multiple insulin injection therapy

• Goals of multiple insulin injection.• High light of treatment method... • Type 1 diabetes is dependent on insulin for survival.• Insulin is classified by source or duration of action..

• Goals of multiple insulin injection.

• High light of treatment method.

• Glycemic control effect.

• Elimination of hyperglycemia and it’s symptoms.

• Prevention of chronic complications.

Additional Goals:

• Maintaining desirable weight.

• Maintaining normal growth and sexual maturation.

• Maintaining psychosocial well-being.

• Achieving normal fertility and pregnancy.

• Sustaining normal family and sexual life.

• Type 1 diabetes is dependent on insulin for survival.

• Insulin is classified by source or duration of action.

• Human insulin has less allergy or lipoatrophy.

• More than one injection is needed and different types.

• Proper action During honeymoon phase.

• The commonest side effect is hypoglycemia.

Nutrition:

• Enable near normal blood glucose level.

• Maintain a reasonable body weight.

• Protein 10-20%, Fat 15-25%, Carbohydrate 65%.

• Fibers, vitamins, and minerals.

• Food exchanges or carbohydrate counting.

• Total daily calorie intake adjustment.

Exercise:

• Should be integrated.

• Weight control and improve well being.

• Pre-exercise medical evaluation.

Monitoring:

• Glucometer use SMBG to monitor blood glucose level.

• Adjustment of insulin, diet, and exercise.

• Urine testing for both glucose and ketones.

• HbA1c the best index for control.

35 30 25

40 35 30

Carbohydrate 100 gm Protein (10%) 15 gm Fat (25%) 17 gm

Diet Carbohy Protein Fat _ Arabian bread 30 gm - - Cheese 5 gm 10 gm 10 gm Honey 50 gm 2 gm 3 gm Glass of milk 10 gm 5 gm 5 gm_

Total 95 gm 17 gm 18 gm

Carbohydrate (65%) 520 Protein (10%) 80

Carbohydrate 130 gm Protein (10%) 20 gm Fat (25%) 22 gm

Diet Carbohy Protein Fat _ Rice 80 gm - 6 gm chicken 5 gm 15 gm 12 gm Salad 30 gm 4 gm 4 gm Orange 10 gm - - _

Total 125 gm 19 gm 22 gm

Carbohydrate (65%) 260 Protein (10%) 40

Carbohydrate 65 gm Protein (10%) 10 gm Fat (25%) 11 gm

Diet Carbohy Protein Fat _ Tuna sandwich 45 gm 12 gm 10 gm Apple 15 gm - - Tea - - - _

Total 95 gm 17 gm 18 gm

60 Kg X 30 kcal = 1800 kcal

Breakfast 600 kcal Lunch 800 kcal Dinner 400 kcal

The total calories intake depends on patients age

and activity but have to related to the desirable

body weight.

Total daily calories = IBW X Estimated daily energy

• Add 300 kcal/day during pregnancy.

• Add 500 kcal/day during lactation.

Fibers, sweeteners, vitamins, and minerals.

- The shape of glucose curve.

- The diet and exercise.

0 10 20

INSULIN TYPES DURATION OF ACTION

Very rapid Lispro / Novo rapid 10-15 min 2-3 hrs Rapid Crystalline zinc (CZI) 30-45 min 4-6 hrs Intermediate Neutral Protamine

Hagedorn (NPH) 1-2 hrs 6-12 hrs

Long acting Ultralente zinc 6-8 hrs 18 hrs

Lantus (glargine) 4-8 hrs 24 hrs Premixed 80% NPH+20%CZI 30-45 min 6-12 hrs

70% NPH+30%CZI 30-45 min 6-12 hrs 50% NPH+50%CZI 30-45 min 6-12 hrs

Very rapid Lispro / Novo rapid Yes (2) Rapid Crystalline zinc (CZI) Yes (2)

Intermediate Neutral Protamine Yes (2)

Lente zinc Yes (2)

Long acting Ultralente zinc No

Lantus (glargine) No_

Adapted from Polonsky et al 1988

Dinner NPH Breakfast Lunch

Simulated s.c injected insulin aspart + NPH Meal

  

 

Two doses:

The usual dosing commonly used.

Initial insulin therapy

50 150

   

Four doses:

Brittle diabetic patient.

Pregnant mothers specially type 1.

50 150

  



Four doses:

Brittle diabetic patient.

Pregnant mothers specially type 1.

Motivated patients.

50 150

  

Three doses:

Used for active patients.

Patients taking two main meals.

 

Two doses:

The usual dosing commonly used.

Initial insulin therapy

50 150

  

Three doses:

Used for active patients.

Patients taking two main meals.

50 150

   

Four doses:

Brittle diabetic patient.

Pregnant mothers specially type 1.

50 150

  



Four doses:

Brittle diabetic patient.

Pregnant mothers specially type 1.

Motivated patients.

Blood Glucose Curve

Diabetic week end day

Glucose variations in our culture:

• Regular and NPH use twice daily the commonest regimen used.

• Premixed with different concentration (30/70, 40/60, 50/50).

• Lunch is the biggest meal usually but no insulin dosing.

Cause:

• NPH evening dose

• ? Late sleep Effect:

Treat by moving am dose late and regular

dose pre-supper and another dose pre bed

• Counter regulatory hormones response to hypoglycemia at med-night.

• Increase in hepatic glucose production.

• Insulin resistance because of the Counter regulatory hormones.

Treatment:

• Decrease pre-supper intermediate insulin.

• Defer the dose to 9 PM.

• Change or start pre-bed snack.

• Less insulin at bed time.

• More food at bed time.

• Not using NPH at night.

Treatment:

• Use enough dose.

• Reduce bed time snack.

• Add NPH pre-supper.