Advanced Diabetes Education Workshop
Presented by LMC Diabetes and Endocrinology
LMC Diabetes
Objectives
1.
2.
3.
4.
5.
6.
Review of oral therapy for type 2 diabetes
Why do people start Insulin
Supporting a patient starting insulin
Types of Insulin and Titrating Insulin
MDI
Carb Counting, Insulin to Carb Ratio and Insulin Sensitivity
Factor
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Review of Oral Diabetes Medication
According to CDA 2013 GPG:
• Monotherapy roughly reduces A1C by 0.5 to 1.5%
• Combination therapy may provide a drop in A1c > 1.5%
• The higher the A1C, the larger effect seen by the use of oral
agent (s).
• As A1C comes closer to target, pc blood sugars become more
important to keep in target
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Why is insulin initiated?
Different reasons:
1. Individuals with symptomatic hyperglycemia and metabolic
decompensation should receive an initial anti-hyperglycemic
regimen containing insulin
2. Maxed out on oral therapy
3. BS difficult to control with oral agents
4. Side effects from oral agents
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Insulin
Type of
Insulin
Starting Dose
Titration
BG to use for
assessment for
titration
Oral Meds
Basal
Typically 10 units
(may be smaller if patient
is elderly and of normal
weight)
1 unit once a day, OR 2
units every 2 days until FBS
target of 4.0-7.0 mmol/L is
reached
FBS
Physician to decide –
typically d/c
secretagogue and keep
metformin
Pre-mixed
5 to 10 units once or
twice daily (pre-breakfast
and/or pre-supper).
1 -2 units for both
injections until targets met
of 4.0-7.0 mmol/L prebreakfast and pre-dinner
FBS from pre-dinner dose
Pre-dinner blood sugar
from AM dose
Physician to decide –
typically d/c
secretagogue and keep
metformin
Basal/Bolus
Total Daily Dose = 0.3 to
0.5 units/kg
40% basal insulin
20% bolus at breakfast
20% bolus at lunch
20% bolus at dinner
Basal first
Work towards using insulin
to carb ratios and insulin
sensitivity factors
Basal – FBS
Bolus – 2 hr pc meal
blood sugars
To be discontinued
except metformin at
times
Patients should be taught how to self titrate. Regular follow ups should be
performed every couple days to monitor hypoglycemia and hyperglycemia.
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Feelings around starting insulin
Common feelings: Nervous, Afraid, Angry, Guilty
How to approach patients starting insulin:
1. Acknowledge their emotions – ask them how they are feeling
2. Remember what is routine for you is VERY NEW to them!
3. Explain physiologically why they are starting insulin in a
sympathetic manner
4. Provide reassurance that you are there for support and
provide your contact information
LMC Diabetes
Activity
Female Patient AZ comes to see you:
• BMI = 32, waist 101 cm
• Diabetes for 7 years
• Maxed out on triple therapy
• SMBG: FBS 9-11 and periodically testing throughout the day –
usually around 6-8 mmol/L when they test
• A1C 8.2%
• Has tried to lose weight – lifestyle hx reveals fair-good diet with
limited exercise – she is very aware of what she needs to do
from a lifestyle perspective
• Patient is seeing the physician after you
What do you think the physician will say? What do you suggest?
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Activity Answer
1. Reinforce lifestyle changes
2. Discuss with physician initiating insulin – triple therapy is
failing with A1C 8.2%
3. Physician sees patient – agrees to initiate insulin
• …………… (cont’d)
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Basal Insulin Activity
Physician suggests Levemir 10 units HS
Questions:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Outline how you would approach the insulin start consultation?
Why is the patient starting insulin?
How should the patient titrate?
Approx. how long does basal insulin last in the body?
How can you assess if it is the right dose?
Where should the patient inject?
When should the patient test and inject?
What is the main side effect of insulin?
Where should the insulin be stored (both current and unopened)?
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Basal Insulin Activity - Answer
1. Outline how you would approach the insulin start
consultation?
A: Ask AZ how she is feeling about starting insulin. Explain to her
how the session will proceed : “Today I am going to start you
on insulin. I am here to help you through this and am always
available for questions. Today we will talk about what insulin
is, why you are starting insulin, the type of insulin you are
starting on, how to inject, storage of insulin, driving
instructions, perform a practice injection, and dose and
titration instructions”.
