This certificate-level program is non-sponsored.

Program Name: Diabetes Education : A Comprehensive Review Module 5 Intensive Insulin Therapy Planning Committee: Michael Boivin, B. Pharm. Johanne Fortier, BSc.Sc, BPh.LPh, CDE Carlene Oleksyn, B.S.P. (Pharm) Accrediation Information: This version of the program is unaccredited and intended for informational purposes only. An accredited version is available online at www.advancingpractice.com until June 1, 2014. Sponsor: This certificate-level program is non-sponsored. 1

Module 5- Intensive Insulin Therapy Introduction Insulin therapy is required for all patients with type 1 diabetes. It is also becoming an ever increasing treatment option in type 2 diabetes, as patients with a decrease in beta-cell function require exogenous insulin to maintain glycemic control. Module 4 of this program reviewed the different types of insulin, administration (e.g. insulin pens, injection sites) and many of the common regimens used in patients with type 2 diabetes. Patients with type 1 diabetes will normally require a more intensive insulin regimen to maintain optimal glycemic control. This regimen will normally involve multiple daily injections (MDI) of insulin with adjustments being made based on readings from self-monitoring of blood glucose (SMBG), carbohydrate content of meals, physical activity and other issues (e.g. illness). Continuous subcutaneous insulin infusion (CSII) is another common selection for patients with type 1 diabetes. The goal with both MDI and CSII regimens is to attempt to mimic the normal physiological insulin response by the beta cells of the pancreas. This module will review the most common regimens in patients with type 1 diabetes and some of the issues associated with these regimens. Learning Objectives Upon successful completion of this continuing education lesson, the participant will be better able to discuss: 1. Current Canadian Diabetes Association clinical practice guideline recommendations for insulin therapy in patients with type 1 diabetes 2. Advantages and disadvantages of multiple daily injections and continuous subcutaneous insulin injection regimens in patients with type 1 diabetes 3. The roles of the different insulin types in both the continuous subcutaneous insulin injection therapy and multiple daily injections therapy. 4. Insulin initiation and the role of carbohydrate counting in patients with type 1 diabetes 5. The key clinical points regarding multiple daily injections of insulin therapy in patients with type 1 diabetes 6. The key clinical points regarding continuous subcutaneous insulin injection therapy in patients with type 1 diabetes The Physiologic Response of Insulin The goal with both MDI and CSII are to attempt to mimic the body s natural insulin response. In a patient without diabetes, the pancreas secretes a low level of insulin constantly. 1 This is known as the basal rate (or basal insulin) and it is secreted at a low enough level to prevent lipolysis and glucose production. 1 The basal rate will adjust based on exercise and periods of fasting and is closely tied to the patient s blood glucose level. 1 After a meal, the beta-cells of the pancreas will secrete a burst of insulin 2

to manage the ingestion of carbohydrates in the meal. 1 This is a temporary and rapid increase in insulin (postprandial insulin) that climbs to a level that is much higher than the basal rate. 1 Both the MDI and CSII treatment options mimic this pattern by providing a basal insulin level and bursts of a rapid/short acting insulin prior to a meal. Unfortunately mimicking this pattern exactly is very difficult as there are: Differences in insulin absorption Errors in self-monitoring of blood glucose (SMBG) Imperfect carbohydrate content calculations Different responses when the patient is under stress Education Requirements Before Initiating Insulin Therapy Initiating insulin therapy is slightly different than starting other treatments for diabetes. The current Canadian Diabetes Association (CDA) diabetes guidelines state that patients initiating insulin therapy must receive initial and ongoing education that includes comprehensive information on: 2 How to care for and use insulin Prevention, recognition and treatment of hypoglycemia Sick-day management Adjustments of food intake (e.g. carbohydrate counting) Physical activity Self-monitoring of blood glucose (SMBG) Diabetes educators can play a crucial role through the management and education process to ensure these patients are safely reaching their glycemic targets with the lowest risk of hypoglycemia. It is also important to remember that the initiation of insulin therapy can create emotional issues such as: Patient worry regarding the consequences of this treatment Concern regarding the progression of their condition The increased workload and support required to appropriately manage their condition. Reluctance to use therapies involving injections The current CDA guidelines advise clinicians to individualize insulin regimens according to a patient s goals, age, general health, motivation, financial and social issues. 2 Lifestyle concerns (e.g. diet and physical activity, cognitive ability) should also be considered before initiating any insulin regimen. 2 Clinical Practice Tip: Initiation of insulin therapy requires ongoing education and support. Educators can play a key role in helping to adjust the education provided based on the patient s self-management skills, cognitive ability and the ongoing needs of the patient. Rationale for Intensive Therapy In the past, the use of conventional therapy was the gold standard for managing patients with type 1 diabetes. 2 These patients were initiated on a fixed dose regimen of a combination of a short-acting 3

