Tips and Tools for Managing Diabetes Bonnie Dunham, RD,CDE ETSU OB/GYN

One Touch Ultra 2 Meter $ 65 at Walmart All meter strips cost about $50 for 50 strips, Lancets are about $10 for 100 gauge ranges from 26-30 altho BD makes an ultra fine which is 33 gauge

One Touch Ultra Mini $19 at Walmart, only store 50 BG results

Freestyle Flash Meter $39 at walmart

Blood Sample Size Most meters now use a tiny sample, the One touch uses 1 microliter and the Freestyle 3/10 of a microliter

How Meters Measure Blood Glucose Today's blood glucose meters use an enzyme found in the blood to measure glucose levels. The glucose in a drop of blood placed on a test strip reacts with the enzyme, and this reaction is measured by an electric current generated by the reaction.

Applying Blood to Test strip Reference : One Touch Ultra 2 Owner’s Booklet

Alternate Site Testing Testing afingertip sample better identifies hypoglycemia Reference: One Touch Ultra 2 Owner’s Booklet

Factors Contributing to Innaccurate Blood Glucose Readings Testing at a low temp may give a BG lower than the actual BG Reference: One Touch Ultra 2 Owner’s Booklet

Testing Errors Problems With Strips Reference: One Touch Ultra 2 Owner’s Booklet

Common Blood Glucose Testing Errors Insufficient blood sample Used or defective strip Fingertip not clean or dry Fabricated readings

Comparing Meter and Lab Results Both meters and lab results are expressed as plasma values . Most meters are accurate to within 20% of lab values

Procedure for Comparing Meter and Lab Values Reference: One Touch Ultra 2 Owner’s Booklet

Writing Prescriptions for Meters Blood Glucose Meter Test Strips – Disp # 200 Lancets – Disp # 200 ( two boxes) Alcohol Pads – Disp # 1 box Test BG at least 4-5 x’s daily, fasting, 2 hrs pp, and prn While most pts only need about120 test strips, if you write for one box, they wil run out. Writing for more also permits them to test for hypoglycemis and at 3Am if needed

Blood Glucose Goals Fasting <95mg/dl 2-hour postprandial < 120 mg/dl Source: ACOG Guidelines

Blood Glucose Log DATE:_______ DATE:______   DATE:_______ DATE:______ BEFORE BREAKFAST BLOOD SUGAR BREAKFAST 2 Hour After BREAKFAST Blood Sugar Result SNACK LUNCH 2 Hour After LUNCH Blood Sugar Result DINNER 2 Hour After DINNER Blood Sugar Result

Insulin Injection 1000 units per vial

Choosing Syringe Size 100 syringes per box, if you anticipate increasing insulin dose and you’re close to the max volume per syringe, go with the larger size http://www.bddiabetes.com/us/main.aspx?cat=3&id=553

NovoNordisk Flex Pen Come in boxes of 5 300 ml pens for a total of 1500 units insulin Cost more, but lessneedle fear and pt does not get syringes, also get more accurate dosing, no bubbles as in syringe, requires less skill

Pen Needles Come in boxes of 100

Writing Insulin Prescriptions Estimate Insulin Dose For Type 1 diabetes, adjust current dosage based upon blood glucose records. Dosage for pts within 20% IBW are usually .5-1.0 units/kg For Type 2 diabetes and Gestational Diabetes, needs vary depending on degree of insulin deficiency and insulin resistance Dosage ranges from .7-1.0 units/kg but may be much higher in obese individuals Reference: A CORE Curriculum for Diabetes Education, 4th edition, Diabetes in the Life Cycle and Research, American Association of Diabetes Educators 2001

Insulin Requirements Throughout Gestation First Trimester 0.7 units/kg Second trimester 0.8 units/kg Third trimester 0.9-1.0 units/kg Jovanoic-Peterson L ed, Medical Management of Pregnancy Complicated by Diabetes. 3 rd ed. Alexandria, VA: American Diabetes Association;2000

Insulin Requirements Source: http://www.diabetesselfmanagement.com/pdfs/pdf_1597.pdf

Insulin Types and Actions http://diabetes.about.com/od/equipmentandbreakthroughs/a/insulinchart.htm

NPH and Regular Insulin

Two Split-Mixed Daily Injections Allows for coverage with only two injections when using vial and syringe Lispro is Humalog, the bottom chart is labeled lispro but Aspart (trade name Novolog) has a similar type of action Diabetes Management Therapies, A CORE curriculum for Diabetes Education,4th edition, 2001.

