If you do not sec well or your hands shake ask someone to help you. Very thick or in growing toe nails should be treated by a Chiropodist.

Do not walk barefoot. Always wear shoes that fit well and do not wear new shoes for more than half an hour at a time.

Avoid excessive heat or cold. Keep the feet warm and wear soft roomy socks or stockings, preferably woolen or cotton. Do not use hot water bottles. If you have cold feet wear bed socks instead. Do not put plasters on corns or try to cut them yourself - see a Chiropodist.

Report any sore places, blisters, discolored areas or callouses, however trivial, to your Doctor.

ILLNESSES

Any illness is likely to cause a deterioration in the control of your diabetes.

If, when you are ill, your urine tests show persistent 1% sugar or more, or your blood tests 13 mmol/per litre or more, seek medical advice.

If you become increasingly thirsty and start to pass more urine than normal, or if you rapidly lose weight and feel unwell or if you vomit, contact your Doctor.

CAR DRIVING

Diabetes is specifically mentioned on the driving license application form and people who have diabetes must mention it when completing the form. If you hold an existing driving licensewhen your diabetes is first diagnosed you should write to the D.V.L.C. at Swansea and inform them. You should also declare your diabetes to your Insurance Company.

ALCOHOL

Like the rest of the population you should be sensible a flout the amount of alcohol you drink. Do not drink more than a couple of ‘shorts’ or 2 glasses of dry wine, or 2 dry sherries, or 2 pints of ordinary beer a day. If you drink spirits, e.g. gin, whisky etc., choose a slim line mixer. Beer or lager drinkers should be aware of carbohydrates and calories. Diabetic lagers (low in carbohydrate) are available, but remember that they are high in alcohol and calories, and tend to be expensive.

Liqueurs, sweet wines and ordinary mixers should be avoided. Never drink on an empty stomach. For those taking diabetic tablets, remember too much alcohol could have the effect of lowering your blood sugar and make you feel unwell.

FINALLY: DON’T DRINK AND DRIVE.

IDENTIFICATION

You should carry some form of identification card with you. Identification cards are available from your Doctor or Diabetic Clinic and should contain details of your name, address, Doctor and tablets.

PRESCRIPTION EXEMPTION

People with diabetes are exempt from prescription charges. Get a form from your Family Practitioner Committee for your General Practitioner to sign in order to receive your Prescription Charge Exemption Certificate.

If you have any questions concerning anything in this booklet please ask your Doctor, Nurse Specialist or Dietitian when you next visit your Diabetic Clinic.

Boehringer produce Diabur Test 5000 for urine glucose testing and BM Test Glyccmie 20-800R for blood glucose testing. Readers are invited to write to B.C.L.. Boehringer Mannheim House, Bell Lane, Lewes, East Sussex, BN7 1LG, for diabetic diaries, pocket guides and other useful literature for use with these tests.

FINALLY REMEMBER

WITH GOOD CONTROL OF YOUR DIABETES

AND REGULAR HEALTH CHECKS

YOU CAN BE AS HEALTHY OR EVEN HEALTHIER

THAN THE NEXT PERSON