insulin

Question 1

when do you give basal insulin

Answer 1

at night

Question 2

how do you know if basal insulin is correct?

Answer 2

you look at the night and morning glucose.

First of all, glucose before bed should be 8 (if lower have a snack)
Glucose in the morning should be within 1 to 3mmol/l of each other. Ideally, the before bed
reading should be taken 2 to 4 hours after eating/giving rapid
insulin.

So if there is a huge change between night and morning then you need to change something. If it drops you need to drop insulin. If it increases, you may need to increase insulin…. but before you do this you need to rule out Dawn phenomenon, which is an increase in the blood glucose in the early hours of the
morning caused by the body’s release of certain hormones. To do this take your glucose at 2-3am.

Question 3

How much do you adjust basal insulin by?

Answer 3

Generally no more than 10%.
Small adjustments at a time.

Question 4

How do you adjust bolus insulin and how do you know how much to change this by?

Answer 4

Generally no more than 10%.
Can be done by carb counting, i.e., if BG rising 2 hours after a meal by >2mmol - Action Required = Decrease the number of
grams of carbs that 1
unit of insulin will cover i.e., if ratio is 1 unit :5g , suggested new ratio change = 1 unit: 4g

Question 5

A 29-year-old woman was admitted to the medical admissions unit with an infective exacerbation of asthma 3 days ago. PMH. Type 1 diabetes, asthma. DH.
Insulin aspart (NovoRapid®) 1 unit per 10 g carbohydrate SC with breakfast and lunch, 1.5 units per 10 g carbohydrate SC with evening meal, insulin degludec (100 units/mL) (Tresiba®) 24 units SC with breakfast, beclometasone dipropionate (Clenil Modulite®) 200 micrograms INH 12-hrly, salbutamol 200 micrograms INH as required, amoxicillin 1 g IV 8-hrly, prednisolone 40 mg PO daily for 7 days.
Investigations
Subcutaneous interstitial glucose sensor data for the last 3 days is available. Why is increasing insulin aspart (NovoRapid®) to 1.5 units per 10 g carbohydrate SC with breakfast the correct answer ?

Answer 5

because the peak is occuring straight after breakfast not midmorning after a long time after breakfast (look at the times- and it would also be very unusual for no spike in glucose to be seen after eating even if the insulin and glucose control was amazing, so the fact that there is a spike indicates that it straight after eating, and the fact it is so high then indicates that it is because the insulin is not high enough to accomodate it. This is common with steroids espeicall as they cause POST PRANDIAL RISES 2NDRY TO INCREASED INSULIN RESISTANCE).