Treatment Modalities

BLOOD GLUCOSE MONITORING
Accurate determination of capillary blood glucose assists patients in the control and daily management of diabetes mellitus. Blood glucose monitoring helps evaluate effectiveness of medication; reflects glucose excursion after meals; assesses glucose response to exercise regimen; and assists in the evaluation of episodes of hypoglycemia and hyperglycemia to determine appropriate treatment.

Procedure
  • The most appropriate schedule for glucose monitoring is determined by the patient and health care provider.
    • Medication regimens and meal timing are considered to set the most effective monitoring schedule.
    • Scheduling of glucose tests should reflect cost effectiveness for the patient. 
    • Glucose monitoring is intensified during times of stress or illness or when changes in therapy are prescribed.
  • Patients with type 2 diabetes controlled with oral hypoglycemic agents or a single injection of intermediate-acting insulin may test glucose levels before breakfast and before supper or at bedtime (twice-per-day monitoring).
  • Patients with type 1 diabetes using a multiple-dose insulin regimen may test before meals and at bedtime, occasionally adding a 2 to 3 a.m. test (four to six times daily monitoring).
  • Alternate site testing has been recommended by some clinicians for patients who complain of painful fingers and for individuals such as musicians, who use their fingertips for occupational activities. However, testing in such sites as the forearm, palm, thigh, and calf have not proved as accurate as fingertip testing in most studies.
    • If alternate site is used, the area should be rubbed until it is warm before testing.
    • Do not use an alternate site when accuracy is critical; for example, if hypoglycemia is suspected, before or after exercise, or before driving.
    • Check with the glucometer manufacturer to see if it is approved for alternate site testing.
INSULIN THERAPY
Insulin therapy involves the subcutaneous injection of immediate-, short-, intermediate-, or long-acting insulin at various times to achieve the desired effect. Short-acting regular insulin can also be given I.V. About 20 types of insulin are available in the United States; most of these are human insulin manufactured synthetically. Only about 6% of diabetics are still using beef or pork insulin due to problems with immunogenicity.

Self-Injection of Insulin
  • Teaching of self-injection of insulin should begin as soon as the need for insulin has been established.
  • Teach the patient and another family member or significant other.
  • Use written and verbal instructions and demonstration techniques.
  • Teach injection first because this is the patient's primary concern; then teach loading the syringe.
  • For patients who have difficulty with the injection procedure, newer insulin pens are available that use a prefilled cartridge that automatically delivers the set dose of insulin by jet stream without a needle.

Community and Home Care Considerations
  • Assist the patient in deciding whether to reuse insulin syringe at home. The patient may decide to do so due to cost; however, reuse has become controversial because the newer, finer needles may become dull or bent after one or two injections, causing tearing of tissue, which can lead to lipodystrophy.
    • Needles should not be reused if painful injection or irritated site results.
    • Needle should be recapped by patient and stored in a clean place if it is going to be reused.
  • Assist the patient in obtaining the appropriate syringe size and needle length for injections.
    • Determine if there are visual or dexterity issues that make a syringe with gradations farther apart more desirable.
    • Determine if the patient is obese and should continue to use standard ½-inch needles or if 5/16-inch needles will be desirable. Shorter needles are more comfortable for some and prevent inadvertent I.M. injection.
  • Advise the patient that it is not necessary to use alcohol to wipe off the top of the vial or prepare the skin before injection. It has not proved to result in lower rate of infection and adds cost and time to the procedure. The patient should maintain good hygiene.
  • Make sure that the patient stores insulin in a clean, secure place away from sunlight and heat. Check manufacturer recommendations for when to discard insulin vials and pens; recommendations may vary from 10 to 30 days after opening.
  • Check manufacturer's recommendations before teaching the patient how to mix insulin; for example, the patient should know that Lantus insulin must never be mixed with any other insulin. 
  • Avoid prefilling syringes if at all possible because manufacturers have no data on the stability of insulin stored in syringes for long periods. If prefilling is the only option, store in refrigerator or suggest an insulin pen injection device.
  • Help the patient develop a plan for the disposal of needles. There are no federal regulations for discarding needles used at home; however, needles and lancets can be a risk for injury.
    • Sharps can be placed in a hard plastic or metal container with a tightly secured lid after use.
    • When one-half to two-thirds full, the container should be secured with duct or masking tape, marked - do not recycle, and placed in the trash.

