Transcript Detection & Treatment2

2-2
Type 1: SMBG and HbA1C Targets
SMBG Targets
• More than 50% of values within target range
• Age < 6: 100-200 mg/dL pre-meal and bedtime
• Age 6-12: 80-180 mg/dL pre-meal and bedtime
• Age >12: 80-140 mg/dL pre-meal
< 160 mg/dL 2 hours after start of meal
100-160 mg/dL bedtime
• No severe (assisted) or nocturnal hypoglycemia
Adjust pre-meal target upward if hypoglycemia
unawareness or repeated severe hypoglycemia occurs
HbA1c Target
• Age < 6: Within 2.5 percentage points of upper
limit of normal
• Age 6-12: Within 2 percentage points of upper
limit of normal
• Age > 12: Within 1.5 percentage points of upper
limit of normal
SMBG Frequency
• Minimum 4 times/day; before and 2 hours after start of
meals and at bedtime
• Check 3 AM as needed
Lispro Insulin (LP) Considerations
• 1 unit of LP = 1 unit of Regular insulin
• Administer within 15 minutes before the meal due to
rapid action
• May need to increase basal insulin dose
• Use both pre-meal and post-meal SMBG data to make
LP dose adjustments
• May have reduced need for snacks between meals
• Consider an additional LP insulin injection before
snacks > 30 gm total carbohydrate
2
3
Type 1: Screening and Diagnosis
Obtain laboratory plasma
glucose and urine ketones
Plasma glucose
< 110 mg/dL?
YES
NO
Fasting plasma glucose
110-125 mgdL or
casual plasma glucose
140-199 mg/dL?
YES
NO
Fasting plasma glucose
> 126 mg/dL or
casusl plasma glucose
> 200 mg/dL and positive
NO
Monitor urine detones
every 4 hours; if posttive,
see immediately; otherwise obtain laboratory
fasting plasma glucose
within 24 hour
Fasting Plasma glucose
> 126 mg/dL?
YES
YES
NO
Plasma glucose
< 110 mg/dL?
NO
No diabetes; evaluate for
infection, steroid use, or
metabolic disorder
YES
No diabetes; evaluate
for infection or metabolic disorder
Immediately have
patient consume meal
with 60-75 gm carbohydrate; obtain laboratory plasma glucose 2
hours post meal
If < 200 mg/dL, evaluate for infection or
metabolic disorder; if
uncertain, consider
OGTT
If > 200 mg/dL, continue with diagnosis
sequence
Diagnosis of type 1 diabetes; move to Type 1
Master DecisionPath
If vomiting, dehydration, and large ketones,
suspect diabetic
ketoacidosis; hospitalize immediately for
insulin initiation and
treatment
Consider inpatred fasting glucose and referral
to Diabetes Specialist
Type 1: Master DecisionPath
At Diagnosis
FPG > 126 mg/dL
CPG > mg/dL
OR
Insulin Stage 2
R/N - 0 - R/N - 0
LP/N - 0 - LP/N - 0
Insulin Stage 1
(Honeymoon)
(R)/N - 0 - 0 - 0
Insulin Stage 3A
R/N - 0 - R - N
LP/N - 0 - LP - N
Insulin Stage 3B
R/N - 0 - R/N - 0
LP/N - 0 - LP/N - 0
Insulin Stage 4A
R/N - R - R - N
LP/N - LP - LP - N
Insulin Stage 4A
R/N - R - R - N
LP/N - LP - LP - N
Medications
Comments
R = Human Regular
Insulin
LP = Lispro Insulin
N = Human NPH
Insulin
UL = Human Ultralente
Insulin
0 = None
Dose Schedule:
AM-MIDDAY-PM-BEDTIME
• Continue with food
plan and exercise program throughout all
stages of therapy.
