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

2. 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 altho BD makes an ultra fine which is 33 gauge

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

4. Freestyle Flash Meter
$39 at walmart

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

6. 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.

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

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

9. 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

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

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

12. 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

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

14. 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

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

16. 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

17. Insulin Injection
1000 units per vial

18. 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

19. NovoNordisk Flex Pen
Come in boxes of 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

20. Pen Needles
Come in boxes of 100

21. 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 units/kg
For Type 2 diabetes and Gestational Diabetes, needs vary depending on degree of insulin deficiency and insulin resistance
Dosage ranges from 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

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

23. Insulin Requirements
Source:

24. Insulin Types and Actions

25. NPH and Regular Insulin

26. 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.

27. 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.

28. 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

29. 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 R

30. 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

31. 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

32. Insulin Pumps

33. Minimed Insulin Pumps

34. Omnipod Insulin Pump

35. 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.

36. Minimed Infusion Site

37. Animas Infusion Site

38. Minimed Basal History

39. Animas Basal History

40. Animas Bolus History

41. Animas Bolus History (continued)

42. Minimed Bolus History

43. 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

44. Animas Combo Bolus

45. Minimed Daily Insulin Use

46. Animas Total Daily Insulin

47. 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.

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