insulin (e.g. regular) with an intermediate acting insulin (e.g. NPH) given twice daily prior to the breakfast and supper meals. In the Diabetes Control and Complications Trial (DCCT) the use of conventional therapy for type 1 diabetes was compared to CSII and MDI therapy (intensive therapy). 3 This landmark trial demonstrated that patients with type 1 diabetes using CSII or MDI therapy had a significant reduction in the onset and progression of microvascular complications (e.g. retinopathy, nephropathy, neuropathy). 3 For this reason the current CDA guidelines advise clinicians that conventional therapy is not preferred for patients with type 1 diabetes. 2 The guidelines recommend that adults with type 1 diabetes should receive MDI therapy or CSII as part of an intensive regimen to reach glycemic targets. 2 Types of Insulin for MDI and CSII The different types of insulin were discussed in detail in module 4 of this series and will not be discussed in greater details in this section. Educators must be familiar with the types of insulin used with MDI and CSII regimens. Insulin for MDI Therapy The most common regimens for MDI therapy is a combination of a rapid acting insulin therapy (e.g. aspart, lispro, glulisine) for bolus doses and either an intermediate acting insulin (e.g. NPH) or a longacting analogue (e.g. detemir, glargine) to provide the basal doses. In the past, short-acting insulin (e.g. regular) was commonly used for intensive therapy regimens. Rapid acting insulin analogues offer the same level of glycemic control but have significantly less episodes of hypoglycemia. 2 For this reason, current CDA guidelines recommend the use of rapid-acting analogues in combination with a basal insulin over the use of regular insulin in patients with type 1 diabetes on a MDI regimen. 2 Long-acting analogues (e.g. detemir, glargine) have an extended duration of action and a blunted insulin peak and are associated with a lower incidence of nocturnal hypoglycemia compared to intermediate insulin. 2 Nocturnal hypoglycemia is very concerning as many times it is asymptomatic and can often last for > 4 hours. 2 The current CDA guidelines recommend that clinicians consider a long-acting insulin analogue as an alternative to NPH insulin to reduce the risk of hypoglycemia throughout the day and specifically through the night (nocturnal hypoglycemia). 2 Insulin for CSII Therapy CSII (pump therapy) has been used for over 30 years but has recently come of age and is being used much more frequently in patients with type 1 diabetes. 4 The technology in the insulin pump allows for the delivery of basal insulin and the delivery of an adjustable dose of rapid-acting insulin to manage the increase in blood glucose after meals. Current CDA guidelines recommend that insulin aspart, insulin lispro, insulin glulisine be used when CSII is utilized in adults with type 1 diabetes. 2 4