• Initially patient may be
in a honeymoon stage
during which the number of injections and
the amount of insulin
may be decreased
2-5
Type 1: Insulin Stage 2/Start
At Diagnosis
Start insulin within 2-4 hours; hospitalize if acute illness or
DKA at diagnosis, psychosocial factors present, or outpatient
education not available
Start Insulin Stage 3A-Mid
R/N - 0 - R/N - 0
LP /N - 0 - LP/N - 0
At Diagnosis
If patient arrives in AM:
• Calculate total dose based on urine ketones and current weight
• 0.5 U/kg for Negative to Moderate ketones
• 0.7 U/kg for Large ketones
AM MIDDAY PM
BT
Distribution
2/3
0
1/3
0
R/N or LP/N ratio
1:2
1:1
If patient arrives after 12 noon:
• Calculate initial dose based on urine ketones
and current weight
• 0.2 U/kg for Negative to Small ketones
• 0.3 U/kg for Moderate to Large ketones
• Give PM dose of R/N or LP/N; ratio is 1:1
• Monitor BG and ketones every 4 hours
• Supplement with R or LP as needed
• Calculate total dose for next day
• See patient next AM
After initiating insulin, refer patient for nutrition and diabetes education
Follow-up
Medical: Within 24 hours, then office visit in 2 week
Nutrition: Within 24 hours, then office visit in 2 week
Move to Insulin Stage 2/Adjust
2-8
Type 1: Insulin Stage 2/Start
Patient in Insulin Stage 2
and not at target
Is current total daily
insulin dose:
< 1.0 U/kg for age < 12?
< 1.5 U/kg for age < 12-18?
< 1.0 U/kg for age > 18?
If persistent fasting
hyperglycemia or nocturnal hypoglycemia,
move to Insulin Stage
3A; if midday hyperglycemia, move to
Insulin Stage 4A; if
more flexibility
required move to
Insulin Stage 3B
NO
YES
Insulin Stage 2 Pattern Adjustments
R/N - 0 - R/N - 0 or LP/N - 0 - LP/N - 0
< 80 mg/dL
< 80 mg/dL
AM
or 3 AM
MIDDAY
(MID)
PM
ฏ
PM N
1-2 U (a,b)
ฏ AM R or LP
1-2 U (c,e)
ฏ AM N
1-2 U (d,e)
< 100 mg/dL
BEDTIME
(BT)
PM R or LP
1-2 U (e)
ฏ
> 140
> 140
mg/dL
mg/dL
PM N
1-2 U (a)
ญ AM R or LP
1-2 U (f,g)
ญ AM N
1-2 U (f,h)
ญ
> 160 mg/dL
PM R or LP
1-2 U (f)
ญ
Adjust insulin based on BG patterns
Follow-up
Medical: Weekly while adjusting insulin, then office visit
within 1-2 months; use this DecisionPath for follow-up
See Insulin Adjustment Guidelines, 2-14, for considerations designated
by each letter and for BG pattern changes for age < 12 and
hypoglycemia unawareness.
2-9
Type 1: Insulin Stage 3A/Start
2-10
At Diagnosis or from Insulin Stage 2
If persistent AM hyperglycemia, nocturnal hypoglycemia, and/or
lifestyle issues requiring variation in timing of meals
Start Insulin Stage 3A
R/N - 0 - R - N
LP /N - 0 - LP - N
At Diagnosis
• Calculate total dose based on urine ketones and current weight
• 0.5 U/kg for Negative to Moderate ketones
• 0.7 U/kg for Large ketones
AM
MIDDAY
PM
BT
Distribution
2/3
0
1/6
1/6
R/N
or
LP/N
ratio
1:2
From Insulin Stage 2
• Use current total dose
• Move PM N to BT
• R or LP may be modified for activity and timing of meals
• AM R or LP may go down 1-2 units
• PM R or LP may go up 1-2 units
If erratic SMBG or weight gain and current total dose is greater than
values below, consider recalculating and redistributing dose as for new
diagnosis
AGE
CURRENT TOTAL DOSE
< 12
1.0 U/kg
12-18
1.5 U/kg
> 18
1.0 U/kg
After initiating insulin, refer patient for nutrition and diabetes education
Follow-up
Medical: If new insulin start, daily hone contact for 3 days, then office
visit within 2 weeks; 24+hour
emergency phone support needed
Nutrition: If newly diagnosed, within 24 hours, otherwise within 2 weeks
Move to Insulin Stage 3A/Adjust
Type 1: Insulin Stage 3A/Adjust
Patient in Insulin Stage
3 A and not at target
Is current total daily
insulin dose:
< 1.0 U/kg for age < 12?
< 1.5 U/kg for age < 12-18?
< 1.0 U/kg for age > 18?