• Explain why she is starting insulin and the implications of having
an elevated A1C
• Let her know when you will be checking in her with her again –
2 days from now
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Basal Insulin Activity – Answers cont’d
Answers to Questions:
2. Why is the patient starting insulin?
A1C is 8.2% and she is maxed out on oral therapy
3. How should the patient titrate?
2 units every 2 days until FBS is <7
4. Approx. how long does basal insulin last in the body?
Approx 22-26 hrs
5. How can you assess if it is the right dose?
FBS
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Basal Insulin Activity – Answers cont’d
Answers to Questions:
6. Where should the patient inject?
Best spot is abdomen; other sites: back of the upper arms, the
upper buttocks or hips, and the outer side of the thighs
7. When should the patient test and inject?
Test HS and FBS and inject at approx same time at night before bed
8. What is the main side effect of insulin?
Hypoglycemia
9. Where should the insulin be stored (current and unopened)?
Insulin currently being used  room temperature;
Unopened  in the fridge
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Mixed Insulin Activity
Patient BR: The Endocrinologist is starting the patient on Mix 25
15 units BID. AIC was 9.2%
Questions?
1. Why would a doctor start a patient on Mix 25 versus the
other insulin?
2. When should the patient test and inject?
3. When should the patient change the insulin cartridge?
4. How should you titrate the insulin?
5. What dietary issues do you need to make sure they are
following?
LMC Diabetes
Mixed Insulin Activity - Answers
1. Why would a doctor start a patient on Mix 25 versus the
other insulin?
Need mealtime coverage as well
2. When should the patient test and inject?
Before each injection and 2 hrs after breakfast and dinner
and inject 10-15 minutes before the meal
3. When should the patient change the insulin cartridge?
If not finished before 28 days, then every 28 days.
LMC Diabetes
Mixed Insulin Activity - Answers
4. How should you titrate the insulin?
Individualized – but 1-2 units every 2 days until pre breakfast
and pre dinner blood sugars are between 4-7 mmol/L.
5. What dietary issues do you need to make sure they are
following?
No skipping meals, and eating appropriate portions of carbs
at breakfast and lunch to avoid hypoglycemia
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MDI Activity
Patient CW: The Endocrinologist is seeing a pt with an AIC of 10.3%
and plans to switch their therapy from orals to insulin. They start
the patient on MDI with 6 units of Novorapid q meals and 12 units
of Levemir qHS..
Questions?
1.
2.
3.
4.
5.
6.
7.
Why would a patient benefit from MDI?
How do you think the patient feels?
How should you titrate the insulin?
How can you assess if it is the right dose?
When should the patient test and inject?
When does the Novorapid start to work and approximately how long does the
Novorapid last in the body?
What basic dietary issues do you need to make sure they are following?
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MDI Activity - Answer
1. Why would a patient benefit from MDI?
Flexibility
2. How do you think the patient feels?
Major lifestyle change – very nervous
3. How should you titrate the insulin?
Basal first and then rapid –1-2 units at a time
4. How can you assess if it is the right dose?
With testing
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MDI Activity - Answer
5. When should the patient test and inject?
Test: Always before each injection and ideally 2 hrs after each
meal while titrating doses
Inject: 10-15 minutes before a meal
6. When does the Novorapid start to work and approximately
how long does the Novorapid last in the body?
Within 10-15 min and lasts 4-5 hrs in the body
7. What basic dietary issues do you need to make sure they are
following?
Consistent amount of carbs at each meal from day to day
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Insulin to Carb Ratio(IC) and Insulin Sensitivity
Factor (ISF):
A patient is ready to use I:C and ISF:
• Once a he/she has been on MDI and they are interested in
adjusting their own insulin based on their food intake
Insulin to carb ratio:
• A measurement of how much one unit of insulin for will cover
a specified number of carbohydrate grams
Insulin Sensitivity Factor:
• A measurement of how much one unit of insulin will reduce
blood sugars in mmol/L
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4 steps to Accomplish I:C and ISF
•
•
•
•
Step 1:
Step 2:
Step 3:
Step 4:
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Master Carbohydrate Counting
Calculate I:C
Calculate ISF
Put it all together
I:C and ISF Facts
•
•
•
•
•
•
•
•
To use the I:C and ISF, patient must be on a basal and bolus
regimen
Only adjust the bolus insulin for I:C and ISF – never adjust basal
Bolus insulin lasts 4-5 hrs in the body
Very individualized and the patient is the expert!