Insulin Initiation in Type 1 Diabetes The utilization of insulin in patients with type 1 diabetes involves an individualized regimen that allows for optimal control, the lowest risk of hypoglycemia and does not negatively impact the patient s quality of life. Once the regimen (e.g. MDI or CSII) and the types of insulin are selected, the clinician can initiate the patient on the appropriate dose of insulin therapy. To do this the clinician needs to consider the basal and post-prandial requirements and the carbohydrate:insulin ratio. Basal and Post-Prandial Requirements For most patients with type 1 diabetes the requirements for insulin are the following: 1 40-50% of the total daily insulin dose is required to fulfil the basal requirements 50-60% of the total daily insulin dose is required to fulfil the post-prandial requirements Patients Currently on Conventional Therapy When initiating MDI or CSII therapy, some patients may currently be utilizing insulin therapy. In these patients on conventional therapy (i.e. insulin dosed twice daily prior to meals) the clinician should add up the current daily dose of all insulin products. For example: If the patient is injecting o 8 units of regular insulin and 15 units of NPH insulin before breakfast o 5 units of regular insulin and 9 units of NPH insulin before supper The total daily insulin dose is 8+15+5+9 = 37 units Before changing from conventional therapy to MDI or CSII therapy the clinician will normally reduce the total daily insulin dose by 20-25% to accommodate for a more physiological delivery method with both MDI and CSII therapy. 1 For this patient the total daily dose would be reduced by 7-9 units to leave a total daily insulin dose of 28-30 units. The basal insulin dose would be 15 units and the prandial insulin dose would be 15 units distributed over the three meals of the day. Patients not Currently on Insulin Therapy The weight method has been used if a patient is new to insulin therapy. Using this method: 1 An adult is initiated at 0.5 units of insulin per kg of body weight. If the patient is newly diagnosed with type 1 diabetes but not acutely ill or ketotic, this dose may be too high and some clinicians may consider starting with an arbitrary dose of 4 units preprandially and at bedtime. An adolescent is initiated at 0.5 units of insulin per kg of body weight. Clinicians and the patient should expect an increase to a higher dose (e.g. 1.0 IU/kg) due to insulin resistance of puberty. Distribution of Prandial Insulin Approximately half of the total daily insulin requirements are required to fulfil the prandial requirements in patients with type 1 diabetes. 1 Many clinicians will use a 35/30/35 rule for distributing the prandial dose. In this method: 1 35% of the prandial insulin dose is given prior to breakfast 30% of the prandial insulin dose is given prior to lunch 35% of the prandial insulin dose is given prior to supper 5

This distribution is due to most patients having a smaller lunch and a higher activity level in the late morning and afternoon. 1 In our patient example, the total daily insulin dose is 30 units per day, the insulin distribution would be the following: 50% of the total daily dose of insulin would be required for basal insulin and 50% for prandial insulin o The patient would administer 15 units (50%) of an intermediate or long-acting insulin prior to bedtime for the basal insulin requirements o The patient would administer 15 units of a rapid acting insulin for prandial requirements Using the 35/30/35 rule the patient would administer 5-6 units prior to breakfast, 4-5 units prior to lunch and 5-6 units prior to supper A more precise method of calculating the prandial insulin requirements for each meal is to utilize the carbohydrate to insulin ratio. This ratio is used to determine the amount of carbohydrates that one unit of insulin will effectively manage. There are several methods to calculate the carbohydrate:insulin ratio. Clinical Practice Tip: The carbohydrate:insulin ratio is used in patients on MDI or CSII therapy to determine the dose of insulin required for the amount of carbohydrates in a specific meal. For example if a patient has a carbohydrate:insulin ratio of 10, and they are consuming 60 grams of carbohydrates, they will require 6 units of insulin to cover this amount of carbohydrates. The first method is using the total carbohydrate intake and the daily bolus doses of insulin. 1 In this method the total daily carbohydrate intake is divided by the total daily units of prandial (bolus) insulin. The second method is to use the rule of 500. This method assumes the patient eats approximately 2000 calories per day including 250 grams of carbohydrates. 1 Using this method the carbohydrate:insulin ratio is determined by dividing 500 by the total daily insulin dose. 1 This method is not as accurate as the first method due to the assumption in carbohydrate intake. 1 Clinicians using the rule of 500 method should expect to perform more adjustments than in patients using the total daily carbohydrate method. Table 1 demonstrates an example of calculating the carbohydrate:insulin ratio. Clinical Practice Tip: Clinicians should consider using both methods to calculate the carbohydrate:insulin ratio as it is not a perfect science. They can consider choosing a ratio between the two methods and adjusting it based on the results of blood glucose levels two hours post-prandially or incidences of hypoglycemia. Table 1 - Calculating the Carbohydrate:Insulin Ratio 1 Method 1: Daily Carbohydrate Intake Method Calculate the total daily intake of carbohydrates in grams Divide this by the total daily prandial doses of insulin Using the patient example where the patient was injecting 15 units of bolus insulin per day and consuming 180 grams of carbohydrates on average per day. The carbohydrate:insulin ratio will be 180 grams/15 units = 12 grams of carbohydrate per unit of insulin 6

