3Basal Insulin Regulation Basal Insulin’s One And Only Job Is To Hold Blood Glucose Levels Steady In the Absence of Confounding Influences** Food, Exercise, Bolus Insulin, Unusual Hormonal Conditions (illness, rebounds, menstruation)
4Basal Insulin Regulation Conditions for Testing Basal Rates:No food or bolus for at least 4 hrs priorLast meal/snack low in fatNo food or bolus during test phase (water/diet drinks OK)BG above 80, below 250 throughoutNo lows for previous 12 hrsStay connected, no stopping/suspendingExercise OK up until test phase (if usually performed)No heavy activity during test phaseDo not run test if sick or just prior to/start of period
6Basal Insulin Regulation Average basal profiles** Diabetes Research & Clinical Practice (2005)
7Basal Insulin Regulation Example 1: Sara SmileyCurrently:.30 3am-9am,.25 9am-3amSkipped BreakfastBG results:6am 1098am 20110am 23012pm 224Interpretation:Sharp rise 6am-8amModest Rise 8am-10amStable 10am-12 noonAdjustments:Basal by .1 5a-7aBasal by .05 7a-9aRepeat test from 6a-12p
8Bolus Insulin Regulation I:C Ratios:The correct ratio should match pre-meal BG 3-4 hours (not 2!) after eatingI:C Ratio often varies from meal to meal(bkfst dose > lunch & dinner)
9Bolus Insulin Regulation Correction Boluses:1500-Rule (aggressive)(Total Daily Ins.)/15001800-Rule (conservative)(Total Daily Ins.)/1800May vary day vs. night(nighttime often 50% more than day)
10Physical Activity Adjustments Activity Within 2 Hrs After MealActivity Before or Between MealsShort Duration(<90 Minutes)Mealtime BolusSnack Prior to Activity*Long Duration (>90 Minutes)Basal RateSnack hourly
11Physical Activity Adjustments Meal BolusAdjustment*Low Intensity Cardio 25%Mod. Intensity Cardio 33%High Intensity Cardio 50%Competitive/Anaerobic ???* If activity is after mealBasalAdjustment** Basal rate 50%Start basal reduction 1 hr pre-activity** For activities lasting > 90 Min.
12Physical Activity Adjustments Snacking to prevent low (examples)Carbohydrate Replacement Per 60 Minutes of Activity50 lbs100 lbs150 lbs200 lbs250 lbsSkating7-10g14-20g20-30g28-40g35-50gGymnastics8-12g17-23g25-35g34-46g42-57gSoccer13-17g27-33g40-50g54-66g67-82g
13Physical Activity Adjustments Watch Out for D’OH!(Delayed Onset Hypoglycemia)Following high-intensity exerciseFollowing extended- duration activityMay occur up to 24 hours afterwardsExtra snacks or reduction in basal insulin may be necessary
14Physical Activity Adjustments OK To Disconnect Up To 1 Hour w/ Activity
18DKA Prevention Progression to DKA Higher B.G. + Dehydration Higher B.G.+ More Ketones+ Dehydration **KETOACIDOSIS**
19DKA Prevention Causes of insulin deficiency in Pump Therapy Malabsorption (site problems)Insulin SpoilageTubing or infusion set clogsLeaks where the cartridge connects to the tubingAir pockets in the tubingDislodgement of the canula from beneath the skinImproper or insufficient primingExtended pump suspension or disconnection
28Temporary Basal Rates Alcohol Duration Adjustment Notes 2 hrs per drink-40%Begin after drinking
29Prolonged Boluses Description Normal/Standard Boluses are delivered within a few minutes; peak is approx. 1 hr, duration approx. 4 hoursProlonged boluses are delivered over a period of a couple of hours; peak is delayed/blunted and duration is extended.
30Prolonged Boluses Purpose To do a better job of matching the blood sugar rise caused by slow-digesting foods.
31Prolonged Boluses Applications Very Large Portions Low-Glycemic-Index FoodsMeals/Snacks that take a long time to consume
32Prolonged BolusesOptions for slow-digesting food:Normal Bolus
33Prolonged Boluses Square/Extended Bolus Options for slow-digesting food:Square/Extended Bolus
34Prolonged Boluses Dual/Combination Bolus Options for slow-digesting food:Dual/Combination Bolus
35Alternate Basal Patterns Called Pattern A/B (Medtronic), Prog 2-4 (Animas), Pattern 1-4 (Deltec)Useful when basal changes are needed for several days (or more) in succession
36Alternate Basal Patterns Potential Uses:Menstrual cycle phasesExtended illnessRecovery from surgeryPeriodic use of steroid medicationsSeasonal sportsOff-day vs. work/school-dayExtended travelClimate changes