at a particular time or times of day implies a mismatch of insulin therapy to meal pattern
and/or physical activity :
Review whether a repeated change in meal or activity behaviour is occurring; if
so advise on a specific insulin adjustment for that change
Consider change in underlying insulin sensitivity ( age / renal / endocrine )
Refer to the insulin dose adjustment section
Erratic hypoglycaemia
needs thorough assessment of a range of possible causes:
Consider :
missed / varied meals or snacks
rotation between injection sites
erratic physical activity
errors in insulin administration / dose
alcohol
inappropriate dose distribution
injection site abnormalities
gastroparesis
Hypoglycaemia unawareness
is often partially reversible; hypoglycaemia can induce hypoglycaemia unawareness :
Consider ( by self-testing ) the possibility of undetected night-time or
other hypoglycaemia, especially if HbA1c is lower than average
Use adjustment of insulin doses or food
intake to ameliorate such problems
Avoid any glucose excursion to <4.0
mmol/l ( <70 mg/dl )
Provide education and training in recognizing early cognitive dysfunction
for people with the problem and their careers
Provide counselling on any resultant life-style problems; caution over
driving
Nocturnal hypoglycaemia
can be ameliorated by careful attention to insulin therapy :
Consider :
reduction in evening unmodified insulin dose if large or
late; this is a major contributor to 2400-0300 h hypoglycaemia
taking the evening NPH insulin as late as possible –
thus separating the effects of the evening unmodified and NPH insulin preparations
taking a slowly absorbed carbohydrate snack as late as
possible
using a rapid-acting insulin analogue before the main
evening meal
Hypoglycaemic coma / fitting :
Give 20 % glucose IV if unconscious, or 1 mg glucagon IM. Beware of poor
glucagon effect in the starved or inebriated patient. Follow with oral carbohydrate and
review for possible relapse
Train careers to use glucagon if recurrent, unresolved problem; ensure supplies
remain in date