Three Multiple Dose Daily Injections Reduces the risk of nocturnal hypoglycemia and allows for better insulin coverage in the early morning Diabetes Management Therapies, A CORE curriculum for Diabetes Education,4th edition, 2001.

Calculating Insulin Dosages for a Split Mixed Regimen When using intermediate insulin (NPH) and a short-acting (Regular) or rapid –acting insulin (Humalog or Novolog) usually 2/3 of the daily dose is given in the morning using a ratio of 1 part rapid or short-acting insulin to 2 parts intermediate and 1/3 is given in the evening using a 1:1 or 1:2 ratio Sometimes a pt may have PP BG within target but the fasting is elevated and we can give a bedtime dose of NPH only

Sample Calculations Weight 198# (90 kg) Determine insulin requirement .8 units X 90 kg =72 units 2/3 AM dose = 48 u , 1/3 PM dose =24 u 2/3 AM dose is NPH = 32 u , 1/3 is short or rapid-acting = 16 u 1/2 PM dose is NPH = 12 u, 1/2 = short or rapid-acting = 12u or use 1: 2 ratio giving 16 u NPH and 8 R AM = 48 units (32 NPH + 16 R) PM = 24 units (12 NPH + 12 R) 72 total 44 NPH + 28 R

Writing Prescriptions for Insulin To estimate amount of insulin needed for one month, divide daily needs into 1000 for vials and 1500 for pens 33 units insulin/day X 30 days = 990 units (one vial /month or one box of pens) 66 units insulin/day X 30 days = 1980 units ( two vials/month or two boxes of pens) 100 units insulin /day X 30 days = 3000 units ( three vials /month or two boxes of pens) These numbers are so close to the total available , you will want to “cushion” with an extra vial to avoid refill calls. TN care and many other insurances won’t give you extra- I’ll discuss this more later

Writing a Prescription Based on Sample Calculations NPH Insulin Disp # 2 vials Regular Insulin Disp # 1 vial Insulin syringes 1cc Disp # 1 box of 100 Initial dose AM 32 u NPH + 16u R PM 12u NPH + 12 u R Insulin dose to be adjusted and increased weekly 44 units NPH X 30 =1320 and 28 units R X 30 =840, if you think you’ll be making huge increases in the R you may want to write for 2 vials,: I’d choose 1 cc syringes because you are close to 50 units in AM dose; round to even numbers because1 cc syringes are marked every other unit. You can specify Novolin or Humalin , just remember to allow subs so rx filled

Insulin Pumps http://www.minimed.com/pumptherapy/whatispumptherapy/howitworks.html

Minimed Insulin Pumps

Omnipod Insulin Pump

Infusion Set Both Animas and Minimed have an auto insertor to inject the cather into the skin. After the needle is withdrawn, the pt has a tiny silicone cather that infuses insulin subcutaneously. It is held in place by adhesive and the pump tubing can be detached at the site to allow pt to bathe, swim or engage in other activities where the pump would be in the way. Remember that when the pt is detached, they are not getting their basal insulin.

Minimed Infusion Site

Animas Infusion Site

Minimed Basal History http://www.minimed.com/pdf/x15_user_guide.pdf

Animas Basal History http://www.animascorp.com/products/pr_insulinpump_IR1250_UserGuide.shtml

Animas Bolus History http://www.animascorp.com/products/pr_insulinpump_IR1250_UserGuide.shtml

Animas Bolus History (continued) http://www.animascorp.com/products/pr_insulinpump_IR1250_UserGuide.shtml

Minimed Bolus History http://www.minimed.com/pdf/x15_user_guide.pdf

Minimed Special Bolus Features Dual Wave delivers a combo of normal bolus and Square wave and is useful when eating a meal with rapidly absorbed CHO and slowly absorbed CHO http://www.minimed.com/pdf/x15_user_guide.pdf

Animas Combo Bolus http://www.animascorp.com/products/userguide/IR1250/chap12.pdf

Minimed Daily Insulin Use http://www.minimed.com/pdf/x15_user_guide.pdf

Animas Total Daily Insulin http://www.animascorp.com/products/pr_insulinpump_IR1250_UserGuide.shtml

Conclusions Be familiar with tools the patients will use to monitor blood sugar & administer insulin. Be aware of potential problems and common errors made by patients. Familiarize yourself with cost factors and how items are dispensed by pharmacies. Customize your solution based upon patient needs, educational level, financial situation, and willingness to comply with the treatment plan.

Tips and Tools for Managing Diabetes Bonnie Dunham, RD,CDE ETSU OB/GYN