type 1: smbg and hba 1c targets 2-2 smbg targets more than 50% of values within target range age...
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Type 1: SMBG and HbA1C Targets
2-2
SMBG Targets• 50More than % of values wiiiii iiiiii iiiii• - 6 100200Age < : iii -i iii iii iiiiii i/• - - 6 12 80180 - mg/dL pre meal and bedtime• - Age >1 2 : 8 0 1 4 0 m iii -i iii/ 160 2< mg/dL hours after start of meal - 100160mg/ dL bedtime• iiiiiiiiii ii iiiii( )iiii iiiiiiiiii ii iiiiii iii-i iii iiiiii iii ii d if hypoglycemia iiii iiiiiii ii iiiiiiii iii ere hypoglycemia occursHbA
1c Target• iii< 6 : 2 .5 cent age poi nt s of upper limit of normal• - 612 2Age : Within perc ent age poi nt s of upper limit of normal• 12 15Age > : Within . p er cent age poi nt s of upper limit of normal
SMBG Frequency• Minimum 4 times/day; befor 2e and hours after start of meals and at bedtime• i 3 AM ii iiiiii
Lispro Insulin (LP) Considerations• 1 unit of LP = 1 unit of Regular insulin• Administer within 15 minutes before the meal due to rapid action• May need to increase basal insulin dose• Use both pre-meal and post-meal SMBG data to make LP dose adjustments• May have reduced need for snacks between meals• Consider an additional LP insulin injection before snacks > 30 gm total carbohydrate
2-3
Plasma glucose <1 1 0 mg/ dL? Plasma glucose iiiiii110
No diabete s; evaluate for infectio -n or meta bolic disorder
No diabete s; evaluate for infectio -n or meta bolic disorder
Monitor urine detones every 4 hours; if posttive,
-see immediately; other wise obtain laboratory
fasting plasma glucose within 24 hour
Monitor urine detones every 4 hours; if posttive,
-see immediately; other wise obtain laboratory
fasting plasma glucose within 24 hour
-Consider inpatred fast ing glucose and referral to Diabetes Specialist
-Consider inpatred fast ing glucose and referral to Diabetes Specialist
Type 1: Screening and DiagnosisObtain laboratory plasma
glucose and urine ketonesObtain laboratory plasmaglucose and urine ketones
NO
YES
Immediately have patient consume meal - -with 60 75 gm carbo -hydrate; obtain labora tory plasma glucose 2 hours post meal -If < 200 mg/dL, eval uate for infection or metabolic disorder; if uncertain, consider OGTT - If > 200 mg/dL, con tinue with diagnosis
sequence
Immediately have patient consume meal - -6075with gm carbo -hydrate; obtain labora tory plasma glucose 2 hours post meal -If < 200 mg/dL, eval uate for infection or metabolic disorder; if uncertain, consider OGTT - If > 200 mg/dL, con tinue with diagnosis
sequence
NO
Fasting plasma glucose- 110125mgdL or casual plasma glucose- 140199mg/dL?
Fasting plasma glucose- i iii ii110125 casual plasma glucose- 140199mg/dL?
Fasting plasma glucose> 126mg/dL or casusl plasma glucose
> 200mg/dL and positive
Fasting plasma glucose> 126mg/dL or casusl plasma glucose
> 200mg/dL and positive
YES
NO
-Diagnosis of type 1 dia betes; move to 1Type Master DecisionPath
-If vomiting, dehydra tion, and large ketones, suspect diabetic -ketoacidosis; hospital ize immediately for insulin initiation andtreatment
-1Diagnosis of type dia betes; move to 11 Master DecisionPath
-If vomiting, dehydra tion, and large ketones, suspect diabetic -ketoacidosis; hospital ize immediately for insulin initiation andtreatment
No diabetes; evaluate forinfection, steroid use, ormetabolic disorder
No diabetes; evaluate forinfection, steroid use, ormetabolic disorder
Fasting Plasma glucose> 126mg/dL?
Fasting Plasma glucose> 126mg/dL?
YES
Plasma glucose <1 1 0 mg/ dL? Plasma glucose iiiiii110
NO
NO
YES
YES
At Diagnosis FPG > 1 2 6 mg/dL
i iiii> /
At Diagnosis FPG > 1 2 6 mg/dL
CPG > mg/dL
2-5
Insulin Stage 1
(Honeymoon)(R)/N - 0 - 0 - 0
Insulin Stage 3B
R/N - 0 - R/N - 0 LP/N - 0 - LP/N -
0
Comments
• Continue withf ood plan and exerc
-ise pro gram through
out all stages of therapy.• Initially patie
nt may be in a honeymoo
n st age during which tii iii - ber of injectio
ns and the amount of
insulin may be decreased
R = HumanRegular Insulin LP = Lispro Insulin N = HumanNPH Insulin UL = HumanUltralente Insulin 0 = None
Dose Schedule: - - -AM MIDDAY PM BEDTIME
Medications
Type 1: Master DecisionPath
Insulin Stage 2 R/N - 0 - R/N - 0
LP/N - 0 - LP/N - 0Insulin Stage 2 R/N - 0 - R/N - 0
LP/N - 0 - LP/N - 0OR
Insulin Stage 3A R/N - 0 - R - N
LP/N - 0 - LP - NInsulin Stage 3A
R/N - 0 - R - NLP/N - 0 - LP - N
Insulin Stage 4A R/N - R - R - N
LP/N - LP - LP - NInsulin Stage 4A
R/N - R - R - NLP/N - LP - LP - N
Insulin Stage 4A R/N - R - R - N
LP/N - LP - LP - NInsulin Stage 4A
R/N - R - R - NLP/N - LP - LP - N
2-8
Follow-upMedical: Within 24 hours, then office visit in 2 weekNutrition: Within 24 hours, then office visit in 2 week
Follow-upMedical: Within 24 hours, then office visit in 2 weekNutrition: Within 24 hours, then office visit in 2 week
At Diagnosis
Start insulin within 2-4 hours; hospitalize if acute illness orDKA at diagnosis, psychosocial factors present, or outpatient
education not available
Move to Insulin Stage 2/Adjust
Start Insulin Stage 3A-Mid
R/N - 0 - R/N - 0LP /N - 0 - LP/N - 0
At Diagnosis
If patient arrives in AM:• Calculate total dose based on urine ketones and current weight• 0.5 U/kg for Negative to Moderate ketones• 0.7 U/kg for Large ketones
AM MIDDAY PM BT
Distribution 2/3 0 1/3 0R/N or LP/N ratio 1:2 - 1:1 -If patient arrives after 12 noon:• Calculate initial dose based on urine ketones and current weight• 0.2 U/kg for Negative to Small ketones• 0.3 U/kg for Moderate to Large ketones• Give PM dose of R/N or LP/N; ratio is 1:1• Monitor BG and ketones every 4 hours• Supplement with R or LP as needed• Calculate total dose for next day• See patient next AM
After initiating insulin, refer patient for nutrition and diabetes education
Type 1: Insulin Stage 2/Start
2-9
Is current total dailyinsulin dose:
< 1.0 U/kg for age < 12?< 1.5 U/kg for age < 12-18?