Method 2: Rule of 500 Divide 500 by the total daily dose of insulin (bolus and basal) Using the patient example where the patient is injecting 30 units of insulin per day, the carbohydrate:insulin ratio would be 500 divided by 30 = 16.7 ~ 17 grams of carbohydrate per unit of insulin Insulin Sensitivity Factor The insulin sensitivity factor (also called correction factor) is used to help calculate the most appropriate prandial insulin dose. It helps to ensure the correct amount of insulin is given to cover for the patient s current blood glucose level. The insulin sensitivity factor provides the change in blood glucose level that occurs with each unit of insulin for a specific patient. 1 The higher the number the more sensitive the patient is to each unit of insulin. 1 To calculate the insulin sensitivity factor the rule of 100 is commonly used. With this method, 100 is divided by the patient s total daily dose of insulin. 1 Using our patient example, they currently inject 30 units of insulin per day. His insulin sensitivity factor would be 100 divided by 30 or 3.3 which is approximately 3. This translates to 1 unit of insulin will lower the patient s blood glucose by 3 mmol/l. Another method used to calculate the insulin sensitivity factor is the 10% rule. With this method a percentage (10%) of baseline bolus insulin dose for a particular prandial meal is used. 1 This value is used as the correction factor for each 2 mmol/l a patient is above or below their target blood glucose level. For example a patient injecting 8 units prior to their breakfast meal, this calculation would be approximately 1 (8x10%=0.8~1). This would mean that approximately 1 unit of insulin will correct for every 2 mmol/l above a target range. Putting it All Together For many clinicians and patients the use of carbohydrate:insulin ratio and insulin sensitivity factor may seem confusing at first but both are crucial for determining the most appropriate dose of insulin for a particular meal given the patient s current blood glucose level. The best way to demonstrate how to use these values is to use a practical example. A practical example of using the carbohydrate:insulin ratio and the insulin sensitivity factor to calculate a patient s bolus insulin dose is listed in Table 2. Table 2 - Practical Example to Calculate a Patient s Bolus Insulin Dose Brian S. has type 1 diabetes. Using the formulas listed previously you calculated his: Carbohydrate:insulin ratio to be 8 Insulin sensitivity factor to be 2 Brian is preparing to eat his lunch meal. He plans to consume: 250 ml of 1% milk (12 grams of carbohydrate) A sandwich with 2 pieces of cracked wheat bread, two slices of sliced turkey breast, lettuce, tomato and mustard (33 grams of carbohydrates) A cup of chunky soup (15 grams of carbohydrates) NOTE: The amount of carbohydrates in a food can be determined by the Beyond the Basics Tool, other 7

carbohydrate counters or by having the patient read the label on the package. The patient s current blood glucose is 8.7 mmol/l and his target blood glucose level prior to this meal is 6.5 mmol/l. For this reason he needs extra insulin to help with the insulin level above target. To calculate the bolus insulin dose the first calculation is to determine the dose of insulin required to manage the blood glucose level that is currently above target. This patient s insulin sensitivity factor is 2, which translates to 1 unit of insulin dropping this patient s blood glucose by 2 mmol/l. To calculate the supplement dose for the high reading the following formula is used: 5 (Current blood glucose level - Goal blood glucose level) insulin sensitivity factor For this patient: (8.7 mmol/l - 6.5 mmol/l) 2 = 1.1 ~ 1 unit For this patient 1 extra unit of insulin should be given due to his above target reading To calculate the dose of insulin for the amount of carbohydrates in the meal the following formula is used: 5 Total number of carbohydrates with the meal carbohydrate:insulin ratio This meal has 60 grams of carbohydrate (12+33+15) 8 = 7.5 units ~ 7 units of insulin are required for this meal The dose of prandial insulin required is the sum of the supplemental dose and the dose required for the level of carbohydrates. For this patient = 1 unit + 7 units = 8 units of rapid-acting insulin should be given to manage both his above target blood glucose reading and the level of carbohydrates he will be consuming Clinical Practice Tip: 1 The insulin sensitivity factor is to correct for blood glucose levels that are out of target range The carbohydrate:insulin ratio is a method to proactively adjust the insulin dose based on the level of carbohydrates consumed Properly utilizing these two values can help to reduce glycemic excursions and help to reduce the risk of hyperglycemia and hypoglycemia. NOTE: The carbohydrate:insulin ratio is variable even in a single patient. For this reason it may require some fine tuning based on post-prandial readings and a patient may have a slightly different ratio with each of his meals of the day. Insulin Regimens In the past, conventional therapy was commonly used in patients with type 1 diabetes. This therapy involves using two doses of a combination of short and intermediate insulin given twice daily before breakfast and supper meals. This therapy is currently not recommended in patients with type 1 diabetes due to: 6 Lack of mealtime flexibility 8

