cations of diabetes. Modern research shows through an intensive diabetes manage- ment. with diabetes, and sometimes I address your family or …
INSULIN-DEPENDENT DIABETES
in Children, Adolescents and Adults
Insulin
Oxygen dioxide
Carbon Water Energy
How to become an expert on your own diabetes
Ragnar Hanas, MD, Department of Pediatrics, Uddevalla, Sweden
This book shows in a practical way what you need to know to be able to take good care of your diabetes Having diabetes means that you need to know more about the disease than the average doctor, to be able to understand and take care of your illness in an appropriate way This is necessary both to enjoy your life today, and to avoid and postpone late complications of diabetes Modern research shows unambiguously that a lower mean blood glucose will lessen the risk of late complications By reading this book you will learn how this can be accomplished through an intensive diabetes management Sometimes in this book I speak directly to you, the person with diabetes, and sometimes I address your family or parents At other times there is even information for third parties, like the diabetes team members When you are reading this book, just imagine that we are all together, sitting around a table, discussing diabetes Remember that you run your own life - don let your
diabetes take over Instead you can learn t how to handle your diabetes in the different situations that life has to offer This book is applicable to children, adolescents and adults having insulin-dependent diabetes It is also meant for teaching persons involved in diabetes and diabetes care, such as nurses, doctors, dietitians, teachers, child care staff and others The author is consultant pediatrician at Uddevalla Hospital in Sweden, specializing in diabetes The book was awarded the price for best pedagogical book by the Swedish Society for Diabetology in 1998 You will find more information about the book at http://wwwpiaracom/eng and http://wwwchildrenwithdiabetescom/d_06_b00htmhanas
The cover illustration shows how glucose enters into the cell with the help of insulin
ISBN 91-630-6261-5 First edition in English 1998
104
Insulin pump
Our aim is to be able to offer all diabetic individuals an insulin treatment that is right for them When multiple injection treatment does not give acceptable glycemic control we usually suggest an insulin pump Many of our teenagers with brittle diabetes feel much better after the transition to pump therapy More than 40 of those in the intensive
treatment group in the DCCT-study chose an insulin pump There are 32000 patients on insulin pumps in North America 1997 Insulin pump therapy is more expensive than conventional syringe or pen therapy Since insulin pumps are not subsidized in most countries they may be a financial burden Ask your diabetes team how this can be solved in you community Only short acting insulin is used in the insulin pump Often short-acting insulin with special solvent is used to avoid blockage of the catheter buffered insulin, Velosulin, Isuhuman Infusat The action time and effect of this insulin is similar to ordinary short-acting insulin eg Actrapid, Humulin Regular, Isuhuman Rapid Today most catheters are made of a material with less risk of blockage, and ordinary short-acting insulin will usually suffice375 Buffered U-40 insulin for smaller children is not available We have had no problems with catheter blockage using regular short-acting 40 U/ml insulin in insulin pumps Direct-acting insulin Humalog has also been tried with success in insulin pumps 438 see page 119 The insulin pump will deliver a steady basal rate of insulin 24 hours a day Most modern pumps can be adjusted for different basal
insulin rates during the day and night Extra insulin is given with meals by pushing a button on the pump bolus dose The insulin is pumped through a thin tubing catheter that is connected to a metal needle or indwelling catheter placed subcutaneously
Insulin level in blood mU/L
Non-diabetic persons Pen Pump
AM
PM
AM
Breakfast
Lunch
Dinner
Bedtime insulin
This figure is from a study where insulin levels in the blood were compared when using different types of insulin treatment309 The patients in this study used insulin pens with 3 premeal doses of short-acting insulin and one dose of bed time insulin The graph shows that pump therapy resulted in higher insulin peaks after meals but also higher insulin levels between meals Compare with the shaded area showing that the insulin level in non-diabetic individuals rises very steeply after a meal In the early morning insulin pumps give higher insulin levels than multiple injections
Insulin-dependent diabetes in children, adolescents and adults R Hanas 1999
105
Insulin pump
Advantages with insulin pump
Disadvantages with insulin pump
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The basal rate will give you sufficient amounts of insulin in the early morning to avoid a
high blood glucose level when you wake up Certain individuals need a higher level of insulin between meals which the insulin pump can provide The continuous supply of basal insulin will make you less dependent of the mandatory interval of not more than 5 hours between meals in multiple injection treatment You always have your insulin with you and it is easier to take a bolus dose with the pump than to take an injection with a pen or syringe, especially if you dont feel like injecting when out with a group of people If the pump can be programmed for different basal levels you will have the advantage of adjusting the pump for the differing needs of basal insulin during the day and night The pump uses only short-acting insulin which ensures a more predictable insulin effect compared to intermediate- and long-acting insulin Possibility of adjusting the premeal doses in 1/10th unit increments The risk of severe hypoglycemia is usually reduced when using an insulin pump A small insulin depot will decrease the risk for unpredictable release of insulin during physical exercise During exercise a temporary basal rate can be used
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A small insulin depot will make you very sensitive to an
interruption in the insulin supply, risking the rapid development of ketoacidosis You must take more tests when using an insulin pump The insulin pump will be connected to you 24 hours a day Some feel that this makes them more tied up to their diabetes The pump will be very obvious, for example when going to a public bath Your diabetes will no longer be a secret disease Often you will get curious questions about the pump, something that a person who has not fully accepted his/her diabetes fully might experience as uncomfortable The pumps alarm will trigger every now and then and you might need to stop your activities to change the needle or tubing at an inconvenient time
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often improves, resulting in a lower HbA1c58,105 Some patients especially teenage girls will gain weight when they start using an insulin pump if they dont decrease their food intake as their glycemic control improves The extra glucose that was earlier lost with the urine will now remain in the body and be transformed into fat instead The risk of severe hypoglycemia usually decreases with pump treatment,56,58,105 whereas the risk of ketoacidosis diabetic coma may increase according
to some studies 105 while it decreases in others58 Ketoacidotic episodes usually occur early after initiating pump treatment when the patient is new to the method291 Some teenagers are frequently hospitalized due to ketoacidosis caused by interrupted insulin supply Such episodes can drastically be reduced with an insulin pump that makes a continuous insulin supply possible50
A common problem with pen injectors and syringes is that the insulin will not always give quite the same effect even if the dose is exactly the same With an insulin pump the insulin will be deposited in the same site for several days and the absorption will be more even251 Insulin absorption after a premeal dose will be constant for at least 4 days provided that the needle is inserted in an area free of lipohypertrophies311 The total insulin requirement per 24 hours usually decreases 15 - 20 after starting with insulin pump treatment 58,105,377 and the glycemic control
Insulin-dependent diabetes in children, adolescents and adults
The basal rate
Approximately 40 - 50 of the daily insulin requirement is given as the basal rate often close to 1 U/hour for an adult person and the rest as premeal bolus
injections196 After a change in the basal rate it will take 2 - 3 hours before the blood glucose level is affected191 The basal insulin is absorbed
R Hanas 1999
Insulin pump
106
Insulin pump treatment will be easier if you: adapted from 391
Daytime basal rate