< 1.0 U/kg for age > 18?
Is current total dailyinsulin dose:
< 1.0 U/kg for age < 12?< 1.5 U/kg for age < 12-18?
< 1.0 U/kg for age > 18?NO
YES
Type 1: Insulin Stage 2/Start
Patient in Insulin Stage 2and not at target
Patient in Insulin Stage 2and not at target
If persistent fasting -hyperglycemia or noc
turnal hypoglycemia,iiii ii Insulin Stage3A ii i iiiii iiiii-;
glycemia, move to Insulin Stage 4A ; i f more flexibility
required move to Insulin Stage 3B
If persistent fasting -hyperglycemia or noc
turnal hypoglycemia, move t o Insulin Stage
3A -; if midday hyper glycemia, move to
Insulin Stage 4A ; i f more flexibility
required move to Insulin Stage 3B
Insulin Stage 2 Pattern AdjustmentsR/N - 0 - R/N - 0 or LP/N - 0 - LP/N - 0 80< mg/dL > 1 4 0 mg/dLAMor 3 AMMIDDAY
(MID)
PM
BEDTIME(BT)
100< mg/dL > 1 6 0 mg/dL
80< mg/dL > 1 4 0 mg/dLฏPM N1-2 U (a,b)ฏ AM R or LP
- 12 U (c,e)
ฏPM N1-2 U (a)ฏ AM R or LP
- 12 U (f,g)ฏAM N1-2 U (d,e)
ฏAM N1-2 U (f,h)
ฏ PM R or LP- 12 U (e)
ฏ PM R or LP- 12 U (f) Adjust insulin based on BG patterns
-Follow up Medical: Weekly while adjusting ins ulin, then office visit
- within 1 2 months; use this - DecisionPath for follow up
See Insulin Adjustment Guidelines, 2-14, for considerations designated by each letter and for BG pattern changes for age < 12 and hypoglycemia unawareness.
2-10
Follow-upMedical: If new insulin start, daily hone contact for 3 days, then office visit within 2 weeks; 24+hour emergency phone support neededNutrition: If newly diagnosed, within 24 hours, otherwise within 2 weeks
Follow-upMedical: If new insulin start, daily hone contact for 3 days, then office visit within 2 weeks; 24+hour emergency phone support neededNutrition: If newly diagnosed, within 24 hours, otherwise within 2 weeks
At Diagnosis or from Insulin Stage 2If persistent AM hyperglycemia, nocturnal hypoglycemia, and/or
lifestyle issues requiring variation in timing of meals
Move to Insulin Stage 3A/Adjust
Start Insulin Stage 3A - - - 0R/N R N
- 1 - 11 - 1/ 0
At Di agnosi s
• Calculate total dose based on urine k etones and current weight• 05. U/kg for Negative to Moderateket ones• 07. U/kg for Large ketones
AM MIDDAY PM BT
Distribution 23 0 16/ /16/ - R/N or LP/N ratio 1:2 - -
From Insulin Stage 2• i ii iiiiiii iiiii iiii• iiii PM i ii BT• R or LP may be modified for activity aii iii iii ii i iiii• AM - R or LP may go down 1 2 units• PM - R or LP may go up 1 2 units
If erratic SMBG or weight gain and curr ent total dose is greater than values below, consider recalculating a nd redistributing dose as for new
di agnosi s AGE CURRENT TOTAL DOSE 12 10. U/kg -1218 15. U/kg >1 8 10. U/kg
After initiating insulin, refer patient for nutrition and diabetes education
Type 1: Insulin Stage 3A/Start
2-11
Is current total dailyinsulin dose:
< 1.0 U/kg for age < 12?< 1.5 U/kg for age < 12-18?
< 1.0 U/kg for age > 18?
Is current total dailyinsulin dose:
< 1.0 U/kg for age < 12?< 1.5 U/kg for age < 12-18?
< 1.0 U/kg for age > 18?NO
YES
Type 1: Insulin Stage 3A/Adjust
Patient in Insulin Stage 3 A and not at target
Patient in Insulin Stage 3 A and not at target
-If persistent midafter noon hyperglycemia
or no significant improvement in 6
months,iiii ii Insulin
Stage 4A/Start
-If persistent midafter noon hyperglycemia
or no significant improvement in 6
months,iiii ii Insulin
Stage 4A/Start
Insulin Stage 3A Pattern AdjustmentsR/N - 0 - R - N or LP/N - 0 - LP - N 80< mg/dL > 1 4 0 mg/dLAMor 3 AMMIDDAY
(MID)
PM
BEDTIME(BT)
100< mg/dL > 1 6 0 mg/dL
80< mg/dL > 1 4 0 mg/dLฏBT N1-2 U (a,b)ฏ AM R or LP
- 12 U (c,e)
ฏBT N1-2 U (a)ฏ AM R or LP
- 12 U (f,g,)ฏAM N1-2 U (d,e)
ฏAM N1-2 U (f,h)
ฏ PM R or LP- 12 U (e)
ฏ PM R or LP- 12 U (f) Adjust insulin based on BG patterns
-Follow up Medical: Weekly while adjusting ins ulin, then office visit
- within 1 2 months; use this - DecisionPath for follow up
See Insulin Adjustment Guidelines, 2-14, for considerations designated by each letter and for BG pattern changes for age < 12 and hypoglycemia unawareness.