o Patient must eat a consistent number of carbohydrates with each meal Increased risk of nocturnal hypoglycemia Inability to easily adjust the insulin dose for changes in exercise and diet Many patients have to give two injections at each meal. This would include one for the rapid/short acting insulin and one for the intermediate insulin Daytime control is more difficult Potentially more weight gain with this regimen The most common regimens used in patients with type 1 diabetes include MDI therapy with 4 injections per day and CSII therapy. Multiple Daily Injection Therapy The most commonly used regimen with MDI therapy involves the administration of 4 doses of insulin per day. This includes a basal insulin dose given at bedtime with either a long-acting insulin analogue (e.g. detemir, glargine) or NPH insulin. The prandial (bolus) insulin is administered prior to each meal with a rapid acting insulin (e.g. lispro, aspart, glulisine). This prandial dose is adjusted based on the calculations demonstrated in Table 2. Table 3 lists the typical insulin injections of a patient using MDI therapy and table 4 lists some of the key advantages and disadvantages of MDI therapy. Table 3: Intensive insulin therapy utilizing four or more injections of insulin Breakfast Lunch Supper Bedtime Regular/Rapid Flexible dose Flexible dose Flexible dose Long acting Analogue* Normally fixed dose * - An alternative is to give NPH or a long-acting analogue with the breakfast meal and at bedtime but this would increase the number of injections to 5 per day and this may not be acceptable in a particular patient. Table 4 - Advantages and Disadvantages of MDI Therapy over Conventional Therapy 6 Advantages Disadvantages Increase in flexibility as the patient can adjust the dose of insulin based on differing food Need for frequent testing of blood glucose levels (SMBG) intake and exercise levels Need for the cognitive ability to perform the Easier to adjust for hyperglycemia mathematics of carbohydrate counting Reduces the risk of hypoglycemia Requires an increased level of dedication by Reduced risk of microvascular complications the patient to achieve optimal blood glucose More expensive (due to increased blood glucose testing) Requires more support from clinicians to aid the patient in fine-tuning his regimen 9

Continuous Subcutaneous Insulin Infusion (Pump Therapy) The use of CSII therapy has increased significantly since its introduction over 30 years ago. This technology now allows for better glycemic control and optimal flexibility to adjust for changes in a patient s daily lifestyle. With this technology, an insulin pump will deliver rapid-acting insulin through an infusion set that is inserted into the subcutaneous tissue of the patient. These pumps not only provide a basal rate but can be programmed to provide a bolus dose of insulin prior to a meal. Many of these pumps will aid in the calculation of the patient s bolus insulin dose by incorporating blood glucose measurement into the device, aiding with the mathematics of carbohydrate counting and incorporating the insulin sensitivity factor into the calculations. In addition to flexibility in the patient s regimen, there is increasing evidence that patients using CSII can attain lower A1C results compared to patient s using MDI therapy. 4 This improvement in A1C may influence the therapy decision when discussing different treatment options in patients and family members with type 1 diabetes. CSII therapy is not for every patient. The American Diabetes Association has developed some criteria of patients that are not optimal candidates for CSII therapy. These patient characteristics are listed in table 5. The American Association of Clinical Endocrinologists has developed proposed clinical characteristics or profiles of suitable insulin pump users. These criteria/profiles are listed in table 6. The key advantages and disadvantages of CSII that patients and clinicians should consider are listed in table 7. A more detailed discussion on the different aspects of CSII therapy is beyond the scope of this continuing education lesson. Clinicians wanting to read more on insulin pump management are encouraged to read: Statement by the American Association of Clinical Endocrinologists Consensus Panel on Insulin Pump Management For more information on a specific pump type, the clinician may try contacting the insulin pump manufacturer directly. The main insulin pump manufacturers in Canada include: Medtronic Roche Diagnostics Canada Animas Canada Table 5 - Characteristics of Patients that are NOT Good Candidates for CSII Therapy 4 Unable or unwilling to perform multiple daily insulin injections ( 3 to 4 daily), frequent blood glucose monitoring ( 4 to 6 daily), and carbohydrate counting Lack motivation to achieve tighter glucose control and/or have a history of non-adherence to insulin injection protocols History of serious psychological or psychiatric condition(s) (e.g. psychosis, severe anxiety, or depression) Reservations about pump usage interfering with lifestyle (e.g. contact sports or sexual activity) Unrealistic expectations of pump therapy (e.g. belief that it eliminates the need to be responsible 10