If persistent midafternoon hyperglycemia
or no significant
improvement in 6
months,
move to Insulin
Stage 4A/Start
NO
YES
Insulin Stage 3A Pattern Adjustments
R/N - 0 - R - N or LP/N - 0 - LP - N
< 80
< 80
mg/dL
mg/dL > 140
> 140
mg/dL
mg/dL
AM
or 3 AM
MIDDAY
(MID)
PM
BEDTIME
(BT)
BT N
1-2 U (a,b)
ฏ AM R or LP
1-2 U (c,e)
ฏ AM N
1-2 U (d,e)
BT N
1-2 U (a)
ญ AM R or LP
1-2 U (f,g,i)
ญ AM N
1-2 U (f,h)
ฏ
ญ
< 100 mg/dL
> 160 mg/dL
PM R or LP
1-2 U (e)
ฏ
PM R or LP
1-2 U (f)
ญ
Adjust insulin based on BG patterns
Follow-up
Medical: Weekly while adjusting insulin, then office visit
within 1-2 months; use this DecisionPath for follow-up
See Insulin Adjustment Guidelines, 2-14, for considerations designated
by each letter and for BG pattern changes for age < 12 and
hypoglycemia unawareness.
2-11
2-12
Type 1: Insulin Stage 4A/Start
From Insulin Stage 3A
If persistent midafternoon hyperglycemia and/or lifestyle
issues requiring variation in timing of meals
Start Insulin Stage 4A
R/N - 0 - R - N
LP /N - 0 - LP - N
From Insulin Stage 3A
• Use current total dose
• Add MIDDAY R or LP at 20 % of current AM N
• Decrease AM N by 50%
• Increase AM R or LP by 1 unit
• Increase PM R or LP by 1 unit
If erratic SMBG or weight gain and current total dose is greater than
values below, consider recalculating and redistributing dose as shown
AGE
< 12
12-18
> 18
Distribution
1/3
0
-R/N or LP/N ratio
CURRENT TOTAL DOSE
1.0 U/kg
1.5 U/kg
1.0 U/kg
AM
2/3
1:1
MIDDAY
-
0
PM
Refer patient for nutrition and diabetes eduaction
Follow-up
Medical: Within 24 hours, then office visit in 2 weeks
Nutrition: Within 24 hours, then office visit in 2 weeks
Move to Insulin Stage 4A/Adjust
BT
-
Type 1: Insulin Stage 4A/Adjust
Patient in Insulin Stage
4 A and not at target
Is current total daily
insulin dose:
< 1.0 U/kg for age < 12?
< 1.5 U/kg for age < 12-18?
< 1.0 U/kg for age > 18?
If no significant
improvement in
6 months,
refer patient to a
Diabetes Specialist
NO
YES
Insulin Stage 4A Pattern Adjustments
R/N - R - R - N or LP/N - LP - LP - N
< 80
< 80
mg/dL
mg/dL > 140
> 140
mg/dL
mg/dL
AM
or 3 AM
MIDDAY
(MID)
PM
BT N
1-2 U (a,b)
ฏ AM R or LP
1-2 U (c,e)
ฏ MID R or LP*
1-2 U (d,e)
ฏ
< 100 mg/dL
BEDTIME
(BT)
PM R or LP
1-2 U (e)
ฏ
BT N
1-2 U (a)
ญ AM R or LP
1-2 U (f,g,i)
ญ
ญ
MID R or LP
1-2 U (f,h,j,k)
> 160 mg/dL
PM R or LP
1-2 U (f)
ญ
Adjust insulin based on BG patterns
Follow-up
Medical: Weekly while adjusting insulin, then office visit
within 1-2 months; use this DecisionPath for follow-up
See Insulin Adjustment Guidelines, 2-14, for considerations designated
by each letter and for BG pattern changes for age < 12 and
hypoglycemia unawareness.