These guidelines apply to pumps with programmable basal rates Make changes in basal rates in collaboration with your doctor and diabetes nurse It may often be appropriate to divide the hours of the day into different basal rate profiles where each contains a main meal Measure the blood glucose level before the meal a couple of days in a row Change the basal rate profile preceding the meal first check that the preceding meals bolus dose was set correctly: Blood test before meal 5 mmol/L 90 mg/dL 8 - 10 mmol/L 144 - 180 mg/dL Measure Decrease the basal rate by 01 U/hour Increase the basal rate by 01 U/hour
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Are comfortable with the pump being constantly attached to your body and understand how it works Regularly check your blood glucose, at least 2 - 3 times daily including morning and evening Regularly perform urine tests for ketones: every morning, when ill or having nausea or when blood glucose is above 15
mmol/L 270 mg/dL Recognize symptoms of low blood glucose Always carry glucose tablets Recognize early symptoms of ketoacidosis diabetic coma Always carry extra insulin and a pen or syringe to be able to treat this condition Have frequent contact with a diabetic clinic Persons living alone should have frequent contact with a close friend or relative
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twice as rapidly if the person has a thin subcutaneous layer less than 10 mm in a lifted skin fold compared to a thicker subcutaneous fat layer more than 20 mm193 The bodys insulin requirement is about 20 lower between 1 - 3 AM compared to 5 - 7 AM63 If one uses a pump with the possibility of different basal rates you can administer a lower basal rate between 11 - 12 PM to 3 AM to avoid nighttime hypoglycemia63 If you have problems with high glucose readings in the morning you can try a slight increase in the basal rate 01 - 02 E/hour between 3 and 7 AM The insulin sensitivity will increase when the blood glucose level has been lowered for some time from a few days up to a week To avoid hypoglycemia you should be prepared to decrease the basal rate especially at night when blood tests start to show lower readings The advice
on basal rates in this chapter are written for a pump that can be adjusted for different basal rate levels throughout the day and night With some pumps the basal rates are adjustable every hour and others can be set for different profiles for a longer
Insulin absorption U/h
Another way of adjusting your daytime basal rate is to skip breakfast and the prebreakfast bolus and adjust the basal rate to keep the blood glucose level constant until lunch57 Repeat the procedure with the other meals during the day
Changes in the basal rate
hours Basal dose 1,1 2,2 1,1 U/hour
When you change the basal rate it will take 2 - 3 hours before any effect will appear, eg an increased absorption of insulin into the blood stream The reason for this is that when you increase the basal rate, part of the insulin will stay in the subcutaneous tissue as an insulin depot When you decrease the basal rate, the insulin from the depot will continue to be released and absorbed into the blood stream for another 2 - 3 hours until the depot has decreased in size The graph is from reference 191
R Hanas 1999
Insulin-dependent diabetes in children, adolescents and adults
107
Insulin pump
Nighttime basal
rate
Check your blood glucose levels during a night after an ordinary day when you have been feeling well and have not had extra exercise Adjust the premeal bolus dose before the evening meal to reach a blood glucose level of about 7 - 8 mmol/L 126 - 144 mg/dL at 10 - 11 PM63 Blood test at 3 AM and in the morning 6 mmol/L 108 mg/dL Measure
When should the basal profiles be changed? adapted from 57
You should not change the profiles of the basal rate too often When you are used to the pump it may be practical to change the basal profiles once or twice in a month according to what your 24 hour blood glucose profiles show Change the premeal bolus injections to adjust for temporary changes in diet or blood glucose readings In the following situations it may be necessary to change the basal profiles:
Decrease the basal rate after midnight and/or early in the morning by 01 U/hour Increase the basal rate after midnight and/or early in the morning by 01 U/hour
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Illness with fever and increased need of insulin Change in school or work activities with a new schedule or different physical activity Change in body weight with 5 - 10 or more Pregnancy Women may have different
insulin needs during different phases of the menstrual cycle see page 194 Initiation of treatment with drugs that increase the need of insulin such as cortisone Prolonged physical exercise 12 - 24 hours duration or more
9 - 10 mmol/L 162 - 180 mg/dL
If your pump cannot be adjusted for different basal rate profiles you should adjust it to fit the nighttime need of basal insulin to reach a blood glucose level of 6 - 7 mmol/L 110 - 125 mg/dL at 3 AM 63 Make the changes in basal rates in collaboration with your doctor and diabetes nurse
or shorter period of time If you have a pump that can be programmed for only one basal rate you should adjust it according to your nighttime blood glucose values You will then have to adjust the premeal bolus doses to fit the fixed basal rate
Temporary change of the basal rate
On many pumps you can make temporary changes of the basal rate for one or several hours This is
practical if, for example, you have problems with low blood glucose and repeated hypoglycemia for sustained periods despite extra food intake It will usually help to decrease the basal rate or stop the pump completely for an hour or two If your blood glucose is high at bedtime
you can temporarily increase the basal rate by 01 - 02 U/hour for a couple of hours If your blood glucose is low early in the night you can temporarily decrease the basal rate for a few hours The temporary basal rate is very useful for prolonged exercise For example, during a 5 hour bike ride, decrease the basal rate by 50 If you have exercised in the evening you should decrease the basal rate by 01 - 02 U/hour for the whole night
A modern insulin pump is small and handy You will quickly learn how to use the different controls
Premeal bolus doses
Take a bolus dose 30 min before the meal when using regular insulin in the pump and just prior to the meal if using direct-acting insulin Humalog
R Hanas 1999
Insulin-dependent diabetes in children, adolescents and adults
Insulin pump
mmol/L B-glucose
108
mg/dL
Changing the basal rate
Since it takes 2 - 3 hours before a change in the basal rate will have effect, you must plan ahead
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Change the dose 2 hours before you want it to have effect, eg increase from 3 AM if you want an increased insulin effect from 5 AM on If you want to quickly increase the effect of the basal rate eg if you are ill with fever you should administer an
extra dose of insulin of the same size as 2 hours of the basal rate You will then quickly increase the insulin depot resulting in a quicker absorption of insulin into the blood If you want to quickly decrease the effect of the basal rate eg if you are going to exercise you should stop the basal rate for 2 hours and then start it again with a lower level The insulin depot will then quickly decrease in size and the change in basal rate will soon have effect
AM
PM
AM
Time
8U
6U
5U
4U 09
414 U/24 h 05 07
09 07 Basal rate pump U/hour
Interpreting the 24-hour profile It is best to take tests for a couple of days in a row to be sure that any one day was not just an exception Start by looking at the evening meal since it determines what blood glucose you will have when going to bed The dotted line shows what the blood glucose values might have been with the suggested changes Evening meal: The blood glucose after the meal is a bit low Decrease the dose by 1 unit Adjust the dose to have a blood glucose of about 8 mmol/L when you go to bed Night: Early in the night the basal rate needs to be increased slightly to 06 U/hour as the blood glucose is rising until 3 AM The blood
glucose level from 3 AM to 7 AM is stable so this rate does not need to be changed Breakfast: The blood glucose rises very quickly after breakfast The insulin could have been given even earlier before breakfast to prevent the peak at 8 AM An increased breakfast bolus dose or basal rate would increase the risk of hypoglycemia before lunch Lunch and dinner: No changes Dont change all doses at the same time as it can be difficult to see which change resulted in what Let a few days go by between changes to make sure that the profiles look similar from day to day