Patient must be willing to carbohydrate count
Patient must be willing to work at figuring out the I:C and ISF by
recording intake, insulin dosage, and testing BS ac and pc meals
A ½ unit pen may help with accuracy for patients
Patients may have a different I:C and/or ISF at different times of
day
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Insulin to Carb Ratio – Mastering Carbohydrate
Counting
Carbohydrate Counting Review:
1. What is a Carb? - Grains, fruits, milk, and sweets
2. How to figure out amount of Carbohydrates in Food:
A. Beyond the Basics – ½ cup cooked pasta = 15 grams, 1
small apple = 15 grams…….
B. Estimate portions: Hockey Puck (1/2 cup), Golf Ball (1/3 cup), Tennis
Ball (3/4 cup), Baseball (1 cup), Deck of Cards (3 oz), 6 Dice (1 oz), 1 fist = ~ 1
cup, 2 handfuls = ~ 2 cups
C. Use Food Labels – BEST WAY TO CARB COUNT
• Most accurate
• Every gram counts!
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Carb Counting Cont’d
Reading Food Labels cont’d:
• Subtract fibre from total carbohydrate grams
• Subtract Sugar alcohols from total carbohydrate grams
Other facts to consider with carb counting:
1. Choose low GI (glycemic index) foods
2. Have balanced meals with protein , fat and fibre
• Both low GI foods and balanced meals slow down absorption
of food and match the 4-5 hrs of the rapid insulin in the body
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Activity
Mr. ES is in your office…
• Pre-breakfast blood sugar = 6.2
• Breakfast: 1 slice whole wheat toast, 1 tsp non-hydrogenated
margarine, and ½ cup OJ = 30 grams carbs, patient took 2
units of insulin based on I:C of 1:15
• 2 hr pc blood sugar = 11.1
• Pre-lunch blood sugar = 7.1
Questions?
1. Why is the 2 hr pc 11.1 and the pre-lunch 7.1?
2. What do you need to change to get better BS results?
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Activity Answer
• Breakfast meal is high glycemic index and not balanced
How to change the breakfast:
• Add protein - more balanced with carbs, protein and fat
• Switch orange juice to an orange – lower GI
• Overall the addition of protein and switch to lower GI fruit will
slow down the absorption of the carbs  match the rapid
insulin better
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Calculating the Insulin to Carb Ratio
1. Have at least one days worth of carb intake from your
patient:
• Option 1: have patient bring in 3 days of typical eating
• Option 2: record a usual day of eating with them
2. Teach patient how to carb count and have them carb count
their food record/typical day (during their session with you)
3. Record how much insulin the patient takes before each meal
and before bedtime, if their blood sugars were in target
when they tested (the goal is not to have them include
“extra” insulin they use for correcting high blood sugars)
• Note: if patient is always “high” or “low” then use their
current numbers, but keep this in mind when calculating
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Calculating the Insulin to Carb Ratio
• Three methods to use for calculating the I:C:
• Method 1: 480 Rule
480/TTD(Total Daily Dose) _____of insulin units = _____
• Method 2: Usual Carbs
Actual Carbs Eaten ÷ Actual Meal Bolus Dose
• B= _____g Carbs ÷ _____ U insulin = 1 U for every _____ g Carbs
• L= _____g Carbs ÷ _____ U insulin = 1 U for every _____ g Carbs
• D= _____g Carbs ÷ _____ U insulin = 1 U for every _____ g Carbs
Method 3: Average Carbs
• Average Carbs/day = ______÷ total daily bolus requirement______ = 1
unit for every _____ g Carbs
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Which I:C method to try?
1. The patient should ask themselves – which one are they most
comfortable with?