NPH Only
  • Used alone only in type 2 diabetes when patients are capable of producing some exogenous insulin as a supplement for better glucose control.
  • Traditionally given as a morning dosage to assist with normalization of glucose during the afternoon and evening.
  • Evening or bedtime dosage can be helpful in controlling early-morning hyperglycemia.
  • NPH can also be given twice daily (morning and bedtime) to eliminate afternoon hypoglycemia yet provide nighttime coverage. Typically, 2/3 to ¾ of the daily dosage is given before breakfast and 1/3 to ¼ is given at bedtime.
NPH/Regular or NPH/Lispro
  • Short-acting regular insulin or immediate-acting lispro (Humalog) or aspart (Novolog) insulin is added to NPH to promote postprandial glucose control.
  • Short- or immediate-acting insulin added to morning NPH controls glucose elevations after breakfast.
  • Increased blood glucose levels after supper can be controlled by the addition of short- or immediate-acting insulin before supper.
  • NPH and regular, lispro, or aspart insulin given before breakfast and before supper is termed a split-mix regimen, providing 24-hour insulin coverage for type 1 diabetes.
Intensive Insulin Therapy
  • Designed to mimic the body's normal insulin responses to glucose.
  • Uses multiple daily injections of insulin.
  • NPH or ultralente or glargine (Lantus) insulin is used for basal insulin control.
  • Regular insulin acts as a premeal bolus given 30 minutes before each meal. Lispro or aspart insulin may be used instead of regular and is taken just before eating.
  • 24-hour insulin coverage designed in this way can be flexible to accommodate mealtimes and physical activity.
Sliding Scale Versus Algorithm Therapy
  • Sliding scale therapy uses regular insulin to retrospectively correct hyperglycemia.
  • Algorithm therapy prospectively determines regular insulin dosages, taking into account meal content and physical activity.
  • Individualization of regular insulin dosages is the most important aspect of sliding scale and algorithm therapy.
    • The patient is encouraged to test blood glucoses to analyze insulin dose response.
    • A pattern of increased blood glucose associated with certain foods (eg, pasta, pizza) can help determine the appropriate regimen of insulin dosage.
    • Physical activity, which enhances insulin activity and decreases serum glucose, may indicate the need to reduce the dosage of premeal regular insulin.
Continuous Subcutaneous Insulin Infusion and Insulin Pump Therapy
  • Continuous subcutaneous insulin infusion (CSII) and insulin pump therapy provide continuous infusion of regular, lispro, or aspart insulin via subcutaneous catheter inserted in the abdomen. Regular insulin is used during pregnancy.
  • The catheter should be replaced every 72 hours or sooner if the site becomes painful or inflamed.
    • Frequently, the insulin pump is removed for bathing, and tubing and catheter are changed at that time.
    • To reduce tubing and catheter blockage, diluted insulin is used.
  • Intensive insulin management by pump therapy requires patient motivation.
    • Blood glucose monitoring must be done at least four to six times each day.
    • Frequent contact with health care team is necessary to adjust insulin dosage.
    • Careful recordings of diet, insulin, and activity are required to evaluate adjustments.
    • Increased cost of insulin pump and infusion set compared to usual syringe method.
    • Heightened risk of hypoglycemia with tighter glucose control.
    • Danger of hyperglycemia exists should insulin pump fail to deliver correct insulin dosage.
    • Increased visibility of diabetes by use of an external device.
  • Advantages of CSII in improving blood glucose control:
    • Insulin pump can deliver basal insulin at individualized programmed rates throughout a 24-hour period.
    • Bolus injections of regular insulin given 30 minutes before eating and lispro or aspart immediately before a meal allow for flexibility in meal content and timing.
    • Correction supplements of regular, lispro, or aspart insulin are easily given to rapidly correct elevated glucose levels.
Combination Oral Agent and Insulin Therapy
  • Appropriate only in type 2 diabetes.
  • Intermediate-acting insulin (NPH) is given in the evening and an oral sulfonylurea agent in the morning called BIDS therapy (Bedtime Insulin, Daytime Sulfonylurea).
    • No oral antidiabetic agent is given at bedtime.
    • Controlling hepatic glucose production overnight with evening insulin helps to start the day with a lower FBS.
    • Daytime antidiabetic agent (usually sulfonylurea), along with diet and exercise, controls daytime blood glucose levels.
    • Some patients may require regular/NPH insulin injected before supper to assist with elevated postprandial evening glucoses.
  • Combination therapy may also include the use of a thiazolidinedione (pioglitazone [Actos], rosiglitazone [Avandia]), metformin (Glucophage), or other agents.
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