Checking & Adjusting Basal Rates MDI
Adjusting Insulin (MDI): testing & tweaking basal rates
Basal insulin is the background insulin which, at the correct dose, keeps blood glucose steady in the absence of food and exercise. But how can you tell whether the current basal insulin dose is working well or not? Here we look at how to assess the current basal dose in a Multiple Daily Injection (MDI) program, then we outline in detail the process of fine-tuning basal insulin - including the reason why we should check blood sugar in the middle of the night.
Before Reading This Article...
If you have not done so already, we recommend that you read the following WaltzingTheDragon.ca pages on insulin adjustment within Basal-Bolus/MDI programs as background for the information that follows:
Basal insulin is the background insulin which keeps blood glucose steady in the absence of food and exercise. A healthy pancreas secretes a small amount of basal insulin into the bloodstream every few minutes, to match the small amounts of glucose released by the liver on a continuous basis, so that glucose can be used by the body’s cells for basic energy needs. For a person with type 1 diabetes on a Multiple Daily Injections (MDI) program, basal insulin is delivered as long-acting “peakless” insulin, such as Lantus® or Levemir®.
Basal insulin needs vary from person to person, and across the lifespan. Adults and adolescents typically need more basal insulin in the early morning hours to deal with the release of hormones involved in waking (known as the Dawn Phenomenon). Children often need more basal insulin in the late evening hours to deal with the release of growth hormones a few hours after they fall asleep.
Initial Basal Doses
When your child is first diagnosed, her doctor should determine an initial dose of basal insulin that is appropriate for your child’s age, growth stage, and activity level. As she grows, changes will need to be made to these basal insulin doses. Periodically, you may want to test/verify how well the existing basal insulin doses are meeting her current need for insulin. You could then use the results as a basis of discussion with your child’s diabetes health care provider.
Fine-Tuning Basal Doses
Since basal insulin (Lantus® or Levemir®) is supposed to keep blood glucose steady in the absence of food, exercise and bolus insulin, if your child is on an injected insulin program, a good indication of whether or not the current basal dose is accurate is whether blood glucose remains steady overnight (when these factors are absent for longer periods). As such, if your child’s basal dose of insulin is correct, his blood glucose should not vary by more than 2.0 mmol/L from bedtime to waking the next morning (presuming that the conditions outlined below are met).
If you choose to check your child’s current basal dose overnight:
1. Have him eat a healthy supper, avoiding high fat food and restaurant/takeout food. Fat affects blood glucose by causing it to rise over several hours, thereby confounding test results.
2. Have him engage in no more than the usual amount of exercise before bedtime. Limit activity to moderate intensity and duration. Physical activity affects blood glucose by lowering it for up to several hours afterward.
3. Until the next morning, have your child refrain from eating/drinking anything other than water and diet drinks (0 calorie, 0 carb). Even low carb foods and protein can affect blood glucose, thereby confounding the test results.
4. Check blood glucose 3 hours after supper*.
- If the reading is 4.0 mmol/L or less, stop the test and treat the low as usual. You’ll need to wait until another night to test basal rates. (And this may indicate a need to adjust the supper I:C ratio, if this is not an isolated incident.)
- If the reading is 14.0 mmol/L or greater, stop the test and give the usual correction for the high blood glucose. You’ll need to wait until another night to test basal rates. (Again, this may indicate a need to adjust the supper I:C ratio, if this is not an isolated incident.)
- If the reading is between 4.0 and 14.0 mmol/L, proceed with the basal test as outlined in the steps that follow.
5. Check blood glucose again midway through your child’s sleep time* (responding as above if blood glucose is below 4.0 or greater than 14.0).
6. Check blood glucose again when your child wakes up*.
*Times to check blood glucose:
If your child finished eating at 6 pm, you could check blood glucose at 9 pm, 2 am, and 7 am, for example.
7. Assess the test results:
- If blood glucose stayed steady (within 2.0 mmol/L from bedtime to waking), no changes to the basal dose are likely needed at this time.
- If blood glucose dropped more than 2.0 mmol/L from bedtime to waking:
You may choose to decrease the basal dose of Lantus® or Levemir® (by 10%, for example) and repeat the test on the next possible night.
For example, if the bedtime reading was 9.5, middle of the night reading was 8.5, and morning reading was 6.0, and your child’s current dose of Lantus is 6.0U, you could subtract 10% to arrive at 5.4U, round off to 5.5U, and repeat the test with a basal dose of 5.5U.
