Recently I cared for a 14 year old newly diagnosed diabetic. Our usual routine is to do blood sugar monitoring four times daily, and twice-daily mixed insulin injections (before breakfast and dinner). This young man's physician, a family practitioner, chose for him to have twice-daily blood sugars (at 6am and 4pm) with sliding scale Regular insulin and his mixed (NPH and Regular) insulin injections at 7:30am and bedtime.
My coworkers and I have never heard of such a routine and were wondering if this is common or even feasible for a juvenile diabetic. We would appreciate any information you could give us on this matter. Thanks.
A concerned nurse.
This question was referred to our two of our endocrinologists, who have each given an answer:
Answer from Dr. Quick:My initial thought: Ye gads. Giving Regular on a twice-daily sliding scale is wrong. And using Regular at bedtime is inviting nocturnal insulin reactions if the dose is too big. This program is unrealistic for a teenager with diabetes.
More: it sounds like this FP is misunderstanding how long insulin can last. For example, using a "sliding scale" of a short-acting insulin (Regular) is frequently done, but it has to be done at least 3 (or 4) times daily. Doing it only twice a day (as I understand from your question) isn't reasonable, as the sliding scale concept wouldn't be available to be of help during the afternoon hours unless it's also applied to the noontime meal. (Remember, also, that "sliding scales" are putting the cart after the horse if they are based on blood sugar levels at that moment: they really should be based on the carb content of the upcoming meal.)
But the proof of the pudding about the efficacy of this program is missing from your letter: what's his glycohemoglobin doing; and, is he getting noctural or other insulin reactions, and how is he coping with his diabetes? Was his lifestyle considered when this program was set up? If he's having problems, he should be referred to a knowledgeable Diabetes Team and have his program revamped.
Answer from Dr. Lebinger:This does not sound like a common schedule; however I suggest you ask the physician who recommended this schdule to explain the rationale behind it. Whatever schedule is used, it is helpful to obtain blood sugar readings at least 4 times a day when possible to evaluate the blood sugar at the peak times of action of the different insulins.
One has to be careful when giving Regular insulin before bedtime to make sure the blood sugar isn't going low during sleep (this may be asymptomatic and lead to rebound hyperglycemia the next day).
Original posting 1 Jun 96
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