* Consider discontinuing AM N
2-13
2-14 Type 1: Insulin Adjustment Guidelines 2, 3A,
4A
How to Use These Tables
1. Find current insulin stage
2. Find the pattern of blood glucose
problem (column)
3. Identify time of day (row) pattern occurs
4. Recommended adjustment is given where the column and
row intersect
5. See notes for additional considerations
Insulin Pattern Adjustments
• Adjust insulin from 3-day
pattern
• Determine which insulin is
responsible for pattern
• Adjust by 1-2 units
• Adjust only one dose at a time
• Correct hypoglycemia first
• If total dose > 1.5 U/kg,
consider overinsulinization
• If hyperglycemia throughout
day, correct highest SMBG
first; if all within 50 mg/dL
correct AM first
• For age < 6 years, change
pattern values to
< 100 mg/dL and > 200
mg/dL; reduce adjustment
dose by 50%
• For age 6-12 years,change
pattern value to
> 180 mg/dL; reduce
adjustment
dose by 50%
• For hypoglycemia unawareness
(age > 12),change pattern values to < 100 mg/dL
and > 160 mg/dL
Notes
a. Evaluate nocturnal hypoglycemia; check 3 AM BG
b. Consider increasing bedtime snack
c. Consider adding or adjusting mid-morning snack
d. Consider adding or adjusting afternoon snack
e. Evaluate if previous exercise is causing hypoglycemia
f. Consider adding exercise
g. Consider decrease in mid-morning snack
h. Consider decrease in afternoon snack
i. No mid-morning snack usually needed with LP
j. No afternoon snack usually needed with LP
k. Consider adding AM N if long interval between middy and evening
meal or afternoon hyperglycemia
AM N:
MIDDAY R or LP:
AM and PM R or LP: No change
50% MIDDAY R or LP dose
ฏ 50%
No change
2-16
Type 1: Insulin Stage 3B/Start
From Insulin Stage 3A
If persistent midafternoon hyperglycemia and/or lifestyle
issues requiring variation in timing of meals
Start Insulin Stage 3B
R/(UL) - R - R/UL - 0
LP/UL - LP - LP/UL
-0
From Insulin Stage 2 and using R or LP and AM UL
• Use current total insulin dose
• Stop N
• Add UL at 50% total dose
• Add MIDDAY R or LP
BT
DISTRIBUTION
AM
MIDDAY
PM
BT
DISTRIBUTION
AM
MIDDAY
PM
R40%
or LP (50% 0of total dose)
35%
25%
UL
(50%
of
total
dose)
33%
0
67%
0
From Insulin Stage 2 and using R or LP and no AM UL
• Use current total insulin dose
• Stop N
• Add UL at 40% total dose
• Add MIDDAY R
R or LP (60% 0of total dose)
35%
25%
40%
UL
(40%
of
total
dose)
0
0
100%
0
If erratic SMBG or weight gain and current total dose is greater than
values below, consider recalculating and redistributing as above
AGE
CURRENT TOTAL DOSE
< 12
1.0 U/kg
12-18
1.5 U/kg
> 18
1.0 U/kg
Refer patient for nutrition and diabetes education
Follow-up
Medical: Phone or office visit within 1 week, then office visit within
1 month
Move to Insulin Stage 3B/Adjust
Type 1: Insulin Stage 3B/Adjust
Patient in Insulin Stage 3B
If AM hyperglycemia after adding PM UL, discontinue PM
UL and add N at bedtime at same dose of PM UL
R/UL-R-R-N or LP/UL-LP-LP-N
Is current total daily
insulin dose:
< 1.0 U/kg for age < 12?
< 1.5 U/kg for age < 12-18?
< 1.0 U/kg for age > 18?
If no significant
improvement in
6 months,
refer patient to a
Diabetes Specialist
NO
YES
Insulin Stage 3B Pattern Adjustments
R(UL) - R - R/UL - 0 or LP/UL - LP - LP/UL - 0
< 80 mg/dL
< 80 mg/dL
> 140
> 140
mg/dL
mg/dL
AM
or 3 AM
MIDDAY
(MID)
PM
BT UL
1-2 U (a,b)
ฏ AM R or LP
1-2 U (c,e)
ฏ MID R or LP
1-2 U (d,e)
ฏ
< 100 mg/dL
BEDTIME
(BT)
PM R or LP
1-2 U (e)
ฏ
BT UL
1-2 U (a)
ญ AM R or LP
1-2 U (f,g)
ญ
ญ
MID R or LP
1-2 U (f,h,j,k)
> 160 mg/dL
PM R or LP
1-2 U (f)
ญ
Adjust insulin based on BG patterns
Follow-up
Medical: Weekly while adjusting insulin, then office visit
within 1-2 months; use this DecisionPath for follow-up
See Insulin Adjustment Guidelines, 2-18, for considerations designated
by each letter and for BG pattern changes for age < 12 and
hypoglycemia unawareness.
