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Insulin
Principles of insulin therapy
Insulin dose adjustments
Soon after diagnosis
- Frequent advice by members of the diabetes care team on how to make graduated alterations of insulin doses is of high educational value
- Insulin adjustments should be made until target BG levels are achieved
- If frequent BG monitoring is not possible, urinary tests are useful especially in the assessment of nocturnal control
Later insulin adjustments
- On twice-daily insulin regimens, insulin dosage adjustments are usually based on recognition of daily patterns of BG levels over the whole day or a number of days, or in recognition of glycemic responses to food intake or energy expenditure
- On basal-bolus regimens, flexible or dynamic adjustments of insulin are made before meals and in response to frequent BG monitoring. The new analogs may require postprandial BG tests to assess their efficacy
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Health care professionals have the responsibility to advise parents,
other care providers and young people on adjusting insulin
therapy safely and effectively. This training requires regular
review, reassessment and reinforcement
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Advice
- Elevated BG level before breakfast
 increase pre-dinner or pre-bed intermediate or long-acting insulin (BG tests during the night might ensure that this change does not result in nocturnal hypoglycemia)
- Rise in BG level after breakfast increase pre-breakfast short or rapid-acting insulin
- Elevated BG level before evening meal increase pre-breakfast intermediate-acting insulin or increase dose pre-lunch of short or rapid-acting insulin if on basal-bolus regimen
- Rise in BG level after evening meal increase pre-evening meal short or rapid-acting insulin
In addition
- Unexplained hypoglycemia requires re-evaluation of insulin therapy
- Hyper- or hypoglycemia occurring in the presence of intercurrent illness requires a knowledge of ‘sick day management’
- Day-to-day insulin adjustments may be necessary for variations in lifestyle routine especially exercise or dietary changes
- Various levels of exercise require adjustment of diabetes management
- Special advice may be helpful when there are changes of routine, travel, school outings, educational holidays or other activities which require adjustment of insulin doses
Development of skills in the independent adjustment of insulin doses varies greatly among young people and families. To facilitate these skills 24-h telephone access to personnel experienced in pediatric diabetes care should be available. This assists not only general diabetic management and safe insulin adjustment but also provides invaluable support during illness and other crises. In this way, admissions to hospital may be prevented
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