Management Of Type 1 Diabetes

By editor | August 30, 2007

Depending on the management program you are in, once the acute state of the diabetes management is controlled you may be discharged from the hospital and asked to return to the doctor on a daily, weekly, or monthly basis, plus receive some education on initial survival skills (how to administer the insulin, how to plan a meal, how to treat a reaction, how to monitOr blood-glucose levels and urine ketones, and when and what to tell the doctor) . You may be asked to return a few weeks or months later for more intensive education. If your stay in the hospital lasts one to two weeks or so, you will receive education and psychological support during this time.

If the hospitalization time is short, the physician will start the total amount of daily insulin delivery at a lower level and increase the dosage until the suitable level of diabetes control is achieved. With the longer hospitalization, the physician will administer what is termed a “physiological’ amount of insulin,” based on the patient’s body size and food intake. The insulin is then lowered on a daily basis until the baseline, or normal, blood-glucose levels are stabilized.

Each method has its pros and cons. The former gives less early support, allowing the person to develop habits that might not be appropriate. But it does get the person back to work or school sooner and into a scheduled life style from which individual needs can be assessed. The latter approach gives more initial psychological and physiological support. With this approach, most programs try to have the person’s daily lifestyle mimicked by the activity and education program planned. This approach also appears to have a longer “honeymoon” period, during which the control of blood sugar may be easily obtained through the use of small amounts of insulin. This is due to the beta cells having recovered some ability to produce insulin internally. It has not been proved that this is better in the long run, but certainly the diabetes is easier to control for a longer period of time (from six months to three or four years).

Whatever the program, it needs to be individualized, with the person’s life style taken into account: When is exercise scheduled? When are the coffee breaks? What time is bedtime? When are meals usually eaten and so forth. The food should be patterned to meet the everyday needs. The insulin is then patterned to get the products of the food (such as glucose or proteins and, indirectly, fats) to go to the places they are supposed to go. As needs and age requirements change, the program must also change. If a person becomes more sedentary, the food intake needs to be decreased and the insulin (or oral agent, for adults) decreased. If too much insulin is given, the person could either have trouble with insulin reactions or may eat to compensate for the symptoms of hunger that occur with the low blood sugar, and thus become overweight. As a child grows and requires more food (not just more carbohydrates, but more total calories), he or she will require more insulin. As the child becomes an adult, stops growing, and requires less food, less insulin will be required.

In the normal non-diabetic person, the body produces a small amount of insulin continuously. This is called basal insulin. The body then produces a burst of insulin after each intake of food. It is this pattern that must be duplicated for the diabetic, whatever treatment regimen is chosen. For people with Type 1, diabetes mellitus (lDDM), this pattern can be duplicated in many ways, with many food patterns and insulin patterns (four, three, or two doses of insulin per day). The minimum requirement for duplicating the normal pattern is three meals, with one to three between meal and bedtime snacks and an insulin pattern of two doses per day (before breakfast or supper) of a mixture of a short acting (Regular) insulin and intermediate acting insulin (NPH or LenteB). These insulins last twice as long as regular insulin, about 12 hours and half as long as long acting insulin, i.e. Ultralente). The two doses of intermediate acting insulin provide the needed 24 hour basal insulin and do a moderate job of supplying the bolus insulin for lunch. The added two doses of short acting insulin with breakfast and supper provide the boluses or bursts for these meals. The two doses are given as mixed insulin before break fast and before supper. Usually, twice as much insulin is given in the A.M. as in the P.M., because two meals are eaten for the A.M. dose and one meal for the P.M. dose. And twice as much intermediate as short-acting insulin is usually given in each dose, since the intermediate insulin must last 12 hours, while the short acting insulin lasts only 6 hours. In many cases, indeed in most cases of Type 1 diabetes after the honeymoon or remission period, we cannot get by with two shots per day. The most common problem is a high fasting blood sugar in the morning upon arising. This is caused by the insulin taken at supper not lasting through the night. If we try to correct this by increasing the supper NPH we frequently cause night time low blood sugars that can have very bad consequences. A better solution to the problem is to split up the supper insulin and give only regular or lispro and give the NPH at bedtime. In this regimen, you must test blood sugar and make the appropriate corrections to the insulin doses. Remember to (1) use the blood sugar measurement after breakfast or pre-lunch to adjust the morning regular insulin, (2) use the blood sugar in the afternoon or pre-supper to adjust the morning NPH insulin, (3) use the after supper blood sugar to adjust the supper regular, and (4) use the fasting blood sugar in the morning to adjust the evening NPH. There is a new insulin called Lispro or Humalog that is very fast acting and can be substituted for the regular in a two ” three” or four-dose-a-day regimen. This insulin is taken with the meal instead of 30 minutes before the meal which adds convenience as well as better control with less problem of low blood sugars. The dose of this insulin can be modified at the meal based on how much food is on the plate and can even be given after the meal, especially for small children with erratic eating patterns. Humalog is a much more physiologic insulin since it is absorbed much more like the food is. It peaks in 1 hour as does the food and is gone in about 3 to 4 hours. It therefore does not carry over to the next meal like regular, which can cause pre, meallow blood sugars. Flexibility, better control, and less low blood sugars makes this a very good insulin for most people who need insulin. Remember, though, : that this is a short, acting insulin and is gone before the next meal so that the blood sugar measurement must be taken 2 hours after the 1 meal instead of before the next meal. A given blood sugar measurement is then used to adjust the preceding insulin dose. Thus patterns of blood sugar are used to adjust the next day’s dose instead of the next dose as is done in sliding scale or algorithm programs that do not work well with Humalog insulin.


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