2-17
2-18 Type 1: Insulin Adjustment Guidelines 3B
How to Use These Tables
1. Find current insulin stage
2. Find the pattern of blood
glucose
problem (column)
3. Identify time of day (row)
pattern occurs
4. Recommended adjustment
is given where the column
and row intersect
5. See notes for additional
considerations
Insulin Pattern Adjustments
• Adjust insulin from 3-day
pattern
• Determine which insulin is
responsible for pattern
• Adjust by 1-2 units
• Adjust only one dose at a
time
• Correct hypoglycemia first
• If total dose > 1.5 U/kg,
consider overinsulinization
• If hyperglycemia throughout
day, correct highest SMBG
first; if all within 50 mg/dL
correct AM first
• For age < 6 years, change
pattern values to < 100
mg/dL and > 200 mg/dL;
reduce adjustment dose by
50%
• For age 6-12 years,change
pattern value to > 180
mg/dL; reduce adjustment
dose by 50%
• For hypoglycemia unawareness (age > 12),change pattern values to < 100
mg/dL
and > 160 mg/dL
Notes
a. Evaluate nocturnal
hypoglycemia; check 3 AM BG
b. Consider increasing bedtime
snack
c. Consider adding or adjusting
mid-morning snack
d. Consider adding or adjusting
afternoon snack
e. Evaluate if previous exercise is
causing hypoglycemia
f. Consider adding exercise
g. Consider decrease in
midmorning snack
h. Consider decrease in afternoon
snack
i. AM UL is a basal insulin and
usually does not require
adjusting. If PM BG
> target due to a long interval
between midday and evening
meal, consider increasing UL
by 1-2 units
Compensatory Adjustment
• Made with R or LP insulin only
• Given at times of R or LP
insulin injections
• May be added or subtracted
on basis of BG, food, or exercise
• Used with caution at bedtime;
3 AM BG is used to determine
the bedtime dose
Blood Glucose
(mg/dL)
ฏ
1-2 U< 80
140-200
201-250
251-300
> 300
Adjust R or LP
1U
2U
ญ 3U
ญ 4 >U
ญ
ญ
Type 1: Insulin Stage 1/Adjust
Patient referred on
Insulin Stage 1
(R)/N - 0 - 0 -0
SMBG and/or HbA1c
within target range and
patient in “honeymoon”
phase?
NO
Move to Insulin
Stage 2/Start
YES
Patient enters Insulin
Stage 1/Maintain
Continue current dose;
use this DecisionPath
for follow-up
Follow-up
Medical: Every 1-2
months
2-19
Type 1: Preconception Planning
2-25
Patient planning pregnancy
History, physical exam, and
laboratory evaluation by clinician
• History: Diabetes therapy and
control, miscarriages, and birth
control
• Medications: If hypertensive,
switch to Methyldopa or
Hydralazine; ACE inhibitors
and beta blockers contraindicated
in pregnancy
• Complications: Hypoglycemia
unawareness; DKA; retinopathy;
nephropathy; neuropathy
• Discuss pregnancy-related risks
including association of hyperglycemia with complications;
DKA with fetal death; fetal
malformations
• Physical exam: Include
funduscopic eye exam with
dilation by Ophthalmologist
• Laboratory: CBC; UA/UC; thyroid
studies; screen for albuminuria;
HbA1c; EKG if diabetes duration
> 10 years
Correlate SMBG and HbA1c; assess
nutritional status selfmanagement
skills, and psychological status
SMBG and/or HbA1cwithin
target range?
SMBG Targets
• Pre-meal: 80-120 mg/dL
• Post-meal: < 140 mg/dL
2
hours after start of meal
• Bedtime: 100-140 mg/dL
(bedtime)
• No severe (assisted) or
nocturnal hypoglycemia
• Adjust if hypoglycemia
unawareness
HbA1c Target
• At least 2 balues 1 mohth
apart within normal range
SMBG Frequency
• 4 times/day; before meals
and 2 hours after start of
meals and at bedtime
• Check 3 AM as needed
YES
NO
Work with patient to establish BG control
• Reassess current therapy
• Start or adjust intensified regimen as needed
See Insulin Stage 3A or 4A
• Continue with birth control
• Consider co-management with a Diabetes Specialist
Stop birth control and
continue current insulin
stage; maintain SMBG
and HbA1c within target
range until pregnancy
confirmed
Move to Management
During Pregnancy
2-26 Type 1: Management During Pregnancy
Maternal Monitoring
• Baseline: Thyroid functions, if not done
• Each visit: Dipstick UA; UC as appropriate; verify SMBG
• Every 4 weeks: HbA1C
• First trimester: Eye exam with dilation by Ophthalmologist
(follow-up as indicated)
Screen for albuminuria
If complications exist or develop, refer patient to Diabetes
Specialist and other specialists as necessary
Nutrition
• Increase calories 300/day in the second and third trimesters
• Adequate weight gain according to table below
BMI
%DBW
15-25 lbs.
90-120
>120
(wt/ht2=kg/m2)
90%
28-40 lbs.
19.8-26
Self-Management Education
• Emphasize hypoglycemia prevention/treatment
• Instruct family member on glucagon administration
• Instruct on self adjustment of insulin as appropriate
• No skipped meals
Wt. Gain
<19.8
20-35 lbs.