2-12
Follow-upMedical: Within 24 hours, then office visit in 2 weeksNutrition: Within 24 hours, then office visit in 2 weeks
Follow-upMedical: Within 24 hours, then office visit in 2 weeksNutrition: Within 24 hours, then office visit in 2 weeks
From Insulin Stage 3AIf persistent midafternoon hyperglycemia and/or lifestyle
issues requiring variation in timing of meals
Move to Insulin Stage 4A/Adjust
Start Insulin Stage 4A - - - 0R/N R N
- - - 0LP /N LP N
From Insulin Stage 3A
• i ii iiiiiii iiiii iiii• Add MIDDAY R or LP at 20 % of curreii AM N• Decrease AM N by 50%• Increase AM R or LP by 1 unit• Increase PM R or LP by 1 unit
If erratic SMBG or weight gain and curr ent total dose is greater than values below, consider recalculating a nd redistributing dose as shown
AGE CURRENT TOTAL DOSE 12 10. U/kg -1218 15. U/kg >1 8 10. U/kg
AM MIDDAY PM BT
Distribution 23 0/ 13 0/ - R/N or LP/N ratio 1:1 - -
Refer patient for nutrition and diabete s eduaction
Type 1: Insulin Stage 4A/Start
2-13
Is current total dailyinsulin dose:
< 1.0 U/kg for age < 12?< 1.5 U/kg for age < 12-18?
< 1.0 U/kg for age > 18?
Is current total dailyinsulin dose:
< 1.0 U/kg for age < 12?< 1.5 U/kg for age < 12-18?
< 1.0 U/kg for age > 18?NO
YES
Type 1: Insulin Stage 4A/Adjust
Patient in Insulin Stage 4 A and not at target
Patient in Insulin Stage 4 A and not at target
If no significantimprovement in
6 months,refer patient to a
Diabetes Specialist
If no significantimprovement in
6 months,refer patient to a
Diabetes Specialist
Insulin Stage 4A Pattern AdjustmentsR/N - R - R - N or LP/N - LP - LP - N 80< mg/dL > 1 4 0 mg/dLAMor 3 AMMIDDAY
(MID)
PM
BEDTIME(BT)
100< mg/dL > 1 6 0 /
< 8 0 /mg dL 140> mg/dLฏBT N1-2 U (a,b)ฏ AM R or LP
- 12 U (c,e)
ฏBT N1-2 U (a)ฏ AM R or LP
- 12 U (f,g,)ฏMID R or LP*1-2 U (d,e)
ฏMID R or LP1-2 U (f,h,j,k)
ฏ PM R or LP- 12 U (e)
ฏ PM R or LP- 12 U (f) Adjust insulin based on BG patterns
-Follow up Medical: Weekly while adjusting ins ulin, then office visit
- within 1 2 months; use this - DecisionPath for follow up
See Insulin Adjustment Guidelines, 2-14, for considerations designated by each letter and for BG pattern changes for age < 12 and hypoglycemia unawareness.* Consider discontinuing AM N
Type 1: Insulin Adjustment Guidelines
2, 3A, 4A
2-14How to Use These Tables1. Find current insulin stage2. Find the pattern of blood glucose problem (column)3. Identify time of day (row) pattern occurs4. Recommended adjustment is given where the column and row intersect5. See notes for additional considerations
Notesa. Evaluate nocturnal hypoglycemia; check 3 AM BGb. Consider increasing bedtime snackc. Consider adding or adjusting mid-morning snackd. Consider adding or adjusting afternoon snacke. Evaluate if previous exercise is causing hypoglycemiaf. Consider adding exercise g. Consider decrease in mid-morning snackh. Consider decrease in afternoon snacki. No mid-morning snack usually needed with LPj. No afternoon snack usually needed with LPk. Consider adding AM N if long interval between middy and evening meal or afternoon hyperglycemia AM N: 50% MIDDAY R or LP dose MIDDAY R or LP: ฏ 50% AM and PM R or LP: No change No change
Insulin PatternAdjustments• Adjust insulin fr -3om day iiiiiii• Determine whic h insulin is responsible for piiiiii• - Adjust by 1 2 uni t s• Adjust only one dose at a t i me• Correct hypogly cemia first• If total dose > 1 i iiii 5
consider overinsulinization• If hyperglycemi a throughout day, correct hig hest SMBG first; if all within 50mg/dL correct AM fi r si
• For age < 6 yea rs, change pattern values to 100< mg/dL and>2 0 0 mg/dL; reduce adiiiii iii dose by 50%• - For age 6 1 2years,change pattern value to > 1 8 0 mg/dL; reduce adjustmeni dose by 50%• For hypoglycemi a unawareness ( > 1 2 ),iii iii- tern values to < 100mg/dL and > 1 6 0 m/
2-16
-Follow up Medical: Phone or office visit within 1 week, then office visit within 1month
-Follow up Medical: Phone or office visit within 1 week, then office visit within 1month
From Insulin Stage 3AIf persistent midafternoon hyperglycemia and/or lifestyle
issues requiring variation in timing of meals
Move to Insulin Stage 3B/Adjust
Start Insulin Stage 3B - - - 111/() / 0 / - - - 0UL LP LP/ UL
From Insulin Stage 2 and using R o1 11 111 AM UL
• Use current total insulin dose• Stop N• Add UL at 50% total dose• Add MIDDAY R or LP
DISTRIBUTION AM MIDDAY PM BT
R or LP (50% of total dose) 35% 25 40 0
50 33UL ( % of total dose) 0 67 0% % From Insulin Stage 2 and using R o r LP and no AM UL• Use current total insulin dose• Stop N• Add UL at 40% total dose• Add MIDDAY R
DISTRIBUTION AM MIDDAY PM BT
R or LP (60% of total dose) 35% 25 40 0% % 40 0UL ( % of total dose) 0 100 0%
If erratic SMBG or weight gain and curr ent total dose is greater than values below, consider recalculating a nd redistributing as above
AGE CURRENT TOTAL DOSE 12 10. U/kg -1218 15. U/kg >1 8 10. U/kg
Refer patient for nutrition and diabete s education
Type 1: Insulin Stage 3B/Start
2-17
Is current total dailyinsulin dose:
< 1.0 U/kg for age < 12?< 1.5 U/kg for age < 12-18?
