Building Competency in Diabetes Education THE ESSENTIALS

BASAL-BOLUS INSULIN THERAPY | 12-57

INSULIN DOSE ADJUSTMENTS

An important key to achieving success with insulin therapy is for diabetes educators to teach, and patients to engage in self-management behaviours, such as pattern management (88). Injecting insulin and recording BG results alone will not improve glycemic control. Reviewing BG records and making adjustments based on pattern management principles is a factor associated with a lower A1C (124). Pattern management is a systematic approach that allows people to identify patterns in their BG results to determine if changes are required to improve control (124). It helps people gain insight into their own personal BG patterns and avoid responding inappropriately to transient variations in BG levels. A pattern is a consistent trend in BG that occurs at the same time of day for at least two out of three days. If a pattern is seen at the same time of day, an adjustment to insulin may be needed (124). However, the person also needs to assess the impact of carbohydrate intake, activity, illness, stress and daily schedule in their problem-solving process to optimize BG control (124. Pattern-management principles are used to find the correct baseline dose. The baseline dose is effective only in the following situations: 1. When BG is in the target range. 2. When the usual food (carbohydrate) will be eaten. 3. When the usual activity is planned. It is important to remember that the usual dose is not expected to be effective unless all three conditions apply. Pattern adjustments are determined while the patient maintains relatively stable carbohydrate intake and activity. See the sample patient handout below (Figure 9). Tips for insulin dose adjustment • Fix the lows first and the highs later. Once the lows are gone, rebound hyperglycemia is often eliminated. • Overnight control is often the hardest to achieve. It is important to get the right basal dose. The correct dose will keep BG between 4 and 7 mmol/L from bedtime to morning without causing a low and usually without requiring a bedtime snack. • To assess for Somogyi (nocturnal hypoglycemia with rebound hyperglycemia in the