>26
2-27
Type 1: Food Plan and Exercise
Establish Food Plan and Exercise
Assessment
•Food history or 3 day food
record (meals, times, portions)
• Nutrition adequacy
• Height/weight/BMI; see BMI
Chart, 4-3
• Weight goals/eating disorders
• Psychosocial issues (denial,
anxiety, depression)
• Economic/cultural factors
• Nutrition/diabetes knowledge
• Readiness to learn/barriers to
learning
• Work/school/sports schedules
• Fitness level (strength, flexibility,
endurance)
• Exercise (times, duration, types)
• Tobacco/alcohol use
• Vitamin/mineral supplements
Goals
• SMBG/HbA1c in target
• Desirable body weight (adults)
• Normal growth and development
(children)
• Consistent carbohydrate intake
• Regular exercise
Plan
• Establish adequate calories for
growth and development/reasonable body weight
• Set meal/snack times
• Integrate insulin regimen with
food plan
• Set consistent carbohydrate
intake
• Establish regular exercise regimen based on fitness level
• Establish adequate calories for
pregnancy/lactation/recovery
from illness
Medical Nutrition Therapy
Guidelines (non-pregnant)
• Total fat: 30% total calories;2
ries; less if BMI > 27 kg/m
or LDL > 130 mg/dL
• Saturated fat: < 10 % total
calories; < 7% with LDL
> 130 mg/dL
• Cholesterol: < 300 mg/day
• If BMI > 27 kg/m2,
decrease calories by
10-20% and add exercise
• If BP > 130/85 mm/Hg,
reduce sodium to
< 2400 mg/day
• If albumin > 300 mg/24
hour or creatinine
> 300 mg/g, reduce protein
to 0.8g/kg/day or ~10%
total calories
Calorie Requirements
Adults
Most men/active women:
DBW x 15 kcal
Most women/inactive
men/most adults > age 55:
DBW x 13 kcal
Inactive women/obese
adults/inactive adults
> age 55: DBW x 10 kcal
Children/Method 1
First year: 1000 kcal
Age 1-10: Add 100 kcal/year
Age 11-15: Boys add 200
kcal/year; girls add
100 kcal/year
Age > 15: Boys add for activity
(23 kcal/lb very active, 18
kcal/lb
normal, 16 kcal lb inactive); girls
calculate as adult
Children/Method 2
First year: 1000 kcal
Age 1-3: Add 40 kcal/inch
Age > 3: Boys 125 kcal x age;
girls 100 kcal x age; add up to
20%kcal for activity
3-2 Gestational: SMBG and Weight Gain Targets
SMBG Targets
• All values within target range
• Pre-meal and bedtime: 60-95 mg/dL
• Post-meal: < 120 mg/dL 2 hours after start of meal; < 140 mg/dL
1 hour
after start of meal
Urine Ketones Target
• Negative
SMBG Frequency
• Test 7 times/day; before and 1-2 hours after start of meals
and at bedtime
• Minimum 4 times/day; fasting and 1-2 hours after start of meals
Urine Ketones Monitoring
• Test every AM for 1 week, then every other AM
Weight Gain Guidelines
%DBW
90%
90-120
>120
BMI
<19.8
19.8-26
>26
GAIN
28-40 lbs.
20-35 lbs.
Target weight gain for significantly obese women
(BMI > 29 kg/m2): ~ 15 lbs
15-25 lbs.
3
3
Gestational: Screening and Diagnosis
Patient is pregnant
With risk factors: Screen at
first prenatal visit
No risk factors: screen at
24-28th gestational week
Screen with 50 gram glucose
challenge test (GCT)
50 gram glucose
challenge (GCT) test abnormal
(plasma glucose > 140 mg/dL
or whole blood > 120 mg/dL?
NO
YES
With risk factors: Rescreen
at 24 and 32 weeks; if normal
at 32 weeks, no further
testing
No risk factors: No further
testing
With risk factors: Repeat
OGTT at 32 weeks
No risk factors: No further
testing
Perform 100 gram oral glucose
tolerance test (OGTT) within
3 days of positive screen
Two abnormal
OGTT values?
