Insulin Use: Basic Self Adjustment Strategies

***NOTE: Always Discuss your self care plans with your health care professionals before making changes, especially with insulin dose adjustments. The comments here are made as a general guideline and not for an individual to follow without support from their usual diabetes  team.***

Guest Post by David Mapletoft, Diabetes Educator

When first diagnosed with diabetes type 1, or when moving onto insulin treatment as a people living with type 2 diabetes, frequent dosage adjustments are necessary to achieve safe and effective insulin therapy.

“However, a controversy surrounds the pertinent clinical parameters required to make effective and safe insulin titrations. We hypothesize that glucose readings are sufficient to adjust insulin dosage provided that it is done on a weekly basis” From here

Some basic things to know about insulin:

Starting insulin for people living with type 2 diabetes is not a sign of failure. Type 2 diabetes is naturally progressive, i.e. over time the pancreas makes less insulin.

Basal insulin: This injection of long acting (up to 24 hours duration) is usually given in the evening before bed. Some insulins may be given at any time of the day as long as it is the same time each day. This type of insulin provides the body an ability to use glucose (released by the liver to fuel the body) between meals.

Bolus insulin: Insulin injected to support a meal, usually injected immediately before eating the meal. This is sometimes injected after the meal e.g a toddler who may not eat the whole meal always may’ve the part of the meal eaten assessed and insulin dose selected and injected after the meal.

Mixed Insulin:Contains a mix of basal (long ing insulin) and bolus (short acting insulin). Using this type of insulin usually involves 2 injection per day, with the breakfast and with the dinner (evening meal). This type of insulin has its drawbacks if you day is not consults the same. This type of insulin is more likely to have a person fitting their day into their diabetes  rather than their diabetes into their day. This is because of the over lap of the 4 doses of insulin being injected.

Single Dose Insulin: Often prescribed for people living with type 2 diabetes for problematic overnight (fasting) blood glucose levels.

Insulin and Tablet Mixes: Often prescribed for people living with type 2 diabetes as the pancreas begins to slow down insulin production. Some or all of the tablet medication can be maintained to enable the injected insulin to work more effectively.

“Sliding Scale” Insulin Dosing: This is often used in hospitals to manage a critical situation, e.g. illness, infection, post operation. This type of insulin dosing is not usually very effective when used at home.

What Factors affect insulin dose change?

  • Carbohydrates: amount and GI
  • Physical activity: duration and intensity
  • Illness and infections
  • Stress: positive and negative
  • Body mass
  • Level of Insulin resistance
  • Confidence: talk to your health care professionals – particularly your dietitian and diabetes educator  – ask them how you and they can achieve a high level of self confidence in this dose adjustment strategy
  • Incorrect storage:
    • Store insulin in an area that is protected against extreme heat and extreme cold. Avoid areas prone to temperature extremes, such as in your car, freezer or in direct sunlight.
    • Check the expiration date on your insulin before using, and inspect it to be sure the insulin looks normal. Discard insulin that is expired, crystallized or clumped.

Self Adjustment

  • Self-adjustment involves estimating the appropriate amount of insulin to inject through each day to strike a balance between high and low blood sugar levels.
  • Regular  blood glucose testing and recording the results will help you to see how your blood sugar numbers change and allow you to improve your overall diabetes management.

Safety First

  • Keep your hypoglycaemia treatment with you at all times (and within arms reach)
  • Have a friend or family member check up on your each day – phone, social media or email contact
  • Ask your health care professional for phone or email support to guide you through your self adjustment decisions: you make the decisions, they give you advice on how safe your decisions  are.
  • Measure your blood glucose level before you drive: ALWAYS.

Problem Areas

Remember first that we work on individual targets now. So consider whatever your targets are based on your type of diabetes, age, general health etc

Fasting (wakeup) blood glucose level – the long acting basal insulin dose is usually the problem here: if your blood glucose level is over your individual target, it would be best to firstly exclude a low blood glucose level at around 2-3 am (or whatever time your ‘middle of the night’ is), as your liver could release glucose in response and cause a rebound high.

Once you have proven that no low blood glucose levels are happening overnight you can chat with your doctor about making small changes to your insulin dose to get towards your target.

***Confirm with your health care professional by how much and how often it is safe to adjust.

Post meal blood glucose level over your target is related to either the pre meal bolus insulin or the appropriate portion of the mixed insulin. e.g if your post breakfast blood glucose level is over target then the pre breakfast dose of insulin may need to be adjusted upwards.

If using a mixed insulin the problem with increasing the pre-breakfast fast acting insulin is that you will also (by nature of it being a mixed insulin) have to adjust the long ting insulin- and this could cause some low blood glucose levels later in the day.

If using the mixed insulin and the blood glucose level 2 hours after lunch is the problem, then the insulin pre breakfast may need to be increased – and this may lead to a low blood glucose level after breakfast.

Discussing with your doctor, and then monitoring your blood glucose level pre and post meal until the correct dosing is achieved is a safe method of reaching your target blood glucose level.

At least weekly dose assessment is suggested if you have not reached your blood glucose level targets.

With good self care knowledge everything is possible.

In some states of Australia (and in the UK) consider finding and enrolling in a DAFNE course. DAFNE stands for Dose Adjustment for Normal Eating.

Although designed for people living with type 1 diabetes, this course or something similar would be of great help to those wanting to reach their health care goals.

Medications – Prednisone 

It isn’t unusual for people with diabetes to sometimes require corticosteroid treatment. Corticosteroids, or steroids for short, are used to reduce inflammation and suppress the immune system. They are often a last resort for a wide variety of conditions, in everything from asthma, to allergy attacks to arthritis and ulcerative colitis. Steroids are also prescribed to prevent the immune system from seeing donated organs as foreign bodies and rejecting them after an organ transplant. One of the most commonly used steroids is prednisone.

Prednisone induces elevated glucose levels by stimulating glucose secretion by the liver as well as reducing glucose transport into adipose and muscle cells. The overall effect is a reduction in glucose clearance. Elevated glucose levels can lead to glucose toxicity further impairing insulin secretion. Prednisone can also impair GLUT-2 expression. GlUT-2 is a protein mediated glucose transporter that ferries glucose across cell membranes. That means that people with diabetes taking prednisone are likely to see a significant bump in their blood glucose numbers depending on the dose of steroid given.

One of the most difficult things about taking prednisone is that it doesn’t elevate glucose readings consistently throughout the day. Prednisone taken in the morning usually doesn’t cause glucose levels to start to rise until lunch time. Blood glucose readings usually stay high through the early evening hours and then decline over night. Many people have normal or low glucose readings in the morning while taking prednisone.

If you are prescribed prednisone talk to your endocrinologist about how to adjust your blood glucose medication/s – especially doses of insulin.

The good news about prednisone is that it is cleared from the system fairly rapidly and once you stop taking it, blood glucose levels return to normal fairly rapidly.

One of our community writes:

Hi there, I’ve been doing this for a long time, one of  the best things I ever did was get a blood glucose meter. Once you have it set up you can confidently monitor and adjust as required, it produces excellent reports that you can print and take to your doctor. Over time you will learn to simply look at a meal and calculate your insulin needs. In the end the answer is to monitor often and listen to what your body is telling you, hope this helps

***NOTE: Always Discuss your self care plans with your health care professionals before making changes, especially with insulin dose adjustments. The comments here are made as a general guideline and not for an individual to follow without support from their usual diabetes  team.***

Kind Regards

David, Diabetes Educator