Carolyn Robertson

Understanding Your Insulin Prescription (Part 2)

INSULIN PRESCRIPTIONS

Insulins are mixed and matched to create an insulin prescription. Since no two individuals are alike, it is not surprising that there are so many different insulin prescriptions. You should share the details of your lifestyle with your health provider. Are you very regimented and willing to maintain a consistent schedule of eating and activity; or do you want or need to vary your schedules daily? If you are more consistent, then it is possible to utilize a basic insulin regime. If you are more varied in your schedule, then you require a more complex insulin prescription — a prescription that utilizes a combination of several different insulin types. While variability in daily activities can be accommodated by insulin, it increases the likelihood that your blood sugar levels may not be predictable. Therefore, when flexibility is increased, you must become more actively involved in the daily management of the disease. In other words, more blood sugar monitoring, record keeping and data analysis are necessary. As a result, some people chose insulin plans that have obvious disadvantages because they want to keep their involvement with disease management at a minimum.

Some typical insulin regimes include

1. Single injection a day (not appropriate for patients with Type 1 Diabetes)

Breakfast Lunch Supper
Bedtime
None
None
None
NPH, Lente, or LANTUS
NPH or Lente
None
None
None


When the insulin is taken at bedtime, it will provide insulin overnight mimicking nature’s usual pattern of insulin release. Dependent on the insulin, there is potential for an insulin reaction overnight.

When the insulin is taken at breakfast, it supplements the body’s daytime need for the hormone. In addition, when NPH or Lente is given in larger doses, it can provide the insulin that is needed for a mid day meal. However, that meal must be eaten at a specific time and the size of the meal cannot vary. With this insulin plan, there is a risk of a low blood sugar (insulin reaction) early to late afternoon. People with Type 1 Diabetes can use neither plan because they do not provide 24-hour insulin coverage.

 2. Two injections per day

Breakfast
Lunch
Supper
Bedtime
NPH or Lente & Regular or Humalog None NPH or Lente & Regular or Humalog None
70/30
None
70/30
None
75/25
None
75/25
None
50/50
None
50/50
None


These schedules of insulin provide insulin for a 24-hour period mimicking nature’s usual pattern of insulin release. The plan, however, has a high potential for an overnight insulin reaction since the intermediate acting insulin will be at its strongest soon after bedtime. It also has a potential for a high blood sugar level on awakening the next morning since the effect of the intermediate acting insulin is waning by the morning. In addition, there is a risk of a low blood sugar (insulin reaction) mid morning and again in the mid afternoon. It does give the individual sufficient insulin for three meals. However, those meals must be eaten at a specific time and the size of the meals cannot vary.

3. Three injections per day

Plan
Breakfast
Lunch
Supper
Bedtime
A
NPH or Lente
None
Regular or Humalog
NPH, Lente, or LANTUS
& Regular or Humalog
B
70/30
None
Regular or Humalog
NPH, Lente, or LANTUS
C
75/25
None
Regular or Humalog
NPH, Lente, or LANTUS
D
Ultralente
& Regular or Humalog
Regular or Humalog
Ultralente
& Regular or Humalog
None


Plan A,B,C: This plan also provides insulin for a 24-hour period. It has a low potential for an insulin reaction overnight since the intermediate acting insulin taken at bedtime will be at its strongest before wakening the next morning helping to normalize the morning blood sugar. It still has the potential for causing an insulin reaction mid morning as well as mid afternoon. It, too, gives the individual sufficient insulin for three meals. While breakfast and lunch still must be eaten at a specific time and the size of the meals cannot vary, the size and the timing of the supper meal can be varied.

Plan D: This insulin schedule provides 24-hour insulin coverage. The plan does have the potential for an insulin reaction overnight since the impact of the evening dose of the long acting insulin occurs throughout the evening and the night. If the premeal insulin is Regular, there is a risk of a low blood sugar (insulin reaction) several hours after each meal. The risk is virtually eliminated when the premeal insulin is Humalog. This plan provides the individual with a great deal of flexibility since meal times and sizes can be modified easily.

 4. Four injections per day

Breakfast
Lunch
Supper
Bedtime
Ultralente
Regular or Humalog
Regular or Humalog
Ultralente
& Regular or Humalog
NPH or Lente
Regular or Humalog
Regular or Humalog
NPH, Lente, or LANTUS
& Regular or Humalog


These plans provide insulin for the 24-hour period. They have less potential for an insulin reaction overnight since the impact of the bedtime dose of the intermediate acting will be at its strongest before wakening the next morning and provides the insulin necessary in the pre wakening hours to assure a lower fasting blood sugar. If the premeal insulin is Regular, there is still a risk of a low blood sugar (insulin reaction) several hours after each meal. That risk is virtually eliminated when the premeal insulin is Humalog. This plan provides the individual with a great deal of flexibility since meal times and sizes can be modified easily.

5. Continuous Insulin Infusion System (Insulin Pump)

Breakfast
Lunch
Supper
Bedtime
Bolus of Regular or Humalog Bolus of Regular or Humalog Bolus of Regular or Humalog None
  • Continuous basal delivery of insulin


Short acting insulin delivered by portable computerized delivery device. Pumps can be programmed to vary the rate of insulin delivered by basal throughout the 24-hour period. Meals can be scheduled at any time. This system offers the greatest flexibility. However, it has some limitations. A pump must be worn continuously. They require a significant amount of involvement from both the pump wearer and the health care team. Additionally, pumps are expensive and are not always fully reimbursed by insurance companies.

CONCLUSION

Regardless of the prescription, no insulin regime can meet every need of every patient all of the time. In addition, individual factors such as site of injection, size of the dose, time of the day, amount and type of activity and even stress can alter an individual intensity of response. Self-monitoring of the blood sugar levels, self study and collaboration with a medical team that is willing to teach you about diabetes will help you learn the tricks that are necessary to make winning combinations.