YES
Diagnosis of gestational
diabetes
MoveNO
to Gestational
Master DecisionPath
100 gram Oral Glucose Tolerance
Test
Fasting
1 hour
2 hour
3 hour
Risk Factors
• BMI > 27 (especially waist-tohip ratio > 1)
• Family history of type 2 diabetes (especially first-degree
relatives)
• Age > 30
• Multiparity
• Previous gestational diabetes:
Macrosomic or large-for-gestational age infant
• Previous impaired glucose tolerance (IGT) with fasting BG
110-125 mg/dL
• Previous impaired fasting glucose (IGT) with 2 hour OGTT
140-199 mg/dL
• American Indian; African
American; Asian American;
Mexicah/Hispanic American;
Pacific Islander
NO
NO
One abnormal value?
YES
Monitor
fastng and 2 hours
after
plan start of meal; start food
If average fasting BG > 95 mg/dL
WHOLE BLOOD
or average 2 hour post-meal BG >
> 105 mg/dL > 90 mg/dL 120 mg/dL, treat with food plan and
> 190 mg/dL > 165 mg/dLrepeat OGTT at 32 weeks
> 165 mg/dL > 145 mg/dL
> 145 mg/dL > 125 mg/dLSee Food Plan/Start, 3-8
PLASMA
Gestational: Master DecisionPath
At Diagnosis
OGTT fasting
plasma glucose
< 95 mg/dL
Food Plan Stage
Insulin Stage 2
R/N - 0 - R/N - 0
LP/N - 0 - LP/N - 0
At Diagnosis*
OGTT fasting
plasma glucose
> 95 mg/dL
OR
*
Plasma Glucose
criteria for starting
each therapy may be
modified
Medications
R = Human
Regular Insulin
N = Human
NPH Insulin
0 = None
Dose Schedule:
AM - MIDDAY - PM - BEDTIME
Insulin Stage 3A
R/N - 0 - R - N
If persistent midafternoon
hyperglycemia, start Insulin
Stage 4A
Food Plan Stage
Medications
• Continue with food plan
and exercise program
throughout all stages of
therapy
• Lispro (LP) insulin has
not been tested during
pregnancy
3-5
3-8
Type 1: Insulin Adjustment Guidelines 3B
Start Food Plan
Assessment
• Food history or 3-day food
record (meals and snacks
with times and portions)
• Nutrition adequacy
• Weight gain/change
• Exercise times, duration,
and type
• Fitness level (strength, flexi
bility, endurance)
• Alcohol use
• Vitamin and mineral suppoement
Goals
• Good pre-natal nutrition
• Proper weight gain based on
BMI
• SMBG within target range
• Negative ketones
Plan
• Two carbohydrate choices at
breakfast and consistent
bedtime snack
• Set meal and snack times
• Set consistent carbohydrate
intake at meals and snacks
to meet BG targets (see
sample food plan)
• Encourage regular exercise
based on usual activity prior
to pregnancy
Refer for nutrition and diabetes
education within 48 hours
Follow-up
Medical: Phone within 3
days to review
SMBG, urine
ketones, and
food records,
then office visit
within 1-2 weeks
Move to Food Plan/Adjust
Sample Food Plan
MEAL CHO MEAT/SUB FAT
Bkfat. 2
0-1
0-1
Snack
0-1
0-1 1-2
Lunch
1-2
Snack
0-1
3-4
2-3
1-2
0
Dinner
3-4
2-4
1-2
• 1 CHO = 1 carbohydrate
serving = 15 gm 0
Snack
0-1 1-2
carbohydrate;
60-90 calories
• 1Meat/Sub = 1 oz serving
(28 gm) = 7 gm protein; 5
gm fat; 50-100 calories
• 1 Added Fat = 1 serving =
5 gm fat; 45 calories
• Vegetables = 1-2
servings/day
with each meal; not counted in
plan
Gestational: Food Plan/Adjust
Patient in Food Plan
Stage
Patient enters Food
Plan/Maintain
Continue current therapy;
use this
DecisionPaht for follow-up
SMBG and/or HbA1c
within target range and
patient in “honeymoon”
phase?