However, the timing also depends on what your actual blood glucose level is see page 107 Adjust the doses up or down in the same way as when on multiple injections The breakfast dose is usually slightly larger than the other premeal bolus doses Since the basal need of insulin between meals is now supplied via the pump your premeal bolus doses will be lower than when on multiple injections You will probably need to decrease the size of extra insulin doses as well if, for example, you eat something extra You can calculate the amount of insulin needed for a given amount of carbohydrates by dividing the total amount of
carbohydrates eaten during the day by the amount of insulin taken as a premeal bolus injections109 See example on page 109 Usually one unit will accommodate 10 - 15 grams of extra carbohydrate If, for example, you eat ice-cream containing 26 g of carbohydrate, 2 units of extra insulin will probably be enough You will not be bound to maintaining an interval between meals and insulin injections of at most 5 hours as when on multiple injection treatment The basal rate will probably make it possible to increase the time span between meals to 6 - 7 hours which might be an advantage if you have an irregular schedule
Your should, however, be aware of eating and taking premeal bolus injections with intervals shorter than 5 hours as there will be a risk of overlapping insulin doses when using short-acting insulin in the pump Try reducing the second premeal bolus by 1 or 2 units if the previous meal was only 3 - 4 hours earlier You will not have this problem if you are using direct-acting insulin Humalog in the pump as the action profile of this insulin is considerably shorter
R Hanas 1999
Insulin-dependent diabetes in children, adolescents and adults
109
mmol/L
Insulin pump
B-glucose
mg/dL
How many carbohydrates will one unit of insulin accommodate?109
Example: Carbohydrates g Insulin units 60 50 55 35 200 6 4 5 3 18
Breakfast Lunch Dinner Evening meal Total
Quotient carbohydrates / insulin 111 gram/unit
AM PM AM Time
4U
35 U
3U
3U 06
269 U/24 h 04 05
06 06 Basal rate pump U/hour
In this example of a 12-year old boy 38 kg, 84 pounds one unit of insulin will accommodate 11 grams of carbohydrates without changing the blood glucose level
Interpreting the 24-hour profile See the previous profile for general interpretation Evening meal: No changes Night: The blood glucose does not change early in the night However, late at night it drops significantly, so reducing the basal rate to 07 U/hour is recommended Breakfast: The blood glucose rises quickly after breakfast and the dose should preferably be increased to 5 units The basal rate is probably sufficient as the blood glucose is lowered at lunch again However, when the breakfast bolus dose is increased to 5 units the basal rate might need to be decreased Lunch: The blood glucose two hours after the meal is only slightly increased indicating that the premeal bolus dose is correct However, as the blood
glucose rises prior to dinner, the basal rate could be increased to 07 U/hour Dinner: No changes
teflon catheter, such as Sof-set , Clinisoft , PL Comfort , Disetronic Tender or similar Start by replacing it twice a week and then try to increase the number of days between replacements You can often allow the needle to be in place for 4 - 5 days if your blood glucose readings are not raised Smaller children usually need to replace it more often The longer the catheter remains in one site, the greater the risk of developing lipohypertrophies fat pads, see page 121 and infections If you have problems with fat pads or redness of the skin you should replace the needle/catheter more frequently If the redness doesnt disappear quickly after replacing the needle you can accelerate healing by applying a dressing with warm soapy water for 20 minutes 4 times daily You can also try an antibiotic ointment or hydrogen peroxide If the redness increases or starts hurting, you might need antibiotic treatment Contact your diabetes clinic or doctor
Change of insertion site
The most common site is the abdomen because the absorption of insulin is quickest here With small children it is
preferable to use the buttocks as well to be able to spread the injection sites, thereby decreasing the risk of lipohypertrophies fat pads You can also use the thigh or the upper arm but both sites can result in an increased absorption of insulin when exercising There is also a greater risk of the needle catching on the clothing and being pulled out Individual advice is needed on how often the needle should be replaced We recommend the use of a soft
Insulin-dependent diabetes in children, adolescents and adults
Put the tubing in a sling and fix it with some adhesive to minimize the risk of pulling the needle loose if the tubing is pulled or jerked
R Hanas 1999
Insulin pump
110
When do I replace the parts?
Teflon catheter Metal needle Tubing Start by replacing it twice a week If there are no problems try using it 4 - 5 days before replacement Replace every second day, more often if signs of irritation are noted Replace the tubing at least every other time you replace the needle/catheter and when you replace the reservoir Some pumps have prefilled reservoirs, others need to be filled Do not reuse them as the silicon on the plunger wears off, resulting in no delivery
alarms
Replacement of needle/catheter
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If you replace the needle/catheter before taking a premeal bolus it will be flushed clean from possible tissue rests by the larger volume of fluid Avoid replacing your infusion set before bedtime as you will need to be awake for a couple of hours to see that it functions properly Start by washing your hands with soap and water Disinfect a skin area that is a little larger than the adhesive your are going to apply Use chlorhexidine in alcohol or similar disinfectant Use this for hand-washing as well if you have problems with skin infections Be careful not to touch the sterile needle Pinch a two-finger skin fold and insert the needle at a 45 angle see ill on page 102 Apply the adhesive carefully If it sticks unevenly dont try to move it There is a considerable risk of removing the needle at the same time if you try to move the adhesive Withdraw the old needle after the insertion of the new one Pull the adhesive from the side where the tip of the needle/catheter is located and it will come off more easily
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Insulin reservoir
Problems with irritation or infection of the insertion site can be prevented by careful hand washing,
disinfection and needle/catheter replacement every second or third day Use chlorhexidine in alcohol or similar agent for hand-washing Dont use products containing skin moisteners, since these may cause the adhesive to loosen more easily If you are allergic to the adhesive, it can cause redness or itching see page 103 Insert the new needle or catheter before removing the old one If you do it the other way around there is a greater risk that you will contaminate your hands on the old site, thereby increasing the risk of transferring bacteria to the new one Insert the new needle/catheter at least 2 - 3 centimeters one inch away from the old one to avoid developing fat pads The adhesive should not cover a previous injection site until it is completely healed It is best to change sides on the abdomen left/right with each replacement If you have recurring problems with infected sites in spite of good hygienic routines, the bacteria might originate from you armpits or nostrils Try washing your hands with a disinfection agent as well If a culture reveals bacteria from the nasal cavity, antibiotic treatment may be necessary Avoid inserting the needle in skin folds, close to the belly button
or under the waist-line Straighten your back before you apply the adhesive to avoid tight skin Always check your blood glucose 3 - 4 hours after replacing the needle/catheter to make sure that it works properly
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If you change to a new injection site in the evening you will find it more difficult to detect a blockage in the tubing which will cause the blood glucose to increase Many pump users find it most convenient to replace the injection site when coming home from school or work You will still have plenty of time to find out if something is wrong with the new injections site If you replace the needle/catheter before taking a meal bolus dose the tubing will be flushed clean from possible tissue rests
Insulin depot with a pump
The disadvantage of using an insulin pump is that the insulin depot will be very small, since only short-acting insulin is used If the insulin supply is interrupted you will quickly develop symptoms of insulin deficiency like high blood glucose, nausea and vomiting see Depot effect on page 62 This will be important if the pump is blocked or if you
R Hanas 1999
Insulin-dependent diabetes in children, adolescents and adults
111
Insulin pump
High
blood glucose and ketones?