< 1.0 U/kg for age > 18?
Is current total dailyinsulin dose:
< 1.0 U/kg for age < 12?< 1.5 U/kg for age < 12-18?
< 1.0 U/kg for age > 18?NO
YES
Type 1: Insulin Stage 3B/AdjustPatient in Insulin Stage 3B
If AM hyperglycemia after adding PM UL, discontinue PMUL and add N at bedtime at same dose of PM UL
R/UL-R-R-N or LP/UL-LP-LP-N
Patient in Insulin Stage 3BIf AM hyperglycemia after adding PM UL, discontinue PM
UL and add N at bedtime at same dose of PM ULR/UL-R-R-N or LP/UL-LP-LP-N
If no significantimprovement in
6 months,refer patient to a
Diabetes Specialist
If no significantimprovement in
6 months,refer patient to a
Diabetes Specialist
Insulin Stage 3B Pattern AdjustmentsR(UL) - R - R/UL - 0 or LP/UL - LP - LP/UL - 0 80< mg/dL > 1 4 0 mg/dLAM
or 3 AM
MIDDAY
(MID)
PM
BEDTIME(BT)
100< mg/dL > 1 6 0 /
< 8 0 /mg dL 140> mg/dLฏBT UL1-2 U (a,b)ฏ AM R or LP
- 12 U (c,e)
ฏBT UL1-2 U (a)ฏ AM R or LP
- 12 U (f,g)ฏMID R or LP1-2 U (d,e)
ฏMID R or LP1-2 U (f,h,j,k)
ฏ PM R or LP- 12 U (e)
ฏ PM R or LP- 12 U (f) Adjust insulin based on BG patterns
-Follow up Medical: Weekly while adjusting ins ulin, then office visit
- within 1 2 months; use this - DecisionPath for follow up
See Insulin Adjustment Guidelines, 2-18, for considerations designated by each letter and for BG pattern changes for age < 12 and hypoglycemia unawareness.
Type 1: Insulin Adjustment Guidelines
3B
2-18 How to Use Th ese Tables 1. Find current insulin stage 2. Find the patt ern of blood glucose problem (coluiii 3. Identify time of day (row) pattern occurs 4. Recommend ed adjustment is given where the column and row inters
ect 5. See notes foradditional considerations
Notes a. Evaluate noctur nal hypoglycemia; c heck 3 AM BG b. Consider increa sing bedtime snack c. Consider adding or adjusting - mid morning snack d. Consider adding or adjusting afternoon snack e. Evaluate if previ ous exercise is causing hypoglycemia f. Consider addingiiiiiiii g. Consider decrea se in midmorning snack h. Consider decrea se in afternoon snack i. AM UL is a basal insulin and usually does notiiiiiii adjusting. If PM BG > target due to a long interval between midday and eveni ng meal, consider i ncreasing UL - by 1 2 units
Insulin PatternAdjustments• Adjust insulin f -3rom day iiiiiii• Determine whi ch insulin is responsible foriiiiiii• - Adjust by 1 2 uni t s• Adjust only oni iiii ii i t i me• Correct hypogl ycemia first• If total dose > 15. U/kg, consider overinsulinization• If hyperglycem ia throughout day, correct hig hest SMBG first; if all withi 50n mg/dL correct AM fi r si• For age < 6 y ears, change pattern values 100 mg/dL and > 200 mg/dL; reduce adjustm ent dose by 50%• -For age 6 1 2 years,change pattern value t o>1 8 0 mg/dL; reduce adjustment dose by 50%• For hypoglyce -mia unaware 1ness (age > -2),change pat tern values to 100< mg/dL and > 1 6 0/
1 11 111111111 1djustment • Made with R or L P insulin only• Given at times of R or LP insulin injections• May be added orsubtracted on basis of BG, fo od, or exercise• Used with cautio n at bedtime; 3AM BG is used t o det er mi ne the bedtime dosi
Blood Glucose Adjust R or LP (mg/dLi 80 ฏ - i12
-140200 ฏ 1 -201250 ฏ 2 - 251300 ฏ 3 >3 0 0 ฏ 4 > i
2-19
SMBG and/or HbA1cwithin target range andpatient in “honeymoon”
phase?
SMBG and/or HbA1cwithin target range andpatient in “honeymoon”
phase?
Type 1: Insulin Stage 1/Adjust
Patient referred onInsulin Stage 1(R)/N - 0 - 0 -0
Patient referred onInsulin Stage 1(R)/N - 0 - 0 -0
Move to InsulinStage 2/Start
Move to InsulinStage 2/Start
NO
Patient enters InsulinStage 1/MaintainContinue current dose;use this DecisionPathfor follow-upFollow-upMedical: Every 1-2 months
Patient enters InsulinStage 1/MaintainContinue current dose;use this DecisionPathfor follow-upFollow-upMedical: Every 1-2 months
YES
2-25
SMBG and/or HbA1cwithin target range?
