1. Know the actions of your insulin(s)
Knowing the onset of action, the peak action and duration of action of the insulin(s) that you use to treat your diabetes will help you to know when and how to use your insulin(s) to optimize your blood glucose control. Many people for instance are tempted to correct a high blood glucose level two hours after eating, not considering that the rapid acting insulin they are using (Apidra, Humalog or Novolog) lasts for typically four hours – this can lead to possible overcorrection of the blood glucose level and hypoglycemia (low blood glucose). Know your insulin actions to take the right action!
2. Site rotation of insulin injections is essential
A key element to insulin effectiveness relates to the site in which insulin is injected. Many people with diabetes have ‘favorite’ sites to give their injections or place their pump catheters, often leading to over-use of the site. Over-use of an injection or pump site can lead to the development of hardened areas which can significantly affect the way the insulin is absorbed from the area. Erratic blood glucose levels can result. Also, there is the possibility for infection and / or abscess formation. So let’s get the best from your insulin injection / pump site and rotate sites widely. Areas for injection include the back of the upper arm, abdomen, outer thigh and upper-outer buttock / hip region. Be an equal opportunist!
3. Use the insulin delivery tool that best suits your lifestyle
Insulin therapy is essential for life in Type 1 diabetes. Currently available insulin delivery tools consist of syringes, insulin pens and insulin pumps. The choice of insulin delivery tool is very individualized and should (excluding young children) be left to the individual living with diabetes to decide. There have been many times when the insulin delivery tool being used by the individual has been a significant factor in poor diabetes control – wrong tool for the wrong person. It is essential that all people living with diabetes receive optimal education about all the choices of insulin delivery tools that are available, so that they can make an informed and educated decision. Remember to get updated at least annually because technology is changing very rapidly regarding insulin delivery and blood glucose monitoring devices. Keeping informed keeps you ahead!
4. Correct basal insulin delivery should lead to the greatest flexibility in meal plans
Before the availability of our current injected basal insulins of Lantus and Levemir or if using an insulin pump, typically Apidra, Humalog or Novolog, the insulin choices we had did not provide true basal insulin. Basal insulin refers to background insulin – it helps to control your liver’s output of stored glucose and is the insulin your body uses to control blood glucose levels when you are not eating. If the dose is set correctly, most people should be able to inject their basal insulin dose (syringe, pen or pump) and be able to not eat for 24 hours without their blood glucose level rising or falling more than approximately 30-40mg/dl. If your basal dose is correct, then you have flexibility in the timing of your meals because your basal insulin dose will keep you steady in between the meals you eat, whenever you choose to eat them. Flexibility is key!
5. Matching insulin to the carbohydrate you eat is most physiologic
Except in the cases of hypoglycemia (low blood glucose) or perhaps intensive exercise, insulin is required to cover the carbohydrate that you eat. The dosage of insulin required for carbohydrate coverage will vary depending on the amount and possibly type of carbohydrate eaten, as well as the individual’s specific insulin needs for carbohydrate. Rapid acting insulin (Apidra, Humalog or Novolog) is usually the insulin of choice for carbohydrate coverage because of its rapid onset of action and 4 hour (typically) duration of action. Many people who match insulin to the carbohydrate that they eat have been given a carbohydrate ratio to use. A carbohydrate ratio states how many grams of carbohydrate are covered by 1 unit of rapid acting insulin. Some people may require a different carbohydrate ratio for the various meals of the day or for certain tricky foods, such as sushi, chinese food and high fat foods. Everybody is unique!
6. Monitoring your blood glucose levels is key!
Diabetes cannot be managed successfully by using the ‘How you feel method’ – unfortunately the glucose thermostat is just not that sensitive or specific enough. Blood glucose monitoring is essential. For instance, fasting and pre-meal blood glucose values can give you important information regarding your basal insulin doses and 2 hour post prandial (post meal) blood glucose values can give you valuable data regarding meal coverage. It is very important not to constantly react to specific blood glucose values because you risk a reactive management style. You are best to look for patterns in the blood glucose information and make informed insulin changes based on patterns that you see. This is the key advantage of continuous glucose monitors – pattern recognition. Just like the story of the tortoise and the hare – you will get faster to your desired blood glucose destination by taking a proactive and informed approach rather than a rapid and reactive approach. The tortoise always wins!
September 2009
Kellie Rodriguez, MSN, CDE
Director of Patient Education,
Diabetes Research Institute,
University of Miami