If the blood glucose is higher than 15 mmol/L 270 mg/dL and you have ketones in the urine, this indicates a blocked insulin supply
Causes of ketoacidosis
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Insulin delivery is interrupted, such as a crack in the connector or a loose needle Increased insulin requirements caused by intercurrent illness without the insulin dose being increased, eg a cold with fever Inflammation or infection at the injection site redness or pus Decreased insulin absorption, for example caused by inserting the needle into a fat pad lipohypertrophy Decreased insulin potency, as after it has been frozen or exposed to heat/sunlight
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Take 01 U/kg 05 units/10 pounds body weight of short-acting insulin or preferably direct-acting Humalog with a pen or a syringe Dont use the pump as you are not sure if it works well Measure blood glucose every hour If it doesnt decrease the insulin dose of 01 U/kg 05 units/10 pounds body weight can be repeated every 1 - 2 hours with Humalog, every 2 - 3 hours with regular short-acting insulin Check the pump by disconnecting the tubing and the needle Activate a bolus dose Insulin should immediately appear from the tubing If it drops
slowly you should give another bolus injection If this dose also drops slowly it indicates a partially blocked tubing, eg caused by coagulated blood or crystallized insulin Replace both the tubing and the needle Replace the needle/catheter if the tubing works well Check for signs of redness in the skin and of moisture close to the injection site indicating insulin leakage Other causes of a lack in insulin delivery:
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their depot193 From this follows that thin individuals will be more sensitive to an interrupted basal rate since their insulin depot is smaller
Ketoacidosis diabetic coma
A small insulin depot will result in early insulin deficiency symptoms if something goes wrong with the pump or the tubing One nights interrupted insulin supply is enough to cause incipient ketoacidosis in the morning with symptoms of insulin deficiency such as nausea and vomiting Be extra careful to check both blood glucose and ketones in the urine when you dont feel well If your blood glucose is above 15 mmol/L 270 mg/dL and you have ketones in the urine you should take an extra dose 01 U/kg or 05 U/10 pounds body weight of short-acting insulin preferably direct-acting Humalog if available The
dose can be repeated after 2 - 3 hours if needed 1 - 2 hours with Humalog Contact the hospital if you vomit or have nausea and are unable to drink
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The connector between the tubing and the insulin reservoir can be broken Hole in the tubing A cat bite in the tubing resulted in leakage which lead to ketoacidosis for a teenage girl Air in the tubing is not dangerous as such but will give you less insulin Squeezed or bent tubing, eg by a belt or tight jeans, will take several hours before the pumps blockage alarm is triggered
intentionally turn it off, such as when sporting or swimming Thicker layers of subcutaneous fat will result in a larger insulin depot of the basal dose In one study a basal rate of 1 U/h was used The insulin depot for persons having a subcutaneous fat of 40 mm 1 inch was close to 6 U while those with less than 10 mm 1/3 inch subcutaneous fat had only 1 U in
Insulin-dependent diabetes in children, adolescents and adults
EMLA
Always use local anesthetic EMLA -cream before replacing the needle/catheter when beginning with pump treatment with small children Apply the cream 1 - 2 hours ahead of time to get the full effect Another alternative to lessen the
pain is the Sof-serterTM for automatic insertion of the Sof-set catheter
R Hanas 1999
Insulin pump
112
How many tests should I take when using an insulin pump?
IMPORTANT
When using an insulin pump you have a greater risk of ketoacidosis since you have a very small insulin depot Always check blood glucose and urine tests ketones when you have nausea or vomit If the amount of ketones increases eg from 2 to 3 this means that the insulin deficiency is increasing You must then contact the hospital to discuss what to do next Be aware that insulin deficiency leading to increased ketone production immediately shows up in the urine If you take extra insulin the production of ketones will stop However, the excretion of ketones in the urine will continue for many hours but you will see that the concentration stabilizes and then decreases as the hours pass If you are the least bit doubtful or cannot get hold of someone who knows insulin pumps well, you should take an injection of insulin by pen or syringe and then go to the emergency ward Always bring extra insulin wherever you go even if you are only going to be away from home for a couple of hours
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Blood glucose at least 2 - 3
times daily including morning and before going to bed, preferably 4 - 5/day, especially if using Humalog in the pump 24-hour profile every week or every other week with readings taken before and 1 - 1 hour after each meal and at night Before each meal when ill or not feeling well for some other reason Urine tests: Glucose and ketones every morning Ketones when having nausea, during illness or when the blood glucose level is high 15 mmol/L, 270 mg/dL
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More frequent home testing
Since there is a greater risk of insulin deficiency with a pump you must be willing to take more blood glucose tests A minimum is 2 - 3 tests a day including morning and late evening You must also be careful to check urine tests every morning and when not feeling well ketones are a sign of insulin deficiency A 24-hour blood glucose profile with tests before and 1 - 1 hours after each meal is needed every week or every second week to adjust your doses correctly You should also take nighttime tests when compiling a 24-hour profile at 2 - 3 AM and if needed at 5 AM as well Use a logbook in which you clearly document the pumps basal rate We find it best to use a logbook where every entry is written on a
blood glucose chart This will enable you to visually observe patterns in your blood glucose readings see charts on page 108 Make it a habit to check the pump daily for the total number or units delivered/24 hours and record this in your logbook
again when you want to disconnect the tubing Use self-sticking Velcro to fix it onto the pumps leather case If you have a so called Luer connection between the tubing and needle/catheter you should fill it with insulin before connecting It is easiest to have the pump deliver a bolus dose, letting the drops fall into the Luer connector
Pump alarm
Insulin pumps seldom malfunction If one does, it will stop There is no risk that the pump will pulse or surge, giving you too much insulin The pump alarm will go off when something is wrong, eg blocked tubing, an empty insulin container or low or flat batteries Check the operating instructions to see what the different alarms stand for and how to respond to them Most pumps have an alarm that is triggered if you have not pushed any of the buttons after a certain number of hours It may wake you up early in the morning if you didnt take your evening meal insu R Hanas 1999