SMBG and/or HbA1cwithin target range? YE
S
Type 1: Preconception Planning
Patient planning pregnancyPatient planning pregnancy
NO
History, physical exa m, and laboratory evaluatio n by clinician• History: Diabetes t herapy and control, miscarriage s, and birth control• Medications: If hypertensive, switch to Methyldop a or Hydralazine; ACE inhibitors and beta blockers contraindicated in pregnancy• Complications: Hypoglycemia unawareness; DKA; retinopathy; nephropathy; neuropathy• -Discuss pregnancy related risks including associatio -n of hyper glycemia with complications; DKA with fetal death ; fetal malformations• Physical exam: Incl ude funduscopic eye ex amwi t h dilation by Ophthalmologist• Laboratory: CBC; U A/UC; thyroid studies; screen for albuminuria; HbA
1c ; EKG if diabet es duration > 1 0 years
Correlate SMBG andHbA1c ; assess
nutritional status self management skills, and psychologi cal status
History, physical exa m, and laboratory evaluatio n by clinician• History: Diabetes t herapy and control, miscarriage s, and birth control• Medications: If hypertensive, switch to Methyldop a or Hydralazine; ACE inhibitors and beta blockers contraindicated in pregnancy• Complications: Hypoglycemia unawareness; DKA; retinopathy; nephropathy; neuropathy• -Discuss pregnancy related risks including associatio -n of hyper glycemia with complications; DKA with fetal death ; fetal malformations• Physical exam: Incl ude funduscopic eye ex amwi t h dilation by Ophthalmologist• Laboratory: CBC; U A/UC; thyroid studies; screen for albuminuria; HbA
1c ; EKG if diabet es duration 10> years
Correlate SMBG andHbA1c ; assess
nutritional status self management skills, and psychologi cal status
Work with patient to establish BG control• Reassess current therapy• Start or adjust intensified regimen as needed See Insulin Stage 3A or 4A• Continue with birth control• Consider co-management with a Diabetes Specialist
Work with patient to establish BG control• Reassess current therapy• Start or adjust intensified regimen as needed See Insulin Stage 3A or 4A• Continue with birth control• Consider co-management with a Diabetes Specialist
Stop birth control and continue current insulinstage; maintain SMBGand HbA1c within targetrange until pregnancy
confirmedMove to Management
During Pregnancy
Stop birth control and continue current insulinstage; maintain SMBGand HbA1c within targetrange until pregnancy
confirmedMove to Management
During Pregnancy
SMBG Targets• - -Pre meal: 80 120mg/dL• - Post meal: < i iiii 140
2 hours after sta rt of meal• Bedtime: 1- 00140m/ (bedtime)• No severe (as sisted) or nocturnal hypoglycemia• Adjust if hypoglycemia unawarenessHbA
1c Target• At least 2 balu es 1 mohth apart within no r mal r ange
SMBG Frequency• 4 times/day; before meals and 2 hours a fter start of meals and at bedt i me• Check 3 AM asneeded
Type 1: Management During Pregnancy
2-26
Maternal Monitoring• Baseline: Thyroid functions, if not done• Each visit: Dipstick UA; UC as appropriate; verify SMBG• Every 4 weeks: HbA1C• First trimester: Eye exam with dilation by Ophthalmologist (follow-up as indicated) Screen for albuminuria If complications exist or develop, refer patient to Diabetes Specialist and other specialists as necessaryNutrition• Increase calories 300/day in the secon
d and third trimesters• Adequate weight gain according to ta
ble below BMI
%DBW (wt/ht2=/ 2 ) Wt. Gain
9 0 % 198< . - 2840 lbs. - 90120 19
-826 - 2035 lbs. 120 26 - 1525 lbs.
- Self Management Education• Emphasize hypoglycemia prevention/iiiiiiiii• Instruct family member on glucagon admi ni st r at i on• Instruct on self adjustment of insulin a
s appropriate• No skipped meals
Type 1: Food Plan and Exercise
2-27 Medical Nutriti on Therapy Guidelines (no-n pregnant)
• i: 3 0% otal calories; ries; less if BMI > 2 7 kg/m2
or LDL > 130 mg/• Saturated fat: < 10% total calories; < 7% w ith LDL > 1 3 0 mg/dL• Cholesterol: < 3 00mg/day• If BMI > 27 kg/2m , decrease calorie s by - 1020% an d add exercise
• If BP > 130/85mm/Hg, reduce sodium ti 2400< mg/day• If albumin > 30 0 24mg/ hour or creatinini > 3 0 0 mg/g, reduce protein 08to . g/kg/da y or ~10% total calories
Calorie RequirementsAdults
Most men/active women: DBW x 15 kcal Most women/inactive
men/most adults > age 55: DBW x 13 kcal
Inactive women/obese adults/inactive adults
55> age : DBW x 10 kcal Children/Method1
100First year: 0 kcal - Age 1 10: Add 100kcal/year - Age 11 15: Boys a 200
kcal/year; girls add 100 kcal/year
Age > 15: Boys ad d for activity (2 3 kcal/lb very active, 1 8 kcal/lb
normal, 16 kcal lb i nactive); girlsiiiiiiiii ii iiiii
Children/Method2
100First year: 0 kcal - Age 1 3: Add 40 kcal/inch Age > 3: Boys 125 kcal x age; 100girls kcal x age; add up to iii iiii20iiii
Establish Food Plan and Exercise
Assessment
• Food history or 3 day food record (meals, ti mes, portions)• Nutrition adequaii• Height/weight/B MI; see BMI Char t -i43• Weight goals/eatiii iiiiiiiii• Psychosocial issu es (denial, anxiety, depression)• iiiiii iiiiiiiiii l factors• Nutrition/diabete s knowledge• iiiiiiiii ii iiii n/barriers to l ear ni ng• Work/school/spor ts schedules• Fitness level (str ength, flexibility, endurance)• Exercise (times,iiiiiiiii iiiiii• iiiiiiiiiiiiiii use• iiiii iiii iiiiii supplements
Goals• SMBG/HbA
1c i n tar get• Desirable body w eight (adults)• Normal growth a nd development (children)• Consistent carbo hydrate intake• Regular exercise
Plan• Establish adequa te calories for growth and devel-opment/rea sonable body weiiii• Set meal/snack tiiii• Integrate insulin r egi men wi t h food plan• Set consistent carbohydrate intake• Establish regular -exercise regi men based on fit ness level• Establish adequa te calories for pregnancy/lactation/recovery from illness
Gestational: SMBG and Weight Gain Targets
3-2
SMBG Targets• All values within target range• - - Pre meal and bedtime: 60 95 mg/dL• - Post meal: < 120 mg/dL 2 hours after start of meal; < 140 mg/dL 1 hour after start of meal
Urine Ketones Target• Negat i ve
SMBG Frequency• - 7 12Test times/day; before and h ours after start of meals and at bedtime• - Minimum 4 times/day; fasting and 1 2 hours after start of meals
Urine Ketones Monitoring • Test every AM 1for week, then every other AM
Weight Gain Guidelines %DBW BMI
GAIN 90% 198< . - 2840 lbs. - -90120 19826.