for diabetes management) Table 6 - Patient Characteristics/Profiles of Suitable CSII Candidates 4 Patients with type 1 DM who do not reach glycemic goals despite adherence to a maximum MDI, non-csii program, especially if they have: Very labile DM (erratic and wide glycemic excursions, including recurrent DKA) Frequent severe hypoglycemia and/or hypoglycemia unawareness Significant dawn phenomenon, extreme insulin sensitivity Patients with type 1 DM who are on a maximized basal-bolus MDI insulin regimen, regardless of their level of glycemic control and who, after investigation and careful consideration, feel that CSII would be helpful or more suitable for lifestyle reasons Selected patients with insulinrequiring type 2 DM who satisfy any or all of the following: C-peptide positive but with suboptimal control on a maximal program of basal/bolus injections Substantial dawn phenomenon Erratic lifestyle (e.g. frequent long distance travel, shiftwork, unpredictable schedules leading to difficulty maintaining timing of meals) Severe insulin resistance Special populations (e.g. preconception, pregnancy, children, Selected patients with other DM adolescents with eating types (eg, postpancreatectomy) problems, competitive athletes) CSII - continuous subcutaneous insulin infusion; DKA - diabetic ketoacidosis; DM -diabetes mellitus; MDI - multiple daily injections Table 7 - Advantages and Disadvantages of CSII Therapy 6 Advantages Disadvantage Provides more flexibility in meal timing than MDI, as basal insulin is delivered continuously. Less day-to-day variation in insulin absorption Eliminates the need for multiple daily injections (change infusion set every 2 to 3 days) More flexibility in adjusting basal dose Can bolus between meals to correct for hyperglycemia without taking an injection Requires motivation, technical ability and financial resources (more expensive). May develop hyperglycemia and ketones quickly if insulin delivery is stopped for several hours. Risk of infusion-site infections. Requires access to diabetes professional(s) experienced in CSII therapy. Choosing the Most Appropriate Regimen All patients with diabetes must be given the opportunity to be involved in the selection of different treatment options for their diabetes. Based on current CDA guideline recommendations, all patients with type 1 diabetes should either be managed with a MDI or CSII regimen. The choice of regimen will depend on a variety of factors such as: Patient preference Efficacy 11

Risk of hypoglycemia (especially nocturnal hypoglycemia and patients with hypoglycemia unawareness) Cost of the regimen Cost of the supplies (e.g. blood testing strips, infusion sets, insulin pump) Other patient factors (e.g. cognitive ability, need for portability, performing contact sports) Ultimately both MDI and CSII regimens can be very effective in providing patients with type 1 diabetes optimal control and flexibility to adjust their regimen based on daily lifestyle issues (e.g. diet, exercise). The choice should be based on an open discussion and a collaborative decision with the patient on the optimal therapy for his diabetes. 12