Disconnecting the
pump
Sometimes you will want to disconnect the pump for one reason or another Some needle/catheter sets allow you to disconnect the tubing or between the needle and the tubing by using a rubber membrane as a one way valve Remember to save the needles sterile casing so that you can put it back on
Insulin-dependent diabetes in children, adolescents and adults
113
Insulin pump
Ketones
Causes of high blood glucose
adapted from 375
B-glucose mmol/L
U-glucose
B-glucose mg/dL
À
The pump Basal rate 
too low The pump has triggered an alarm and shut itself off Other pump trouble Insulin reservoir Wrong position in the pump Empty reservoir Leakage in the connection with the tubing Tubing and needle/catheter Forgetting to fill the tubing when replacing Leakage in connections Adhesive and needle is loose Air in the tubing Blood in the tubing Needle/catheter has been in place too long The tubing was replaced in the evening without giving a bolus dose to build up the pressure Bent/squeezed tubing Blocked needle/catheter Injection site Redness, irritation / infection Fat pad at the injection site Placement close to waist band Insulin Cloudy insulin Expiration date passed Exposed to heat /
sunlight
AM PM AM Time
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Needle came loose
New needle inserted 5 units extra
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A few hours of interrupted insulin supply is sufficient to make the blood glucose rise quickly The blood glucose will rise even if you dont eat because the liver will produce glucose when there is a lack of insulin see page 32 When the blood glucose level was raised in the evening the patient was feeling nauseous He checked for ketones and discovered that something was wrong When he checked the needle it was loose and the insulin was not entering his body He gave himself 5 extra units with a pen injector, replaced the needle and started the pump The blood glucose level returned to normal during the night If the blood glucose rises quickly you should remove the needle/catheter Give a bolus dose and see if insulin comes out from the tip Bend the catheter and give another bolus dose The pump should now give a blockage alarm Check the tubing and connections for leakage Replace the needle/catheter and check the blood glucose level frequently to make sure that it decreases Take an extra injection with a pen or syringe of 01 U/kg 05 units/10 pounds body weight if you have ketones in the urine and check
your blood glucose once again after 1 - 2 hours Repeat the dose if necessary
lin or forgot to push one of the buttons before going to bed
No delivery alarm
The pump alarm will be triggered if there is an increased resistance when pumping insulin It cannot tell where that the blockage is in the system It may be that the insulin reservoir is empty, the plunger may be sluggish or the tubing or needle blocked The tubing can be bent or squeezed, for example by a belt buckle If the no delivery alarm is triggered start by checking the tubing for bends or pinches Then give the remainder of the premeal bolus If no alarm is triggered, all is well now and you have received the intended amount of insulin If the alarm goes off again the next step is to stretch
Insulin-dependent diabetes in children, adolescents and adults
out and try careful massaging of the infusion port and catheter under the skin If you havent disconnected the tubing there is no need to take extra insulin other than the remaining premeal dose if the pump now works without alarm assuming that the blood glucose level is not raised If the needle or tubing is blocked it may take several hours before the pressure has increased
enough to trigger the alarm During this time you will not have received any insulin Find out how much is needed to trigger the pump alarm in your pump It may also depend on which tubing you have and how long it is test it by pushing the needle into a rubber cork or pinch the end of the catheter If you
R Hanas 1999
Insulin pump
114
Stopped pump
Time that the pump has been stopped - 1 hour 1 - 2 hours Measure
Occlusion alarm no delivery?
À
No extra insulin needed Take an extra dose when you connect the pump corresponding to the basal rate you have missed Take an extra dose before you disconnect the pump corresponding to the basal rate that you should have had during the missing 2 - 4 hours Check your blood glucose when you connect the pump and take an extra bolus dose if needed Dose before disconnecting as above Using a pen injector or syringes, take extra short-acting insulin every 3 - 4 hours corresponding to the missed basal rate Take the premeal bolus dose with the pen or syringe
Check the tubing for bends and pinching Try a careful massage of the infusion port and the catheter under the skin If the alarm was triggered when taking a premeal bolus, take the remaining
portion No alarm Alarm
È OK, no problems Ô
2 - 4 hours
Á
Disconnect needle/catheter from tubing Start a bolus dose with the pump No alarm Alarm
È Replace needle/catheter Ô
Disconnect tubing from insulin reservoir Start a bolus dose with the pump No alarm Alarm
È Replace tubing Ô
4 hours
Ã
Remove the insulin reservoir from the pump and start a bolus dose No alarm Alarm
È Replace reservoir Ô
Ä
Something is wrong with the pump Contact the pump dealer and deliver insulin with a pen or syringe
then give a bolus dose you will see how many units are pushed into the tubing before the alarm is triggered
Leakage of insulin
If your pump for example has given 43 units of the meal bolus dose when the alarm goes off and you know that 26 units are needed to build up pressure to trigger the alarm, you will have only received 43 - 26 17 units of the bolus dose For smaller children we often use insulin of 40 U/ml You must then remember that fewer units are needed before the alarm goes off since the fluid volume is larger If 25 units of 100 U/ml are needed to trigger the alarm this will equal 1 unit of 40 U/ml Sometimes the pump will alarm for a block in the tubing even after you have
replaced both the tubing and the needle If this happens, remove the insulin reservoir from the pump Then start the pump again If the alarm still goes off, the problem is an internal one, eg motor problems If the pump works well without the reservoir the reason may be that you have reused it When doing so the silicon on the plunger wears off, and this may result in a no delivery alarm The pump cant alarm if there is an insulin leakage It will only trigger if the motor runs against resistance Insulin can be disposed outside the injection site if the needle has been retracted Often this can be only detected when you take a bolus dose When the basal dose is running the amounts of insulin are so small that it can be difficult to pick up if there is a leakage The tubing connector on the pump end can crack, causing leakage, especially if you are too rough when connecting it Feel the connector with your fingers If there is a leakage you can often detect the smell of insulin
Air in the tubing
When you connect the tubing to the pump there is always a risk of air entry, especially if you fill it with cold insulin Air will come out of the solution when the temperature rises Always make sure
that
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Insulin pump
Problems with the pump?