- 2035 lbs. 120 - 26 1525> lbs.
Target weight gain for significantly obes e women
29 2 15(BMI > kg/m ): ~ lbs
3-3
With risk factors: Screen atfirst prenatal visitNo risk factors: screen at24-28th gestational weekScreen with 50 gram glucosechallenge test (GCT)
With risk factors: Screen atfirst prenatal visitNo risk factors: screen at24-28th gestational weekScreen with 50 gram glucosechallenge test (GCT)
Monitor fastng and 2 hours after start of meal; start foodplan If average fasting BG i 95mg/dL - 2or average hour post meal BG i 120mg/dL, treat with food plan and 32repeat OGTT at weeks
See FoodPl an/St ar t -i38
2Monitor fastng and hours after start of meal; start foodplan If average fasting BG i 95mg/dL - 2or average hour post meal BG i 120mg/dL, treat with food plan and 32repeat OGTT at weeks
See FoodPl an/St ar t -i38
Gestational: Screening and Diagnosis
Patient is pregnantPatient is pregnant
YES
50 gram glucose challenge (GCT) test abnormal (plasma glucose > 140mg/dL or whole blood > 120mg/dL?
50 gram glucose challenge (GCT) test abnormal (plasma glucose > 140mg/dL or whole blood > 120mg/dL?
NO
NO
Perform 100 gram oral glucose tolerance test (OGTT) within 3 days of positive screen
Perform 100 gram oral glucose tolerance test (OGTT) within 3 days of positive screen
Two abnormalOGTT values?Two abnormalOGTT values?
YES
Diagnosis of gestational diabetes
Move to GestationalMaster DecisionPath
Diagnosis of gestational diabetes
Move to GestationalMaster DecisionPath
N O
With risk factors: Rescreen 24 32at and weeks; if normal 32at weeks, no further t est i ng No risk factors: No furthert est i ng
With risk factors: Rescreen 24 32at and weeks; if normal 32at weeks, no further t est i ng No risk factors: No furthert est i ngWith risk factors: RepeatOGTT at 32 weeks No risk factors: No furthertesting
With risk factors: RepeatOGTT at 32 weeks No risk factors: No furthertesting
One abnormal value?One abnormal value?
YES
Risk Factors• - -BMI > 27 (especially waist to iiiii i ii1• -2Family history of type dia -betes (especially first degree relatives)• Age > 30• Multiparity• Previous gestational diabetes: - - -Macrosomic or large for gesta tional age infant• -Previous impaired glucose toler ance (IGT) with fasting BG - 110125mg/dL• -Previous impaired fasting glu 2cose (IGT) with hour OGTT - 140199mg/dL• American Indian; African American; Asian American; Mexicah/Hispanic American; Pacific Islander
N O
PLASMA WHOLE BLOOD Fasting i 105mg/dL i 90mg/dL 1 hour i 190mg/dL i 165mg/dL 2 hour i 165mg/dL i 145mg/dL 3hour i 145mg/dL i 125mg/dL
100 gram Oral Glucose Tolerance Test
3-5
Food Plan Stage
Insulin Stage 2
R/N - 0 - R/N - 0 LP/N - 0 - LP/N -
0
Gestational: Master DecisionPath
OR
At Diagnosisiiii iiiiiii
plasma glucose 95< mg/dL
At Diagnosis OGTT f ast i ng
plasma glucose 95< mg/dL
At Diagnosis*iiii iiiiiii
plasma glucose> 95mg/dL
At Diagnosis* OGTT f ast i ng
plasma glucose> 95mg/dL
Insulin Stage 3A
R/N - 0 - R - NIf persistent midafternoonhyperglycemia, start InsulinStage 4A
Food Plan Stage
R = Human Regular InsulinN = Human NPH Insulin0 = None
Dose Schedule:
AM - MIDDAY - PM - BEDTIME
Medications
• Continue with food plan and exercise program throughout all stages of therapy• Lispro (LP) insulin has not been tested during pregnancy
Medications
* Plasma Glucose criteria for starting each therapy may be modified
Type 1: Insulin Adjustment Guidelines
3B
3-8
• 1 CHO = 1 c arbohydrate serving = 1 5 gm carbohydrate ; - 6090 caloriii• 1Meat/Sub = 1 oz serving 28 7( gm) = gm protein; 5 -gm fat; 5 0 1 00 calories• 1 Added Fat = 1 serving = 5 45gm fat;calories• Vegetables =- 12 servings/da y with each meal; not counted in plan
Assessment
•
Food history or- 3day food record (meals an d snacks with times and portions)
•
Nutrition adequacy
•
Weight gain/change
•
Exercise times,duration, and type
•
Fitness level (str ength, flexi bility, endurancei
•
Alcohol use
•
Vitamin and min -eral suppoe mentGoals
•
- Good pre natalnutrition
•
Proper weight g ain based on BMI
•
SMBG within tar get r ange
•
Negative ketoniiPlan
• Two carbohydra te choices at breakfast and consistent bedtime snack• Set meal and sn ack times• Set consistent carbohydrate intake at meals and snacks to meet BG targ ets(see sample food plan)• Encourage regul ar exercise based on usual activity prior to pregnancy
Refer for nutrition and diabetes education within 48hours
Start Food Plan
Sample Food Plan
MEAL CHO MEA T/SUB FAT
Bkfat. 2- -01 01
- Snack 1 2 - -01 01
- -Lunch 3 4 2 - 3 12
- Snack 1 2 -0 01
- Dinner 3 4 2- -4 12
- Snack 1 2 -0 01
-Follow up Medical: Phone within 3 days to review SMBG, urine ketones, and food records, then office visit - within 1 2 weeks
-Follow up Medical: Phone within 3 days to review SMBG, urine ketones, and food records, then office visit - within 1 2 weeks
Move to Food Plan/AdjustMove to Food Plan/Adjust
3-9
SMBG and/or HbA1cwithin target range andpatient in “honeymoon”
phase?