- If blood glucose rose more than 2.0 mmol/L from bedtime to waking:
You may choose to increase the basal dose Lantus® or Levemir® (by 10%, for example) and repeat the test on the next possible night.
For example, if the bedtime reading was 9.5, middle of the night reading was 11.0, and the morning reading was 12.0, and your child’s current dose of Lantus is 6.0U, you could add 10% to arrive at 6.6U, round off to 6.5U, and repeat the test with a basal dose of 6.5U.
Why Check Blood Glucose in the Middle of the Night?
If we checked blood glucose at bedtime and at wakeup only, and found more than a 2.0 mmol/L rise, there are at least a few possibilities in terms of what happened overnight:
A. blood glucose may have risen steadily;
B. blood glucose may have stayed steady in the first part of the night, followed by a sharp increase in the latter part of the night; or
C. blood glucose may have dropped in the first part of the night and then rose sharply as a result of the preceding low blood glucose.
This last scenario is referred to as a “low rebound” (or, the Simogyi Effect): as a result of a low, the liver releases stored glucose (glycogen), resulting in high blood glucose later. In order to rule out an undetected low, it is essential to check your child’s blood glucose at least once midway through your child’s sleep time.
How we deal with the overnight rise in blood glucose depends on which of the above scenarios actually occurred:
- If blood glucose rose steadily overnight as in A: it makes sense to increase the basal dose (Lantus® or Levemir®).
- If blood glucose remained steady for part of the night and then increased towards morning as in B: you may choose to add a correction of rapid-acting insulin at the appropriate time, OR you could consider adding a bit of intermediate-acting insulin (N/NPH) at bedtime to mediate the problem.
- If blood glucose dropped and then rose as a result, as in C: then a decrease in the basal dose may actually result in lower waking blood glucose readings.
If you would like assistance with sorting out the possibilities, please consult your child’s diabetes health care team.
(If you’re a Type A personality like I am, during a basal test you may choose to do 2 checks in the middle of the night: 12 am and 3 am, for example. ~Michelle)
The above information was reviewed for content accuracy by clinical staff of the Alberta Children’s Hospital Diabetes Clinic.
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Insulini ya msingi (BIS) ni insulini ya msingi ambayo, kwa kipimo sahihi, inadumisha sukari ya damu imara bila chakula na mazoezi. Lakini unawezaje kujua ikiwa kipimo cha sasa cha insulini kinafanya kazi vizuri au la? Hapa tunazingatia jinsi ya kutathmini kipimo cha msingi cha sasa katika mpango wa Multiple Daily Injection (MDI), kisha tunaelezea kwa undani mchakato wa kusawazisha insulini ya msingi - ikiwa ni pamoja na sababu ya nini tunapaswa kuangalia sukari ya damu katikati ya usiku. Kabla ya Kusoma Makala Hii... Kwa wale ambao hawajawahi kufanya hivyo, tunapendekeza kusoma kurasa zifuatazo za WaltzingTheDragon.ca juu ya marekebisho ya insulini ndani ya programu za BasalBolus na MDI kama msingi wa habari ifuatayo: Insulini ya msingi ni insulini ya msingi ambayo inadumisha sukari ya damu imara bila chakula na mazoezi. Pancreas yenye afya huondoa kiasi kidogo cha insulini ya msingi katika mtiririko wa damu kila baada ya dakika chache, ili kufanana na kiasi kidogo cha glukosi iliyotolewa na ini kwa kuendelea, ili glukosi iweze kutumiwa na