Method 1: Complete Management by the Physician

The physician mayor may not have the patient do self-blood-sugar monitoring. Whatever the testing methods used, all data are brought to the physician, who makes all decisions on changes in insulin and food.

Method 2: Sliding Scale

With this method the patient is allowed to make decisions on daily changes in insulin based on tables of blood,sugar values and insulin to be injected or withheld. The sliding scale has two major defects. First, insulin is given after the fact-that is, a blood, sugar level at noon, for example, does not predict the insulin needed for the next 4 to 6 hours, but rather reflects the insulin needed 4 to 6 hours ago. You are thus always 4 to 6 hours behind and on a roller coaster of control. The other defect is that there is a cutoff point of blood sugar below which no insulin is given. It must be remembered that Regular insulin lasts only 6 hours (and Lispro, only 3 hours), so even when there is a low normal blood,sugar level, some insulin must be given to cover the time when the previous dose has run out.

Method 3: Algorithms

Algorithms are formulas for changing insulin. They are similar to the sliding scale, except that the formulas are superimposed on a background of two or more doses of intermediate (NPH or Lente) or long, acting (Ultralente) insulin. Regular insulin at mealtimes and/ or in the evening is changed on a formula basis, depending on the blood sugar at the time. The major defect of this system is that insulin is again given after the fact. The system can be made to work, however, by choosing the amount of supplemental insulin based on changes in the food intake or activity levels or on the consistent need to add extra insulin to the previous dose.

An example of the latter management is as follows: Suppose a person is taking a mixture of NPH and Regular for breakfast, with Regular for supper and NPH at bedtime (a common regimen), and he or she has persistently high blood,sugar levels before breakfast. This person has an algorithm to increase the morning Regular insulin by one unit for every 50 mg that the blood sugar is elevated over 150 mg/dl (8 mmol), and would thus increase the morning Regular if this elevated blood sugar occurred. However, the problem of the increased fasting blood sugar means there is a need for more NPH at bedtime, not for more Regular insulin in the morning. An increase in morning Regular may cause a reaction later in the day. If the algorithm is used, the extra Regular insulin given in the morning should be called supplemental insulin and recorded in the logbook separately.

If the problem is recurrent (several days in a row), then the "supplement" should be added by increasing the evening NPH rather than by taking the Regular continually as a morning supplement.

Method 4: Patterned Glucose Approach

In this method, a basic two "three" or four, dose insulin regimen is prescribed, and blood sugar is tested four times (either fasting and 2 hours after each meal, or premeal and at bedtime) for three consecu, tive days. The pattern of blood,sugar values is then analyzed, and the appropriate insulin or insulins are altered prior to the time of altered blood,sugar levels. Example: the person is taking NPH/Regular before breakfast, Regular before supper, and NPH at bedtime. The blood sugar is tested after breakfast or pre, lunch, after lunch or pre,supper, after supper or bedtime, and before breakfast. A target range of blood,sugar values for each time period is prescribed, and the achieved values over the three,day period are compared with the target.

If the pre-breakfast blood,sugar level is too high or too low (our acceptable target is 60-120 mg/dl [3-7 mmo1]), the NPH given at bedtime is changed. If the level after breakfast or pre-lunch is out, side the target range (70-150 mg/dl [4-8 mmol]), then the morning Regular is changed. If the afternoon blood sugar is off (70-150 mg/dl [4-8 mmol]), then the morning NPH is changed. If the evening blood sugar is off (70-150 mg/dl [4-8 mmo1]), then the supper Regular insulin is changed.

If a different insulin regimen is used, the same principles apply-just remember that Regular insulin acts during the 4 to 6 hours after it is given and peaks in 2 to 3 hours; NPH or Lente acts during the 12 hours after it is given, with the peak action time at about 6 to 8 hours after injection. By understanding when a given insulin peaks and what its duration is, you can know when to check your blood sugar and how to use the results to change the insulin dose. Excellent control can be achieved in this way.