SMBG and/or HbA1cwithin target range andpatient in “honeymoon”
phase?
YES
Gestational: Food Plan/Adjust
Patient in Food PlanStage
Patient in Food PlanStage
NO
Patient enters FoodPlan/Maintain
Continue current therapy; use this -DecisionPaht for follow up
-Follow up - Medical: Phone 1 2 times/week Office visit every 2 weeks
Patient enters FoodPlan/Maintain
Continue current therapy; use this -DecisionPaht for follow up
-Follow up - Medical: Phone 1 2 times/week Office visit every 2 weeks
Move to Insulin Stage2,or Insulin Stage 3 A
Move to Insulin Stage2,or Insulin Stage 3 A
• If elevated postprandial BG, decrease carbohydrate at meals if appropriate; redistribute carbohydrate (calories) to other times of the day• If positive ketones or insufficient weight gain, add or increase bedtime snack;assess adequacy of caloric intake; add more food at snack times; assess undereating to avoid taking insulin
Adjust food plan based on BG, ketone, or weight; use this DecisionPath for-follow up
-Follow up - Medical: Phone 1 2 times/week
Office visit every 2 weeks - 24Education: Every weeks as needed
- Nutrition: Every 2 4 weeks as needed
• If elevated postprandial BG, decrease carbohydrate at meals if appropriate; redistribute carbohydrate (calories) to other times of the day• If positive ketones or insufficient weight gain, add or increase bedtime snack;assess adequacy of caloric intake; add more food at snack times; assess undereating to avoid taking insulin
Adjust food plan based on BG, ketone, or weight; use this DecisionPath for-follow up
-Follow up - Medical: Phone 1 2 times/week
Office visit every 2 weeks - 24Education: Every weeks as needed
- Nutrition: Every 2 4 weeks as needed
Food Plan Adjustments
3-12Gestational: Insulin Stage 2/Start
- - - 0 0R/N R/N At Di agnosi s Calculate total dose at 0.4 U/kg based on current weight
AM MIDDAY PM BTDistribution 23 0 13 0/ / - -R/N ratio 1:2 1:1
Refer patient for nutrition and diabetes education
- - - 0 0R/N R/N At Di agnosi s Calculate total dose at 0.4 U/kg based on current weight
AM MIDDAY PM BTDistribution 23 0 13 0/ / - -R/N ratio 1:2 1:1
Refer patient for nutrition and diabetes education
At Diagnosis or from Food Plan StageStart insulin within 24 hours. Hospitalize if
medically necessary
At Diagnosis or from Food Plan StageStart insulin within 24 hours. Hospitalize if
medically necessary
Start Insulin Stage 2
Move to Insulin Stage 2/AdjustMove to Insulin Stage 2/Adjust
Follow-upMedical: Daily phone contact for 3 days, then office visit within 2 weeks; 24-hour emergency phone sup-port neededEducation: Within 24 hours, then office visit in 2 weeks
Follow-upMedical: Daily phone contact for 3 days, then office visit within 2 weeks; 24-hour emergency phone sup-port neededEducation: Within 24 hours, then office visit in 2 weeks
3-13
Is current total dailyinsulin dose:< 1.5 U/kg?
Is current total dailyinsulin dose:< 1.5 U/kg? N
O
Gestational: Insulin Stage 2/Adjust
Patient in Insulin Stage 2Patient in Insulin Stage 2
-If persistent AM hyper glycemia or
nocturnal hypo glycemia, move to
Insulin Stage 3A/Start
-If persistent AM hyper glycemia or
nocturnal hypo glycemia, move to
Insulin Stage 3A/Start
Insulin Stage 2 Pattern Adjustm R/ - - - 0 0N R/N
AM
MIDDAY
(MID)
PM
BEDTIME
(BT)
Pattern of BG in mg/dL
-Pre meal - Post meal 2 hr > 120 60 90< > 90 1 140
Adjust insulin based on BG patternsFollow-upMedical: Weekly while adjusting insulin, then office visit within 1-2 months; use this DecisionPath for follow-up Education: Every 2-4 weeks as needed
See Insulin Adjustment Guidelines, 3-18, for adjustment considerationsdesignated by each letter.