seli za mwili kwa mahitaji ya msingi ya nishati. Kwa mtu mwenye ugonjwa wa kisukari wa aina ya 1 kwenye mpango wa sindano nyingi za kila siku (MDI), insulini ya msingi hutolewa kama insulini ya muda mrefu ya "peakless" kama vile Lantus au Levemir. Mahitaji ya insulini ya msingi hutofautiana kutoka mtu mmoja hadi mwingine, na katika maisha yote. Watu wazima na vijana kwa kawaida wanahitaji insulini zaidi ya msingi katika masaa ya mapema ya asubuhi ili kukabiliana na kutolewa kwa homoni zinazohusika katika kuamka (jina linalojulikana kama Hali ya Dawn). Watoto wanahitaji insulini ya msingi zaidi usiku wa manane ili kukabiliana na kutolewa kwa homoni za ukuaji saa chache baada ya kulala. Kwa mfano, wakati mtoto wako anapata ugonjwa wa kwanza, daktari wake anapaswa kuamua kipimo cha kwanza cha insulini ya msingi ambayo ni sahihi kwa umri wa mtoto wako, hatua ya ukuaji, na kiwango cha shughuli. Kadiri anavyoendelea kukua, itabidi adhibitiwe kwa kiasi cha insulini. Mara kwa mara, unaweza kutaka kupima au kuthibitisha jinsi dozi zilizopo za insulini za msingi zinavyokidhi mahitaji yake ya sasa ya insulini. Unaweza kutumia matokeo kama msingi wa mazungumzo na mtoa huduma wa afya wa ugonjwa wa kisukari wa mtoto wako. Insulini ya msingi (Lantus au Levemir) inapaswa kudumisha kiwango cha sukari ya damu bila chakula, mazoezi, na insulini ya bolus, kwa hivyo ikiwa mtoto wako ana programu ya insulini ya sindano, dalili nzuri ya ikiwa kipimo cha msingi cha sasa ni sahihi au la ni ikiwa sukari ya damu inabaki sawa usiku kucha (wakati sababu hizi hazipo kwa muda mrefu). Kwa hivyo, ikiwa kipimo cha msingi cha insulini cha mtoto wako ni sahihi, sukari yake ya damu haipaswi kutofautiana zaidi ya 0.2 mmol (mmol) kwa lita kutoka wakati wa kulala hadi kuamka asubuhi inayofuata (kwa kudhani hali zilizoelezwa hapa chini zinatimizwa). Ikiwa unaamua kuangalia kipimo cha msingi cha sasa cha mtoto wako usiku kucha: 1. Mfanye ale chakula cha jioni chenye afya, akiepuka vyakula vyenye mafuta mengi na vyakula vya mgahawa au vya kuchukua. Mafuta huathiri sukari ya damu kwa kuifanya iongeze kwa muda wa saa kadhaa, na hivyo kuharibu matokeo ya mtihani. 2. Uwezekano wa kupata Mfanye mazoezi ya kawaida kabla ya kulala. Punguza utendaji kwa nguvu ya wastani na muda. Mazoezi ya kimwili huathiri kiwango cha sukari katika damu kwa kuipunguza kwa muda wa saa kadhaa baada ya zoezi hilo. 3. Uwe na mtazamo wa kweli Kwa hivyo, kabla ya siku ya pili, mtoto wako anaweza kula au kunywa chochote isipokuwa maji na vinywaji vya lishe (kila kalori, hakuna wanga). Hata vyakula vyenye wanga na protini chache vinaweza kuathiri sukari ya damu, na hivyo kuharibu matokeo ya mtihani. 4. Uwe na uhakika Angalia sukari ya damu masaa matatu baada ya chakula cha jioni. Ikiwa kiwango cha mtihani ni 0.4 mmol (mmol) au chini, jaribu na ufanye kama kawaida. Utalazimika kusubiri hadi usiku mwingine kupima viwango vya msingi. (Na hii inaweza kuonyesha haja ya kurekebisha uwiano wa chakula cha jioni I: C, kama hii si tukio la pekee.) Ikiwa kiwango cha sukari ni 14.0 mmol (mmol) au zaidi, jaribu na ufanye marekebisho ya kawaida ya kiwango cha sukari ya damu. Utalazimika kusubiri hadi usiku mwingine kupima viwango vya msingi. (Kwa mara nyingine tena, hii inaweza kuonyesha haja ya kurekebisha chakula cha jioni I: C uwiano, kama hii si tukio la pekee.) Ikiwa matokeo ni kati ya 4.0-4.0 mmol L, jaribu kufanya mtihani wa msingi kama ilivyoelezwa katika hatua zifuatazo. 5. Uwe na mtazamo mzuri. Angalia kiwango cha sukari ya damu wakati wa usingizi wa mtoto wako (kama ilivyo hapo juu ikiwa ni chini ya 4.0. 