Problem Infection/irritation at the injection site Blocked needle or catheter Blocked tubing Measure Wash hands and skin with chlorhexidine in alcohol Replace needle/catheter more frequently It can be bent or blocked by coagulation or insulin crystals Replace it Can be caused by precipitation of insulin Disconnect the needle and tubing and give a bolus dose Replace if the alarm is triggered Disconnect the tubing from the needle and give a bolus dose The pump will then trigger the occlusion alarm if it is blocked See text on page 114 Many kinds of tubings are made of double plastic layers that can come apart, showing as white spots This does not affect the function or the insulin Has the needle/catheter come loose? Is there a bent catheter? Replace the needle/catheter This indicates insulin leakage Replace the needle/catheter Wash the EMLA- cream off carefully with water Dont use disinfectant with skin moistener Let the skin air dry before you apply the adhesive Warm the adhesive with your hand after application Apply extra tape if needed Apply
hydrocortisone cream Use a stoma-type adhesive Wipe off with medical benzine Apply a piece of tape beneath the hard plastic Caused by an infection of the insertion site Replace needle/catheter more frequently Can be caused by insulin allergy See page 122 Try running the pump with both insulin and tubing removed
R Hanas 1999
Blood in the tubing
Air in tubing? White spots on the inner layer of the tubing
An insulin pump needs to be looked after, and tubin and batteries need to be replaced When the alarm tri gers you must know how to deal with it You will be th first line pump mechanic and will probably find th easier if you are technically oriented However, this not a requirement
Leakage of insulin at the insertion site Moisture under the adhesive Adhesive comes off
the insulin is at room temperature before refilling the reservoir Introducing air into the subcutaneous tissue is of no concern, but you will miss the corresponding amount of insulin The alarm will not be triggered since the pumps microcomputer cannot tell the difference between air and insulin in the tubing If you see air in the tubing when you are about to take a meal bolus dose you can compensate with a little
extra insulin Five to seven cm 1 - 1 inch of air in the tubing usually correspond to 1 unit of insulin To find out the exact dimension of your pump tubing give a bolus dose of 1 unit when replacing the tubing Make a mark on the tubing with a felt tip pen corresponding to the insulin travels for that unit If the air in the tubing corresponds to more than - 1 unit when the basal rate is running eg between meals it is best to disconnect the tubing from the needle in the skin Give an extra bolus dose into the air to purge the air in the tubing and fill it with insulin once again
Itching, eczema from adhesive Sticky rests of adhesive Sore skin from plastic wings Scars in the skin from old catheters Redness of the skin at the needle tip Nothing works
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Á
Infusion sets with soft cannula
Brand PL Comfort Clinisoft Sof-set Disetronic Tender
Length cm 60, 80, 110 55, 80, 110 61, 107 30, 60, 80, 110
inches 24, 32, 43 22, 32, 43 24, 42 12, 24, 32, 43
Intermediate-acting insulin at bedtime Look at the pump doses The breakfast dose with a pen will be the sum of the pump prebreakfast dose and the basal rate
between breakfast and lunch If you have a high basal rate 15 - 2 U/hour start by only counting 1 - 15 U/hour when calculating the dose with pen or syringes The bedtime dose of intermediate-acting insulin Insulatard, Humulin NPH, Isuhuman Basal is calculated by adding the basal rates between 10 PM and 8 AM see example on page 117 You can also use short-acting insulin not Humalog during the night, giving two doses, at 10 PM and 3 AM corresponding to the sum of the basal rates during the night
For most tubes, 5 -7 cm 2 - 3 inches contain approximately 1 unit of insulin The Sof-set needle can be used with an automatic inserter Sof-serter TM that lessens the pain
Intercurrent illness and fever
When you are ill, especially with fever, your body will increase its insulin requirements, often by 25 for each degree celsius of fever see page 177 It is advisable to start by increasing the basal rate Start by a 10 - 20 increase when you notice that your blood glucose is rising You will probably also need to increase the meal bolus doses according to your blood glucose readings It is important that you test your glucose level before each meal when ill and preferably 1 - 1 hours after the
meal as well Most often you will also need to check the blood glucose levels in the night
Long-acting basal insulin The most logical choice is to replace the basal dose in the pump with long-acting insulin Ultratard, Ultralente and to use the same bolus doses and type of insulin before meals as when using the pump Take the total basal dose during 24 hours, add 10 - 20 and divide into 2 equal doses that you take with breakfast and dinner around 5 - 6 PM
Being admitted to the hospital
If you are admitted to the hospital in an acute situation you will often find that there is no staff available who are familiar with the pump If you have problems with the pump it is usually best to begin injecting insulin with a pen or syringes until the daytime staff arrives If you vomit or have signs of ketoacidosis the best treatment is intravenous insulin see page 57
Doses without the pump
It is very important that you always carry extra insulin wherever you go in case of pump malfunction Check to see that the insulin has not expired You should have written down what doses to begin with if you temporarily need to use a pen or syringes
Physical exercise
When physical active you can disconnect
the pump for 1 - 2 hours time without taking any extra insulin If your exercise lasts longer than 2 hours you will probably be better off by keeping the pump connected and using the temporary basal rate Try half the basal rate while exercising and for an hour or two following You may need to lower the basal rate even more — but the only way to know for sure is to try it yourself If the time of exercise is within 1 - 3 hours after a meal you can try taking half the meal bolus dose or
À
Use the old doses It is easiest to start with the same doses that you had when you used a pen injector or syringes, on the condition that you have written down the doses and that not too much time has elapsed since then, eg that you still have approximately the same insulin requirements
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Insulin pump
AM PM AM
Insulin pump and illness
Time Pump 42 U /24 h 07 09 Premeal bolus dose Basal rate pump U/h Pen/Syringe 11 U Reg
7 09×5
à à à à à
Continue with your ordinary meal bolus doses, increasing them by 1 - 2 U if necessary Increase the basal rate by 01 - 02 U/hour if the blood glucose continues to be high Never
discontinue the basal rate completely even if you have problems with hypoglycemia Check your blood glucose every 2nd to 4th hour Check for ketones in the urine frequently Keep good records in your logbook Take extra insulin 1 U/10 kg or 05 U/10 pounds body weight, preferably Humalog, if your blood glucose is high and you have ketones in the urine Give another 1 U/10 kg 05 U/10 pounds every 2nd hour until the blood glucose is below 10 mmol/L 180 mg/dL and the level of ketones in the urine is decreasing Give the extra insulin with a pen or syringe The reason for the high blood glucose may be pump malfunction Try to drink large amounts of fluids as this will increase the excretion of ketones and lessen the risk of dehydration As long as there is glucose in the urine you will lose extra fluid Drink glucose-free fluids when the blood glucose is above 10 - 12 mmol/L 180 - 215 mg/dL and change to something containing glucose when the blood glucose is below this level If you are nauseous, try to drink small volumes a couple of mouthfuls at a time
7U 09
5U 08
5U
4U 10
9U Reg
5 08×5
9U 6U 8U Reg Reg NPH
5 4 08×2 10×2 10×2 10 x 2 07×3 09×4
43 U /24 h
Premeal bolus dose
Calculation
Intermediate-acting bedtime insulin
Sometimes you must use an insulin pen or syringes for a while, eg if something is wrong with the pump You can calculate which dose to use if you add the meal bolus dose in the pump with the basal rate You will probably need to increase the night dose since the pump is more effective, giving more insulin late at night and early in the morning than you would get from the intermediate acting bedtime insulin Check with your diabetes nurse if you are unsure what doses you used previously when on multiple injections
7U 5U 12U UT 5U 4U 13U UT 46 U/24 h
à à
Long-acting basal insulin Ultratard UT Basal rate in pump 21 U20 25U divided in 2 doses
Another alternative is to replace the basal rate in the pump with a long-acting insulin Ultratard, Ultralente given twice daily and continue using the same bolus doses and the same type of insulin, short-acting or direct-acting before meals as with the pump You will probably need to increase the amount of basal insulin by 10 - 20
Call the hospital
à à à à
the first time you become ill after having started with the pump if you have nausea that prevents you from eating for more than 6 - 8 hours
if you have vomited more than once during a 4 - 6 hours period if the blood glucose level has not been lowered or the ketones in the urine have not decreased after the second extra dose of insulin if your general well-being is worsening if you are in the least uncertain as to how to handle the situation
even skipping it if the exercise is particularly strenuous However, you will then probably need to keep the pump connected to get the basal rate during the entire time of the exercise419 Dont forget to refill your glucose storages after exercise see page 169 After strenuous exercise eg a ball game or skiing you must decrease the basal rate by 01 - 02 U/hour during the night to avoid hypoglycemia Try this out yourself and note the blood glucose tests in the logbook for future reference if faced with a similar situation
à à
Nighttime pump?
