The practices will occur during the action time of supper dose of Novorapid. As he wants to lose weight, it would be preferable to decrease insulin instead of eating extra food.
As the activity is 120 minutes, he could drop his pre-supper Novorapid by 50% or 6 units. It would be advisable for him to carry extra CHO such as juice and a choice from grains/starches food group.
He could be advised to check his blood glucose levels: Pre-supper
Pre-practice
Mid point in the practice Post practice
Bedtime
Following morning
As there is the possibility of a carry over effect of the evening physical activity, he should also consider reducing his bedtime Levemir, initially by 20% (mid-point in the suggested reduction range of 10-30%). Depending on his bedtime glucose reading, he may need additional
carbohydrate at bedtime and he may need to consider also checking glucose at 3 a.m. until he learns more about the effects of the practice on his night-time glucose.
Saturday afternoon game, 2:30 to 4:30 p.m.
If Jeff takes his Novorapid at noon, he will be past the peak action time by game time. He could make a modest reduction in the pre-noon NR, about 20% or 2 units for the first game. He would check his glucose level at the same times as he did for practices, beginning at pre-noon.
Depending on the pre-game level he may need extra CHO then and/or at the mid-point in the game. . If he needs extra carbohydrate pre or mid-game, he should take a fast acting
carbohydrate choice.
Post game he will need to consider reducing his pre-supper NR because of the carry over effect of the exercise. He could begin with a 20% reduction, assuming a pre-supper glucose of 4-7 mmol/L [see suggested reduction in the Saskatchewan Learning/Procedure Manual]. Depending on his experience with post-activity glucose levels, he many also need to reduce his bedtime Levemir.
ANSWER – CASE #15
What target glucose level would you set with Karen and her physician?
Due to her age, living alone, experience with unrecognized hypoglycemia and previous medical history, the recommended target pre-meal glucose level could be raised from 4-7 mmol/L to, for example; 6-8 mmol/L or slightly higher depending on your assessment of her ability to manage diabetes and recognize hypoglycemia.
What does the current dose of NovoMix 30 represent in terms of types of insulins and how many units of each insulin does this dose represent?
NovoMix 30 insulin represents a mixture of 30% NovoRapid (Aspart) and 70% aspart protamine crystal. The aspart protamine crystal has an activity profile similar to NPH.
8.4 units of rapid-acting insulin
19.6 units of intermediate-acting insulin 16 units of NovoMix 30 insulin is
5 units of rapid-acting insulin
11 units of intermediate-acting insulin
What changes, if any, would you recommend to her current medications?
Current glucose pattern shows: Fasting – above target Noon – at or close to target Supper – too low
Bedtime – at target
The first consideration is always prevention of hypoglycemia, so a 10% minimum reduction in the morning NovoMix 30 would be recommended. 10% is about 3 units or a reduction to 25 units. This would translate to 7.5 units rapid (previously 8.4) and 17.5 units intermediate-acting (previously 19.6). Reinforce the consistency of her afternoon snack.
If the above change increases the pre-supper readings to target, then the pattern of glucose readings can be re-assessed.
What might you consider if the first issue or problem you identify is not resolved?
In some cases, consideration may need to be given to using a different pre-mix (for example, 20/80) or splitting the insulins into their individual components. In order to decide the best action you will need to consider the client’s ability and willingness to manage the proposed changes, target blood glucose levels for her age, overall health and symptoms of hypo or hyperglycemia.
ANSWER CASE #16
The only glucose levels which are above target now are the fasting ones. Before making any changes to insulin:
Review the amount and type of food she is eating at bedtime.
Ask her to test her blood glucose level at 0300 a few times to ensure hypoglycemia is not being missed.
Assuming there are no issues with either of the above, you could consider the following IDA: 1. As bedtime glucose levels are “at target” continue with the amount of rapid-acting insulin
from the NovoMix30 dose (30% of 16 units = 5 units pre-supper). Move the remainder of the dose, (70% of 16 units = 11 units intermediate-acting insulin; Novolin NPH) to
bedtime. Ask Karen to check a couple of glucose levels at ~3 a.m. If the 3 a.m. glucose levels are not too low and the fasting glucose levels remain elevated, increase the bedtime NPH by 10%.