Post-Test Greta W. is in for a follow-up appointment. She has long-standing type 1 diabetes and has always been managed with conventional therapy consisting of: 15 units of regular insulin and 24 units of NPH prior to breakfast 10 units of regular insulin and 18 units of NPH prior to supper She has recently had several episodes of hypoglycemia requiring assistance from family members and her A1C is currently 9%. Although she has been resistant in the past to using multiple daily injections of insulin, the hypoglycemia episodes with her current regimen have changed her opinion. 1. You start with a discussion on the difference between multiple daily injections of insulin and her standard therapy. Which of the following is TRUE regarding multiple daily injections of insulin therapy? a. It is more convenient than standard therapy b. It is more costly than standard therapy c. It has a higher risk of hypoglycemia d. All of the above 2. You need to choose an insulin for the basal insulin component of her regimen. Which of the following is NOT an appropriate choice? a. Glulisine b. Glargine c. NPH d. Detemir 3. You then select an insulin to be administered pre-prandially. Which of the following insulins is the LEAST appropriate choice based on current Canadian Diabetes Association Guidelines? a. Regular b. Aspart c. Lispro d. Glulisine 4. What percentage decrease in the daily insulin dose should clinicians consider when switching from conventional therapy to MDI or CSII therapy to accommodate for a more physiological delivery of insulin? a. 0% b. 10-15% c. 20-25% d. 30-50% 5. If Greta was started on 56 units of insulin daily (basal and bolus), what would be the insulin distribution if you utilized the 35/30/35 rule? a. 28 units basal insulin at bedtime, 10 units of bolus insulin prior to breakfast, 8 units of bolus insulin prior to lunch and 10 units of bolus insulin prior to supper b. 56 units of basal insulin given prior to bedtime 13

c. 40 units of basal insulin at bedtime, 6 units of bolus insulin prior to breakfast, 10 units of bolus insulin prior to supper d. 28 units of basal insulin at bedtime, 8 units of bolus insulin prior to breakfast, 10 units of bolus insulin prior to lunch and 10 units of bolus insulin prior to supper 6. You decide to work out the carbohydrate to insulin ratio for this patient. If her ratio is 8, how many units of insulin will she require if she consumes a meal with 96 grams of carbohydrates? a. 5 b. 8 c. 9 d. 12 7. You start discussing the role of the insulin sensitivity factor. You calculate her insulin sensitivity factor as 2. You give her an example of where she has a target blood glucose reading of 7 mmol/l prior to her supper meal and she tests her blood glucose reading and it is 5 mmol/l. What should she do with her insulin to accommodate for this reading? a. Increase her bolus insulin by 1 unit b. Increase her bolus insulin by 2 units c. No action is required d. Decrease her bolus insulin by 1 unit 8. Greta asks about using an insulin pump. Which of the following statements is TRUE regarding continuous subcutaneous insulin infusion therapy? a. It is less expensive than multiple daily injections of insulin therapy b. It requires more injections than standard therapy c. It offers tremendous flexibility in bolus insulin dosing d. All of the above 9. You discuss both the continuous subcutaneous insulin infusion and multiple daily injections of insulin therapy options with Greta. When choosing a regimen for this patient what should the clinician consider? a. Patient preference b. Cost c. Cognitive ability d. All of the above 14

References 1. Canadian Diabetes Association. Treatment Modalities: Advanced Insulin Therapy. In: Building Competency in Diabetes Education: Advancing Practice. Toronto: Canadian Diabetes Association; 2009. 2. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes. 32(suppl 1):s1 s201. 3. The Diabetes Control and Complications Trial Research Group. The Effect of Intensive Treatment of Diabetes on the Development and Progression of Long-Term Complications in Insulin-Dependent Diabetes Mellitus. N Engl J Med. 1993;329(14):977 986. 4. Grunberger G, Bailey T, Cohen A, et al. Statement by the American Association of Clinical Endocrinologists Consensus Panel on Insulin Pump Management. Endocrine Practice. 2010;16(5):746 762. 5. Anon. Basic Carbohydrate Counting for Diabetes Management. Available at: http://www.diabetes.ca/for-professionals/resources/nutrition/basic-carb-counting/. Accessed January 5, 2011. 6. Canadian Diabetes Association. Treatment Modalities: Pharmacological Therapies. In: Building Competency in Diabetes Education: The Essentials. Toronto: Canadian Diabetes Association; 2009. 15