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FUNCTIONAL INSULIN THERAPY

Who is concerned by this functional therapy and how to profit from it ?

All type 1 diabetics could turn to this technique.
All that is needed is a basal-bolus schema and some experience

.

If you are diabetic and practice a sport on a regular basis, it is important to read this chapter in order to get a better understanding of your dosage of insulin during the day and the relation between your dosage and the effort and intensity of your activity.

source: (Assistance Publique - Hôpitaux de Paris)

What is the definition of functional insulin therapy ?


The term refers to a recent technique which provides information so that the patient can determine as precisely as possible the quantity of insulin he needs.

This technique is adapted for the insulin schemas using the association of basal insulin and rapid insulin injected before meals, the schemas are also called basal-bolus (see chapter on insulin and the insulin pump). Many diabetic departments offer their patients "courses in functional insulin therapy ".
But in practise many diabetics using this schema apply the functional insulin therapy without knowing it.
the tests proposed by doctors which are described below.

However, day after day, the necessity to live with diabetes has given them the knowledge and a feeling for their treatment. Sometimes the practise is worth as much as the course proposed by doctors.

What is the basal-bolus schema ?

To imitate the functioning of a normal pancreas, the ideal situation would be to inject insulin to cover the 24 hour day and rapid insulin at meal time.
The goal of basal or Lantus insulin which covers the 24 hour day is to give you normal blood sugar rate outside of meal time.The rapid or bolus" injected at meal time is adapted according to your intake of carbohydrates .
Their role is to stop the increase of blood sugar level after meals.
Their role is to stop the increase of blood sugar level after meals.

How to determine the basic requirement in the best manner; how to determine slow doses?

These few lines are here only for information. It is useless to try the system by yourself. Only a specialist in diabetes can determine the doses to be injected.

To determine the dose of slow insulin best for you, the reference method is to abstain from absorbing carbohydrates for 24 hours and injecting only slow insulin, without the quick ones and in analysing the results over 24 hours.

CAREFUL ! Naturally this test should be held with the agreement of your doctor and under his control.

On test day, you should have breakfast with tea or coffee (no sugar) and lunch and dinner with meat, salad and cheese.
You will inject slow insulin or basal as usual if you are already using this system. If not the theoretical dose is from 0.3 to 0.4 units per kilo (your weight) and per day. For example for 70 kilos, you will need to inject 21 to 28 units of slow insulin.).
Your capillary blood sugar levers should be taken every two hours during the day and every three hours at night.
The target blood sugar level during these 24 hours of carbohydrate abstinence is situated between 70 and 140 mg/dl.
If the figures are outside of these, you should correct your level with the help of a quick insulin supplement or on the other hand an intake of sugar.

By analyzing at the end of the test the correction of the blood sugar level during these 24 hours, it is possible to more precisely determine your daily dose of basal insulin. An extra day of carbohydrate abstinence will allow you to test the re-evaluated new dose.
This test allows you as well to understand your daily requirement for slow insulin, even if you don't eat and as a result, thanks to the basal insulin, you can skip a meal or delay one without risk of a hypoglycaemia or abstain from eating if necessary.

This test also proves that you have liberty in determining your meal times ! It's when you decide to eat that you inject quick reacting insuline.

How to determine the dose of quick insulin in relation to the carbohydrates of meals?

We can begin with the following base : for 10 gms of carbohydrates, the injection would be 2 units of insulin for breakfast, one for lunch and 1.5 for dinner. (to help you, check out the equivalence page and the blood sugar level index).

Afterwards, you adapt the dose to your case, with the help of the meal tests (for example a breakfast with 40 gm of carbohydrates, lunch and dinner with 60 or 80 g).
On test day, you weigh carefully all the ingredients, you inject the theoretical dose of rapid insulin before the meal and you measure you blood sugar rate an hour and a half after the beginning of the meal.

The rate should not increase by more than 40 mg/dl: for example 100 mg/dl before the meal should not show more than 140 mg/dl an hour and a half afterwards, with a return to a normal blood sugar level 4 hours after your meal.

In this way you can determine the number of insulin units you require for 10 g of carbohydrates, as this number varies for breakfast, lunch and dinner.

Later, the rough part is to predict what you will eat and evaluate more or less the quantity of carbohydrates with the help of pocket size tables and a scale.
.

How to correct an excessive blood sugar level (above 130 or 140) or too low (below 70) ?

As for the excessive blood sugar level it is necessary to evaluate the efficiency of the unit dose of quick insulin.

Usually the dose lowers the blood sugar level by 30 to 40 mg/dl but it is necessary to run a test at the time of a stable blood sugar level, lasting around 2 hours, inject a unit of fast insulin and then control the capillary blood sugar level, every hour during 4 hours.
This test could be run the day of the carbohydrate abstinence test. On the other hand, a test should be run concerning the efficiency of 15 g of carbohydrates in "resugaring" : how much does the blood sugar rate increase 15 minutes after.? Generally it will be around +50 mg/dl.
Therefore if your blood sugar rate is too high, you can correct it, especially before mealtime, by adding the correction to the insulin dose required to cover the carbohydrates in your meal.
.

How to adapt your insulin in case of physical exercise ?

The adjustment of the insulin dose is determined with the help of an analysis of an intense physical activity and a short one (under 2 hours) and then a significant and long lasting activity over 2 hours.
We can start with the following:

In case of an intense and short period of activity following a meal: the dose of rapid insulin for this meal should be reduced by 30 to 50%

In caseof an intense and short period of activity following a meal: l the dose of rapid insulin for this meal should be reduced by 30 to 50%.

In case of an intense and short period of activity at the end of the afternoon: the dose of rapid insulin for the evening meal should be reduced from 30 to 50%..

In the case of significant and long lasting physical activity: The injection of rapid insulin at mealtime and the dose of slow insulin should be reduced (or lower the level of basal temporarily on the pump)

IMPORTANT REMINDER FOR THOSE WHO PARTICIPATE IN SPORTS ON A REGULAR BASIS:

These various schemas must be tested during your training period.
Testing is essential to self-knowledge

Who is concerned by the functional insulin therapy and how to learn about it ?

Any Type 1 diabetic can apply this technique.
You need to have a basal-bolus schema and experience.
You do not need to do all the tests!
But as is the case for the insulin pump, in general more blood sugar controls are needed.

The advantage of this method is that it forces a better knowledge of dietary habits, which is a weak spot for many diabetics.

Some patients are perfectly balanced with their basal-bolus treatment and modify by instinct their dose of quick insulin, depending upon the meal, the blood sugar level at the time and the physical exercise to follow: they use the functional insulin therapy in their way, without a mathematical rule!


As a matter of fact, it would be a mistake to believe that the management of diabetes can be summarized by a calculator which determines the dose of insulin for each meal and that this calculation is good for life...

Some patients choose to undergo these tests professionally to improve their knowledge of their diabetes : those patients are the target for the " courses in functional insulin therapy " organized by most specialized diabetic teams.
Their goal is to bring to you added knowledge so that you can live with your diabetes in the best possible manner.

Of course you can understand that diabetes cannot be cared for with strict mathematical rules
They are bound to fail in everyday life.

Rémi

source (Assistance Publique - Hôpitaux de Paris)


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