NOTE: This would require 3 different insulins which may be confusing to the client..
2.
Change to Levemir or Lantus at HS with short-acting insulin (Novolin Toronto or Humulinrisk of nocturnal hypoglycemia but would provide minimal insulin coverage for meals. Short-acting insulin could provide insulin coverage for all 3 meals with a total of 3 injections per day and 2 types of insulin. Dose calculations would be as follows:
Levemir or Lantus = total intermediate dose for the day – 20% of total dose whenmoving from a BID to OD dose
.
Therefore 19.6 + 11.2 = 30.8 – 6.2 (20% reduction in total intermediate dose) = 24.6 = 25 units at HS
Short-acting insulin dose could be the same as in the premix. Therefore, the morning dose would be 7 units and the supper dose would be 5 units, BUT Karen’s bloodglucose levels decrease from breakfast to lunch. Therefore to be cautious, the morning dose could be decreased by at 2 units to decrease the risk of mid morning
hypoglycemia.
This regimen would require 3 injections per day with 2 different insulins. Also the benefits of rapid-acting insulin on post-meal blood glucose levels in the pre-mix will be lost.3.
Change to Levemir or Lantus at HS (same calculation as above) with rapid-acting insulin (NovoRapid or Humalog) with all meals.
Because Karen has a fairly consistent carbohydrate intake from day to day, a routine dose of insulin with each meal may be an option rather than counting carbohydrates for each meal. Initiate rapid-acting insulin with meals at 1 unit per 15 grams of carbohydrates.
This regimen would require 4 injections per day with 2 different insulins.NOTE: a physician’s order would be needed to implement any of these changes
ANSWER CASE # 17
Mary is already using 0.93 units/kg body weight and although she may have insulin resistance, other variables than lack of insulin may be causing the recent elevation in glucose levels. Before making any IDA, consider the following with Mary:
she is gaining weight – what might be different (food intake and/or activity level, her emotions)?
a general food intake review paying attention to recent changes, food portions, fat intake, cooking methods, using food to cope. You might suggest she log her food for about 3 days, as a food review can be 50% inaccurate, especially if she has poor food awareness or if she is depressed. You might suggest a dietitian consult if there are food issues to be addressed.
review a typical day to assess activity level and routines and possible changes. assess her quality of sleep.
screen for depression.
ask Mary to demonstrate her technique with her insulin pen to ensure accuracy. ask Mary to demonstrate her blood glucose monitoring technique.
ask questions to determine if Mary has any symptoms suggestive of hypoglycemia (even though it’s unlikely).
ask about recent infections
If there are no “clues” to improve glucose control in any of the above, then consider an insulin dose increase. Often it is beneficial to try to improve the fasting blood glucose level first.
ANSWER CASE #18
The first priority will be to eliminate the lows at noon. If these are not related to food or activity changes, then his pre-breakfast insulin grid could be reduced by 1-2 units. Consider that he may feel he cannot eat any more for breakfast and he does not want to add a mid-morning snack. If this change results in elimination of the lows, and high glucose levels persist at 10 p.m. and fasting, he could look at strategies to reduce his bedtime glucose levels, hoping this would also reduce his fasting glucose.
He could check his blood glucose about 2 hours after supper to assist in determining the
effectiveness of his pre-supper insulin. If levels are rising > 10 mmol/L (if the pre-supper level is at target), then he can increase his pre-supper insulin grid by 2 units. If the post supper glucose level is < 10 and the rise occurs between that time and 10 p.m. then his basal insulin is likely responsible. His bedtime NPH may not be lasting 24 hours. He could consider two options:
Try moving the NPH injection to supper time – this may still leave the fasting glucose levels high.
Starting a small dose of NPH at breakfast to help later evening basal coverage. Make sure he understands how to use the insulin grid as less insulin may be needed pre- noon and/or pre-supper insulin to prevent hypoglycemia.
With improved fasting blood glucose levels, he may need a further reduction in his pre-breakfast grid to prevent mid-morning or pre-noon hypoglycemia. He may also need to look at the quantity of his evening snacking. If he needs or wants these calories, he may need a small dose of rapid- acting insulin at bedtime. To make this change you would need to consult with his physician.