6. Uwe na uhakika Angalia sukari ya damu tena mtoto wako anapomkumbuka. • Wakati wa kupima sukari ya damu: Ikiwa mtoto wako amemaliza kula saa 6 jioni, unaweza kupima sukari ya damu saa 9 jioni, 2 asubuhi, na 7 asubuhi, kwa mfano. 7. Uwe na mtazamo gani? Kwa mfano, ikiwa sukari ya damu ilibaki sawa (ndani ya 0.2 mmol-L kutoka wakati wa kulala hadi kuamka), hakuna mabadiliko ya kipimo cha msingi kinachohitajika. Ikiwa sukari ya damu imeshuka zaidi ya 0.2 mmol (mmol) kutoka wakati wa kulala hadi kuamka, unaweza kuchagua kupunguza kipimo cha msingi cha Lantus au Levemir (kwa mfano kwa 10%) na kurudia mtihani usiku uliofuata. Kwa mfano, ikiwa kipimo cha usiku wa kulala kilikuwa 9.5, kipimo cha usiku wa kulala kilikuwa 8.5, na kipimo cha asubuhi kilikuwa 6.0, na kipimo cha sasa cha Lantus cha mtoto wako ni 6.0U, unaweza kuondoa 10% kufikia 5.4U, kuzunguka hadi 5.5U, na kurudia mtihani na kipimo cha msingi cha 5.5U. Ikiwa kiwango cha sukari ya damu kiliongezeka zaidi ya 0.2 mmol (mmol) kutoka wakati wa kulala hadi kuamka, unaweza kuchagua kuongeza kipimo cha msingi cha Lantus au Levemir (kwa mfano kwa 10%) na kurudia mtihani usiku uliofuata. Kwa mfano, ikiwa kipimo cha usiku wa kulala kilikuwa 9.5, kipimo cha usiku wa kulala kilikuwa 11.0, na kipimo cha asubuhi kilikuwa 12.0, na kipimo cha sasa cha Lantus cha mtoto wako ni 6.0, unaweza kuongeza 10% kufikia 6.0, kuzunguka hadi 6.5 na kurudia mtihani na kipimo cha msingi cha 6.5U. Kwa Nini Uchunguze Glucose ya Damu Katikati ya Usiku? Ikiwa tumekagua sukari ya damu wakati wa kulala na wakati wa kuamka tu, na tukapata ongezeko la zaidi ya 0.2 mmol l, kuna angalau uwezekano wa nini kilichotokea usiku mmoja: A. sukari ya damu inaweza kuwa imeongezeka kwa kasi; B. sukari ya damu inaweza kuwa imebaki sawa katika sehemu ya kwanza ya usiku, ikifuatiwa na ongezeko kubwa katika sehemu ya mwisho ya usiku; au C. sukari ya damu inaweza kuwa imeshuka katika sehemu ya kwanza ya usiku na kisha kuongezeka kwa kasi. Hali hii ya mwisho inaitwa "kurudi chini" (au, athari ya Simogyi): kama matokeo ya chini, ini hutoa glukosi iliyohifadhiwa (glycogen), na kusababisha sukari ya juu ya damu baadaye. Ili kuepuka kuwa na kiwango cha chini cha sukari, ni muhimu kuangalia kiwango cha sukari ya damu ya mtoto wako angalau mara moja wakati wa kulala. "Uwezekano wa kuongezeka kwa kiwango cha sukari ya damu wakati wa usiku unategemea hali ya ""Kuweka"" kwa kiwango cha sukari ya damu kwa usiku, kama ilivyoelezwa katika A: ina maana kuongeza kipimo cha msingi (Lanthus au Levemir)." Ikiwa sukari ya damu ilibaki sawa kwa sehemu ya usiku na kisha iliongezeka kuelekea asubuhi kama ilivyo katika B: unaweza kuchagua kuongeza marekebisho ya insulini ya haraka-kufanya kazi kwa wakati unaofaa, au unaweza kufikiria kuongeza kidogo ya insulini ya kati-kufanya kazi (NAP) kabla ya kulala ili kusuluhisha tatizo. - Kama sukari ya damu imeshuka na kisha kuongezeka kama matokeo, kama katika C: basi kupungua kwa kipimo cha msingi kwa kweli kunaweza kusababisha viwango vya chini vya sukari ya damu ya kuamka. Ikiwa unataka msaada wa kuamua uwezekano, tafadhali wasiliana na timu ya huduma ya afya ya kisukari ya mtoto wako. Ikiwa wewe ni mtu wa aina ya A kama mimi, wakati wa mtihani wa msingi unaweza kuchagua kufanya ukaguzi mbili katikati ya usiku: 12 am na 3 am, kwa mfano. Habari zilizotajwa hapo juu zilipitiwa kwa usahihi wa maudhui na wafanyakazi wa kliniki ya Alberta Watoto Hospitali ya Kliniki ya Kisukari. SHARE ARTICLE HII