Case Study: Competitive exercise 32 year-old cyclist Type 1 diabetes since age 15 Last HbA1 54 No complications and hypo aware On Humalog 8/8/8 and Levemir 15 Complains about significant hypoglycaemia when he trains.? Refer to the Training day blood glucoses record page what would you advise to this patient? You may find the supporting information helpful
SMBG (mmol/l) mmol/l 12 Training day blood glucoses 10 8 6 4 2 Breakfast And 6u Start of exercise 5:00 6:00 7:00 8:00 9:00 10:00 Time of day
Three times to think about During 1 Hour after 6-8 Hrs after
Strategy Advantages Disadvantages Reducing pre-exercise bolus insulin Reducing pre-exercise basal insulin Taking extra CHO with exercise Pre- or postexercise sprint Summary of Clinical Strategies to Maintain Glycaemic Control With Exercise Reduces hypoglycaemia during and following exercise; reduces CHO requirement As above Useful for unplanned or prolonged exercise Reduces hypoglycaemia following exercise Needs pre-planning; not helpful for spontaneous exercise or for late post-prandial exercise As above, causes pre- and late post-exercise hyperglycaemia May not be possible with some exercises; not helpful where weight control is important; easy to over-replace causing hyperglycaemia Effect limited to shorter and less intense exercise Lumb AN, Gallen IW. Curr Opin Endocrinol Diabetes Obes. 2009;16:150 155.
Insulin changes need for different exercise times Time of day Pre breakfast no change Change in insulin No change insulin 1-2 hrs after breakfast Reduced pre dose insulin (start 50%) Before lunch and 2 hours after breakfast No change insulin 1-2 hours after lunch Reduced pre dose insulin (start 50%) Before supper and 2 hrs after lunch Between supper and bed Reduce morning background by 10% Reduced pre dose insulin (start 50%) And decrease pm background by 10%
Different insulin regimes Actrapid or Humulin S Hypo risk Novorapid or Humalog Hypo risk 0 2 h 4 h 6h
Guidelines for the reduction of the pre-meal insulin lispro dose in relation to the intensity and duration of postprandial exercise. Exercise intensity (% VO 2 peak ) % Bolus Dose reduction 30 min of exercise 60 min of exercise 25 25 * 50 50 50 75 75 75 - * Extrapolated Rabasa-Lhoret, R. et al. Diabetes Care 2001
Race Day! On race days, he finds that his glucose values rise significantly and are uncontrollable. He often has to drop out of races due to poor performance on these race days Refer to his CGM tracing page. What could you advise to address the following: Strategies to manage race day stress Insulin dosing
Case 1 CGM tracing Breakfast + 4 u of Humalog Lunch + 8u of Humalog Dinner + 8 u of Humalog 15 U Levemir
Strategies for nocturnal hypoglycemia using DAFNE 1. Bedtime snack with protein and starch (Kalergis M et al. Diabetes Care 2003; Campbell et al., Diabetes Care 2014) 2. Basal insulin adjustment? NPH reduce by 20%? Split glargine dose could be reduced by 20%?
Basal reduction of 20% help limit nocturnal hypoglycemia Ages ~13, n=16 60 min aerobic cycling was performed in the afternoon Bedtime with no change in pump setting, or with a 20% reduction in basal at bedtime for 6 hrs, or oral terbutaline (2.5 mg) Taplin Ceet al., J Pediatr. 2010 Nov;157(5):784-8
Case 1 Options are Eat earlier Eat later with greater reduction in insulin Taken addition carbohydrate just before event