2. Allow the patient to run through a scenario using each method and see
which insulin dose seems the most realistic?
3. If method 2 seems like it works – that will be the most accurate
4. If patient’s blood sugars are inconsistent and you don’t know where to
start, use method 1
5. If all 3 methods are giving different numbers, find a happy medium
6. If a patient is always “high” use a lower I:C then they have been using
7. If a patient is always “low” use a higher I:C then they have been using
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……and now the Insulin Sensitivity Factor
Calculating the ISF:
Formula:
100/TDD ___=___. Therefore, 1 unit of rapid acting insulin will ↓ BS ____
mmol/L
Ie. TDD = 50
ISF = 100/50 = 2. Therefore, 1 unit of rapid acting insulin will ↓ BS by 2 mmol/L.
Using the ISF:
Correction Dose: (Current BG – goal BG ) ÷ ISF ____ = _____ U extra insulin to take
with meal.
Ie. Current BS = 12, ISF = 2
Correction Dose: (12-6 (goal BS)) ÷ 2= 3 U extra insulin to take with meal.
NOTE:
• A GOAL BS of 6.0 is a safe target for pre-meal BS
• A GOAL BS of 8.0 is a safe target for a pre-meal BS but pc snack. (this is a tough
concept to teach)
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Putting the two together…….
1. Count your carbs
2. Divide carbs by your I:C
Units of insulin
based on carb
intake
Do not round
3. Test your blood sugars
4. If above target, correct BS
Units of insulin
based on blood
sugar
Do not round
3. Calculate insulin units from #2 and #4 for total insulin needed
at this meal
Total insulin units
Round
to take
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Putting the two together…….
1. Count your carbs
2. Divide carbs by your I:C
Units of insulin
based on carb
intake
Do not round
3. Test your blood sugars
4. If above target, correct BS
Units of insulin
based on blood
sugar
= 45 grams
=45/9
=5 Units
=12.0
ISF = 3 (12.0-6) / 3
=2 Units
Do not round
3. Calculate insulin units from #2 and #4 for total insulin
needed at this meal
Round
5 + 2 = 7 total units
Total insulin units
to take
of insulin
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Useful Tips for IC and ISF
1. Do not correct a 2 hrs pc blood sugar as the patient will get
insulin stacking and may have a hypoglycemic reaction
2. If your 2 hrs pc meal test is > 10 mmol/L – the patient has to
ask themselves – what did I eat? Did I count the carbs
properly? Was the food high GI? Was my meal balanced?
3. If you pre-meal blood sugar is above 4-7, did you just have a
snack 2 hrs before – is this really a post meal/snack blood
sugar? If so, use 8.0 as a target, not 6.0 when correcting
4. Use a half unit pen
5. Limit snacks to 15 grams of carbs or less until I:C and ISF
have been figured out
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Now that you are done…..Let’s see if it works Testing the I:C
Have the patient do the following:
1. Use the I:C and ISF that you and the patient had calculated
and apply it
2. Record food intake – carb amounts, including timing of meals
and snacks for 3 days
3. Record insulin intake for those 3 days
4. Test 7 times/day – before each meal and 2 hrs after each
meal, along with HS
At next appointment, review, adjust and try again!
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I:C AND ISF Activity
Patient DS Food diary reveals:
• Breakfast: 1.5 cups of Special K cereal, 1 cup milk
• Lunch: Tuna Sandwich: 2 slices rye bread, 1 cup skim milk,
Green Salad with 1 T balsamic dressing
• Afternoon Snack: 1 small banana, 7 soda crackers, 1 oz
mozzarella cheese,
• Dinner: 5 oz of chicken with olive oil salt and pepper, 1 ear of
corn, 1 cup broccoli, 1 small apple
Activity:
1. Count the carbs
2. Any other suggestions?
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IC AND ISF Activity Answer
Patient DS Food diary reveals:
• Breakfast: 45 grams
• Lunch: 47 grams
• Afternoon Snack: 30 grams
• Dinner: 45 grams
Suggestions:
1. Balance out breakfast with protein or fibre
2. Limit afternoon snack to 15 grams
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I:C Activity
Her normal dosages: 5 units bolus/meal, 18 units basal HS, TDD = 33 units
Calculate all 3 methods:
• Method 1: 480 Rule
480/TTD _____U = _____
• Method 2: Usual Carbs
Actual Carbs Eaten ÷ Actual Meal Bolus Dose
• B= _____g Carbs ÷ _____ U insulin = 1 U for every _____ g Carbs
• L= _____g Carbs ÷ _____ U insulin = 1 U for every _____ g Carbs
• D= _____g Carbs ÷ _____ U insulin = 1 U for every _____ g Carbs
Method 3: Average Carbs
• Average Carbs/day = ______÷ total daily bolus requirement______ = 1 unit for
every _____ g Carbs
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Activity: Calculating The I:C - Answer
Patient DS dosages: 5 units bolus/meal, 18 units basal HS, TDD = 33 units
Method 1: 480 Rule
480/TTD (33)U = 14.5
• Method 2: Usual Carbs
Actual Carbs Eaten ÷ Actual Meal Bolus Dose
• B= 45 g Carbs ÷ 5 U insulin = 1 U for every 9 g Carbs
• L= 45 g Carbs ÷ 5 U insulin = 1 U for every 9 g Carbs
• D= 45 g Carbs ÷ 5 U insulin = 1 U for every 9 g Carbs
Method 3: Average Carbs
• Average Carbs/day = 135 ÷ total daily bolus requirement 15= 1 unit for every 15 g
Carbs
WHICH METHOD WOULD YOU USE?
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Activity: Answer Cont’d
• Use Method 2!
• Now Calculate the ISF:
100/TDD _____ = ______. Therefore, 1 unit of rapid acting
insulin will ↓ BS _____ mmol/L
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Activity Cont’d
100/TDD 33 = 3. Therefore, 1 unit of rapid acting insulin will ↓
BS 3 mmol/L
Final Summary of the I:C and ISF for the patient to use:
I:C
B=9
L=9
D=9
ISF = 3
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Activity Cont’d
Scenario Questions based on the I:C of 1:9/ meal and ISF of 3
1. Lunch– premeal sugar is 8.2 mmol/L, total carb intake is 35
grams – how much insulin should she take?
2. Dinner - Pre-dinner sugar is 12.2 mmol/L – had snack 2 hrs
before of an apple, total dinner carb intake is 62 grams – how
much insulin should she take?
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Activity cont’d – Lunch Answer
1. Grams of carbohydrates = 35g
2. Divide carbs by your I:C - 9
3.8
3. Blood Sugar = 8.3 mmol/L
4. Use ISF: (8.3 – 6)/3 =
0.77
3. Calculate insulin units from #2 and #4 for total insulin needed at
this meal
I would have patient have a half unit pen and
4.6
take 4.5 units
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Activity cont’d – Dinner Answer
1. Grams of carbs = 62g
2. Divide carbs by your I:C - 9
6.8
3. Blood Sugar = 12.2 mmol/L
4. Calculate ISF = (12.2 – 8)/3 =
1.4
3. Calculate insulin units from #2 and #4 for total insulin needed at
this meal
I would have the patient take 8 units
8.2
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Other Variables to consider with insulin
1. Change in weight – weight gain requires more insulin and weight loss
requires less.
2. Change in weather or season – warmer months people tend to be more
active and insulin is more sensitive in warmer months; therefore, a lower
TDD may be necessary.
3. Menstruation – many women will find that their need for insulin will rise
in the days before their menstrual period beings.
4. Illness – a higher TDD with both larger boluses and higher basal rates is
often needed to counteract this physical stress.
5. Travel – insulin may need to be adjusted when traveling over >3 time
zones.
6. Problems with glucometer – may be using insufficient amount of blood,
not coding, meter accuracy
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Conclusion
• Insulin is a common treatment in diabetes management
• As the diabetes educator, it is important to be a genuine
source of support for the patient
• Every patient is different – individualize their care and make
changes accordingly
• With time & insulin titrations, the I:C and ISF become easier to
manage and adjust
• Help your patients manage their blood sugar with insulin
starts, titrations, and ongoing management for the ultimate
goal of tighter control, and a healthier and happier lifestyle!
LMC Diabetes