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In the winter when its cold you must keep the pump close to your body The tubing is very thin and no part of it must be outside the clothing, or it
will easily freeze It may be a bit awkward to take the bolus dose but since the insulin cant be allowed to freeze, you must protect it from low temperatures
When should I disconnect the pump?
à à à à
In the bath tub In a public bath or swimming pool In a sauna or whirl pool During an X-ray, Cat scan or MRI
ter during the day If you look at the insulin level in the blood it will be slightly higher at night and especially early in the morning, when using a pump see figure on page 104 This is an advantage During the day, in between meals, the insulin level is slightly higher with a pump, which is not desirable since it will increase your need to eat snacks and that can contribute to a weight gain You should not hesitate to try connecting the pump in the evening, letting it stay in place during the night, and disconnecting it in the morning During the day you can use a pen injector or syringes for premeal bolus doses Talk to your diabetes doctor if this sounds appealing
your calory intake when starting with a pump If you have frequent hypoglycemias you will risk weight gain since you will frequently need to snack If you start enjoying extra freedom like candy and chips you will
also gain weight Talk to your dietitian about how to find a way around these problems It might be easier to lose weight without an increase in HbA1c if you have an insulin pump because you can then decrease both your food intake and meal bolus doses but still have the basal rate to ensure your basal insulin requirements
Taking a bath or shower
Most pumps can stand some water but you must disconnect them when taking a bath When taking a shower there is a shower protector to put over the pump, but many prefer to simply disconnect it for a short while You should also disconnect the pump if you have a sauna since insulin cant take the heat The heat in a sauna will cause previously injected insulin to be absorbed much more quickly see page 64 There is a protective waterproof case available which can be used, for example on the beach
Is the pump disturbing?
You must carry your insulin pump 24 hours a day How do you sleep with it? many ask You will be surprised how quickly you get used to wearing the pump at night Some people who lie quite still put the pump besides or under the pillow and wake up in the morning with it still there Others, who are more restless, find it better to have
the pump on a belt or in a pajama pocket What do you do with the pump when having intercourse? was the first question my friends asked me, an 18 year old girl told us It is easiest to disconnect it for a while if it is disturbing Making love is also physical exercise and you might do quite well with a little less insulin for a while
Travel tips
Dont forget to adjust the pumps clock if you travel across time zones Change the clock to the time of arrival when you get on the plane Measure blood glucose before each meal and make necessary adjustments of the bolus dose Always bring extra insulin and an insulin pen or syringes wherever you go You may need a certificate for customs declaring that you need to wear an insulin pump The pump does not usually trigger the metal detector at airports See page 205 for further travel tips
Will I gain weight when I start with the pump?
There is always a risk of gaining weight when your blood glucose improves since you lose less glucose into the urine You should therefore try to reduce
Pregnancy
Using an insulin pump is an excellent method to obtain blood glucose values close to those of a per R Hanas 1999
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Insulin pump
son without diabetes With a close to normal blood glucose, the risk of complications during pregnancy decreases to the same levels as for non-diabetic women see page 191 During the later part of pregnancy it might be difficult to have the pump needle on the distended abdomen You can instead try the buttocks, the upper part of the thighs or the upper arm There is an increased risk of ketoacidosis during pregnancy You should check your blood glucose more often and also change tubing and needle more often every day with metal needles and every other day with teflon catheters Contact the hospital immediately if your blood glucose level is high and you have ketones in your urine Adding a bedtime dose of intermediate-acting insulin 02 U/kg in addition to the normal basal dose delivered by the pump has considerably deceased the risk of ketoacidosis282
will decrease considerably as well This implies that insulin deficiency symptoms will arise quickly if the pump fails In a German study the pump was stopped in the morning in 7 patients316 A deterioration in control was defined as an increase in blood glucose of more than 83 mmol/L 150 mg/dL, an
increase of more than 22 mmol/L 40 mg/dL in 15 min, appearance of ketones in the urine or symptoms of insulin deficiency When the subjects used regular short-acting insulin the deterioration occurred at a mean of 386 min range 135 - 510 min while the mean was 251 min range 45 - 380 min when direct-acting insulin was used In other words one can compare a pump stoppage of about 4 hours with direct-acting insulin compared to about 6 hours with regular short-acting insulin However, notice that variability is great, meaning that the individual differences are considerable Some patients have already tested direct-acting insulin in their pumps and many like it However, if you develop symptoms shortly after the pump stops you are probably better off using regular short-acting insulin When using direct-acting insulin in the pump you may need to lower the bolus doses since the bolus doses of regular insulin you previously used supplied part of the basal insulin, overlapping with the next meal as well To compensate for this you may need to increase the basal rate instead
Humalog in the pump?