YES
ฏAM R
(j)
ฏAM R (b,k)
ฏPM N (a,h,n)
ฏPM R
(k)
ฏ PM
R
(k)
ฏAM N
(c,k)
ฏPM N
(a,d)
ฏAM N
(j,m)
ฏAM R
(j,l)
ฏAM R
(j)
ฏAM R
(f,j)
ฏAM N
(a,k)
ฏAM N (c,k)ฏAM N (k)
3-14Gestational: Insulin Stage 3A/Start
- - - 0R/N R N At Di agnosi s Calculate total dose at 0.4 U/kg based on current weight
AM MIDDAY PM BTDistribution 23 0 16 16/ / / - - -R/N ratio 1:2
From Insulin Stage 2• Use current total dose• Move PM N to bedtime (BTi• R may be modified for activity and timing of meals• AM - R may go down 1 2 units• PM - R may go up 1 2 units Refer patient for nutrition and diabetes education
- - - 0R/N R N At Di agnosi s Calculate total dose at 0.4 U/kg based on current weight
AM MIDDAY PM BTDistribution 23 0 16 16/ / / - - -R/N ratio 1:2
From Insulin Stage 2• Use current total dose• Move PM N to bedtime (BTi• R may be modified for activity and timing of meals• AM - R may go down 1 2 units• PM - R may go up 1 2 units Refer patient for nutrition and diabetes education
At Diagnosis or from Food Plan Stageor Insulin Stage 2
Start insulin within 24 hours. Hospitalize ifmedically necessary
At Diagnosis or from Food Plan Stageor Insulin Stage 2
Start insulin within 24 hours. Hospitalize ifmedically necessary
Start Insulin Stage 3A
Move to Insulin Stage 2/AdjustMove to Insulin Stage 2/Adjust
Follow-upMedical: Daily phone contact for 3 days, then office visit within 2 weeks; 24-hour emergency phone sup-port needed
Follow-upMedical: Daily phone contact for 3 days, then office visit within 2 weeks; 24-hour emergency phone sup-port needed
3-15
Is current total dailyinsulin dose: < 1.5 U/kg?
Is current total dailyinsulin dose: < 1.5 U/kg?N
O
Gestational: Insulin Stage 3A/Adjust
Patient in Insulin Stage 3A
Patient in Insulin Stage 3A
If persistent midafternoonhyperglycemia, move to
Insulin Stage 4A
If persistent midafternoonhyperglycemia, move to
Insulin Stage 4A
Insulin Stage 2 Pattern Adjustm R/ - - - 0 0N R/N
AM
MIDDAY
(MID)
PM
BEDTIME
(BT)
Pattern of BG in mg/dL
-Pre meal - Post meal 2 hr > 120 60 90< > 90 1 140
Adjust insulin by 10% or 2 units, whichever is greaterFollow-upMedical: Phone 1-2 time/week; office visit every 2 weeks; use this DecisionPath for follow-up Education: Every 2-4 weeks as needed
See Insulin Adjustment Guidelines, 3-18, for adjustment considerationsdesignated by each letter.
YES
ฏAM N
(j)
ฏAM R (b,k)
ฏ N (a,n)
ฏPM R
(k)
ฏ PM
R
(k)
ฏAM N
(c,k)
ฏBT N
(a,d)
ฏAM N
(j,m)
ฏAM R
(j,l)
ฏAM R
(j)
ฏAM R
(f,j)
ฏAM R
(b,k)
ฏAM N (c,k)ฏAM N (k)
Gestational Insulin Adjustment Guidelines
3-18
How to Use These Tables1. Find current insulin stage2. Find the pattern of blood glucose problem (column)3. Identify time of day (row) pattern occurs4. Where the column and row intersect, see recommended changes5. See notes for additional considerations
Notesa. Evaluate nocturnal hypoglycemia; check 3 AM BGb. Consider increasing mid-morning snackc. Consider increasing afternoon snackd. Consider increasing bedtime snacke. Consider giving injection 45 minutes before mealf. Consider decreasing carbohydrate at breakfast g. If post AM increase, increase AM snackh. Consider Insulin Stage 3Ai. Consider Insulin Stage 4Aj. Consider adding exercisek. Evaluate if previous exercise is causing hypoglycemial. Consider decreasing mid-morning snackm. Consider decreasing afternoon snackn. Consider decreasing bedtime snack
Insulin Pattern Adjustments• Adjust insulin from 2-3 day BG pattern• Determine which insulin is responsible for pattern• Adjust insulin by 10% or 2 U, whichever is greater• Adjust PM/BT N for 3 AM hypoglycemia or hyperglycemia
4-2Impaired Glucose Homeostasis
Assess Nutritional Needs• HbA1c, SMBG, lipid profile, albuminuria• - Food history or 3 day food record (meals and smacks with time and snacks with times and portions)• Nutrition adequacy• Height/weight/BMI• iiiiiiiiiiii iiiiiiiii/• Exercise times, duration, and type Determine Nutritional Goals• SMBG and HbA 1c within target range• Weight, BP, and lipids in acceptable range• Consistent carbohydrate intake
Design Food Plan Set meal and snack times Set consistent carbohydrate intake at meals and snacks to meet BG targets Design Exercise Plan• Encourage regular exercise based on cardiovascular fitness age, weight, history• - -Low intensity warm up and cool down - 5075 20 3% maximum aerobic capacity for minutes, times/week
Refer patient for nutrition and diabetes education
Assess Nutritional Needs• HbA1c, SMBG, lipid profile, albuminuria• - Food history or 3 day food record (meals and smacks with time and snacks with times and portions)• Nutrition adequacy• Height/weight/BMI• Weight goals/eating disorders• Exercise times, duration, and type Determine Nutritional Goals• SMBG and HbA 1c within target range• Weight, BP, and lipids in acceptable range• Consistent carbohydrate intake
Design Food Plan Set meal and snack times Set consistent carbohydrate intake at meals and snacks to meet BG targets Design Exercise Plan• Encourage regular exercise based on cardiovascular fitness age, weight, history• - -Low intensity warm up and cool down - 5075 20 3% maximum aerobic capacity for minutes, times/week
Refer patient for nutrition and diabetes education
At Diagnosis Impaired fasting glucose (IFG), fasting
- 110125plasma glucose mg/dL, - 2 140199and/or hr OGTT value mg/dL
At Diagnosis Impaired fasting glucose (IFG), fasting
- 110125plasma glucose mg/dL, - 2 140199and/or hr OGTT value mg/dL
Establish food and Exercise Plan
-Follow up Medical: Within 3 months
Nutrition: As meeded
-Follow up Medical: Within 3 months
Nutrition: As meeded
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