As direct-acting insulin Humalog acts more rapidly when taken prior to a meal and more closely mimics
the non-diabetic insulin response, it seems logical to try it when using an insulin pump In a Canadian study regular short-acting insulin and direct-acting insulin were used in insulin pumps during a 3 month double-blind cross-over study438 All bolus doses were given immediately before the meals HbA1c was significantly lower 77 compared to 80 when using direct-acting insulin but there was no difference in the frequency of hypoglycemia One problem when using insulin with an even shorter duration is that your bodys depot of insulin
An insulin pump will enable you to fine tune your insulin doses and will give you more horsepower under the hood to take care of your diabetes However, it will demand greater knowledge and attention to make it work well just like a stronger and faster car If you use it correctly an insulin pump is a very good tool and a powerful support on your long diabetes journey
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The onset of action with a premeal bolus dose of Humalog may be to rapid in certain situations, like when eating a meal that digests slower like pasta or pizza, or a longer dinner with may
courses like when on conference You can the try by taking the bolus dose after the meal If you have a pump that can deliver the dose more slowly square wave bolus this is an ideal solution in these situations You can use it even if you have problems with gastroparesis slower emptying of the stomach due to diabetic neuropathy, see page 216 see the diet chapter on page 147 for further advice on the use of Humalog
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Side effects of insulin treatment
Pain
If an injection is extra painful you have probably hit a nerve or a tactile organ see ill on page 91 If you can stand the pain you can readily inject the insulin, otherwise you must pierce the skin once again
Insulin leakage
It is not uncommon for a drop of insulin to come out on the skin after withdrawing the needle Two to three drops from a pen needle contains approximately one unit of insulin 100 U/ml In one study on children and adolescents with diabetes 68 encountered leakage of insulin after injections during one week Twenty-three percent of the injections were followed by leakage of up to 18 of injected dose 2 units of an intended dose of 11
units379 It may be difficult to avoid insulin leaking, but the risk is smaller if you lift a skin fold and inject at a 45 angle even if you use an 8 mm needle Try to inject more slowly You can also try to withdraw the needle halfway and then wait 20 seconds before withdrawing it completely Earlier the standard advise was to stretch the skin sideways when injecting to avoid this problem, but this is not a good idea because you instead risk an intramuscular injection
Blood vessel Subcutaneous fat If you penetrate a superficial blood vessel with the needle there may be a bleeding A bleeding under the skin will feel like a small bubble, which is often bluish in color
Bruises after injections
If you penetrate a superficial blood vessel in the subcutaneous fat a small bleeding may arise The blood vessels in the subcutaneous fat however are so small that there is no risk that insulin will be injected directly into the vessel It will feel like a small bubble under the skin that sometimes is bluish in color Such a bleeding is quite harmless and is absorbed completely after some time
Blocked needle
Sometimes the needle will be blocked when you inject long- or intermediate-acting insulin
This can be caused by the crystals in the insulin that aggregate It seems to depend on how quickly you inject the insulin Try injecting more slowly or even more rapidly The risk increases when reusing the needles as remaining insulin may crystallize inside the needle barrel
Fat pads
Fat pads lipohypertrophies contain both fibrous and fat tissue401 They are caused by insulins effect of stimulating growth of fat tissue This is a common problem when you dont vary your injection sites frequently enough A child usually wants to prick the skin where it hurts the least, resulting in injections too close together It is important to carefully explain this and to help find a system for rotating the injections sites effectively Younger children less than 10 - 12 years of age should have a parent helping them with 1 - 2 injections per day and then preferably inject at places that the child might have difficulties in reaching, such as the buttocks see Where do I inject the insulin? on page 92
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Insulin effect
Injection in healthy subcutaneous fat Injection in lipohypertrophic
area Time
lems with redness after injections There is a special skin test available to find out if you are allergic to the insulin or the preservative There is often an increased level of insulin antibodies in the blood see below as well If problem with redness continue, adding a small amount of cortisone to the insulin usually has a good effect266 A generalized allergic reaction after insulin injection is very rare83 Allergy towards nickel in pen and syringe needles can cause redness after injections The needles are covered with a layer of silicone lubricant If you are allergic to nickel you should not use the needles more than once as the silicone layer wears off and the nickel will come in closer contact with the skin Needles on syringes have a thicker silicone layer since they need to penetrate the rubber membrane of the bottle when drawing up insulin, thereby being more appropriate if you have a nickel allergy You can take a skin test to see if you are allergic to nickel You will usually react to nickel in other materials as well, for example ear-rings, belt buckles or wrist watches EMLA-creme a topical anesthetic used for venepuncture or when replacing indwelling catheters
can cause an allergic redness that looks very much like an allergy against the adhesive
Insulin will be absorbed slower if you inject in an area with fat pads lipohypertrophy
Reusing needles causes blunting which increases the microtrauma of repeated injections This may contribute to increased lipohypertrophy by build-up of fibrous tissue from the release of local growth factors381 Injections in fat pads will usually result in a slower absorption of insulin245,436 An area with lipohypertrophy should be left alone for a couple of weeks One way to accomplish this can be to use an indwelling catheter Insuflon, see page 101 with which the injection sites can be actively rotated Another way is to use a guide with a rotation scheme, designed with holes or sectors for different days of the week154 Remember that insulin will have a quicker action of you inject it in an area free from lipohypertrophy You may have to lower the dose to avoid hypoglycemia
Insulin antibodies
The body will produce antibodies against foreign substances Insulin antibodies with porcine and bovine insulin were common With the use of human insulin it is not common to have high enough levels of antibodies to cause
problems Insulin antibodies work by binding insulin when there is a high level of free insulin, eg after a meal bolus injection17 When there is a low level of free insulin, eg during the night, they release insulin17 In this way the insulin concentration in your blood will be levelled off in an unfortunate manner When you want a high level of insulin after a meal it will be lowered resulting in high blood glucose and when you want a low level in the blood during the night you will instead have too much insulin resulting in hypoglycemia One can say that with high levels of insulin antibodies you will produce long-acting insulin on your own One possible method to lessen these problems is to give a fairly large dose of short-acting insulin in the morning to saturate the insulin antibodies During the day you give smaller and smaller doses of short-acting insulin prior to meals At bedtime give only a small dose of insulin to lessen the risk of nighttime hypoglycemia
Redness after injections
Redness, sometimes with itching, that occurs immediately or within hours of an insulin injection can be due to an allergy towards the insulin or a preservative This type of reaction will usually
subside after some years as you continue with insulin treatment317 Inform your doctor if you have prob-
Insulin causes the subcutaneous tissue to grow if you often inject into the same spot You will get a fat pad lipohypertrophy in the skin that feels and looks like a bump
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Side effects of insulin treatment
Switching to direct-acting insulin Humalog substantially decreased the level of antibodies and problems with early morning hypoglycemia in a case report247 Apparently, the structural differences between regular short-acting and direct-acting insulin molecules prevented Humalog from binding to the human insulin antibodies You can measure how much of the total amount of insulin which is bound to antibodies with a blood test Normally this level is approximately 6 but we have seen values above 90 in cases where the patient has had especially difficult problems Insulin antibodies can be very troublesome but usually the negative effects will slowly subside after several years even if you have measurable levels of antibodies
Lipoatrophy
Lipoatrophy is manifested as a cavity in the subcutaneous
tissue The reason for its development is somewhat unclear Lipoatrophy usually does not appear in areas where you have given very frequent injections It is instead believed to be an immunologic reaction towards insulin in which subcutaneous tissue is broken down317 Patients with lipoatrophy often have high levels of insulin antibodies You can treat the cavities by injecting insulin along the edges This will cause the formation of new fat pads and eventually the cavities will disappear
Insulin edema
Sometimes you can get a local or generalized edema when you quickly improve the glycemic control This is caused by a temporary accumulation of fluid in the body and usually subsides spontaneously over a period of days to weeks with continued good glycemic control366 In severe cases, ephedrine has been used successfully204
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Source:joslin.org