Follow-up
Medical:
Phone 1-2
times/week
Office visit
every 2
weeks
YES
Move to Insulin Stage2,
or Insulin Stage 3 A
NO
Food Plan Adjustments
• If elevated postprandial BG, decrease carbohydrate at meals if appropriate;
redistribute carbohydrate (calories) to other times of the day
• If positive ketones or insufficient weight gain, add or increase bedtime
snack;assess adequacy of caloric intake; add more food at snack times;
assess undereating to avoid taking insulin
Adjust food plan based on BG, ketone, or weight; use this DecisionPath for
follow-up
Follow-up
Medical: Phone 1-2 times/week
Office visit every 2 weeks
Education: Every 2-4 weeks as needed
Nutrition: Every 2-4 weeks as needed
3-9
Gestational: Insulin Stage 2/Start
3-12
At Diagnosis or from Food Plan Stage
Start insulin within 24 hours. Hospitalize if
medically necessary
Start Insulin Stage 2
R/N - 0 - R/N - 0
At Diagnosis
Calculate total dose at 0.4 U/kg based on current weight
AM
MIDDAY
Distribution
2/3
R/N ratio
1:2
Refer patient for nutrition and diabetes education
-
PM
0
Follow-up
Medical: Daily phone contact for 3 days, then office visit within 2
weeks; 24-hour emergency phone sup-port needed
Education: Within 24 hours, then office visit in 2 weeks
Move to Insulin Stage 2/Adjust
BT
1:1
1/3
-
Gestational: Insulin Stage 2/Adjust
3-13
Patient in Insulin Stage 2
Is current total daily
insulin dose:
< 1.5 U/kg?
NO
If persistent AM hyperglycemia or
nocturnal hypo
glycemia, move to
Insulin Stage 3A/Start
YES
Insulin Stage 2 Pattern Adjustm R/N - 0 - R/N - 0
>140
AM
MIDDAY
(MID)
PM
BEDTIME
(BT)
Pattern of BG in mg/dL
Pre-meal
Post-meal 2 hr > 120
< 60
> 90
< 90
1hr
ฏ
PM N
(a,d)
ฏ AM R
(b,k)
ฏ AM N
(c,k)
ฏ PM R
(k)
ญ
ญ
PM N
(a,h,n)
AM R
(j,l)
ญ AM N
(j,m)
ญ PM R
(k)
ฏ
AM N
(a,k)
ฏ AM N
(c,k)
ฏ AM N
(k)
-
ญ
AM R
(f,j)
ญ AM R
(j)
ญ AM R
(j)
-
Adjust insulin based on BG patterns
Follow-up
Medical: Weekly while adjusting insulin, then office visit
within 1-2 months; use this DecisionPath for follow-up
Education: Every 2-4 weeks as needed
See Insulin Adjustment Guidelines, 3-18, for adjustment considerations
designated by each letter.
Gestational: Insulin Stage 3A/Start
3-14
At Diagnosis or from Food Plan Stage
or Insulin Stage 2
Start insulin within 24 hours. Hospitalize if
medically necessary
Start Insulin Stage 3A
R/N - 0 - R-N
At Diagnosis
Calculate total dose at 0.4 U/kg based on current weight
AM
MIDDAY
Distribution
2/3
R/N ratio
1:2
From Insulin Stage 2
• Use current total dose
• Move PM N to bedtime (BT)
• R may be modified for activity and timing of meals
• AM R may go down 1-2 units
• PM R may go up 1-2 units
Refer patient for nutrition and diabetes education
PM
0
Follow-up
Medical: Daily phone contact for 3 days, then office visit within 2
weeks; 24-hour emergency phone sup-port needed
Move to Insulin Stage 2/Adjust
BT
-
1/6
-
Gestational: Insulin Stage 3A/Adjust
3-15
Patient in Insulin
Stage 3A
Is current total daily
insulin dose: < 1.5 U/kg?
NO
If persistent midafternoon
hyperglycemia, move to
Insulin Stage 4A
YES
Insulin Stage 2 Pattern Adjustm R/N - 0 - R/N - 0
>140
AM
MIDDAY
(MID)
PM
BEDTIME
(BT)
Pattern of BG in mg/dL
Pre-meal
Post-meal 2 hr > 120
< 60
> 90
< 90
1hr
ฏ
BT N
(a,d)
ฏ AM R
(b,k)
ฏ AM N
(c,k)
ฏ PM R
(k)
N
(a,n)
ญ BT
ญ
AM R
(j,l)
ญ AM N
(j,m)
ญ PM R
(k)
ฏ
AM R
(b,k)
ฏ AM N
(c,k)
ฏ AM N
(k)
-
ญ
AM R
(f,j)
ญ AM N
(j)
ญ AM R
(j)
-
Adjust insulin by 10% or 2 units, whichever is greater
Follow-up
Medical: Phone 1-2 time/week; office visit every 2 weeks; use
this DecisionPath for follow-up
Education: Every 2-4 weeks as needed
See Insulin Adjustment Guidelines, 3-18, for adjustment considerations
designated by each letter.
3-18 Gestational Insulin Adjustment Guidelines
How to Use These Tables
1. Find current insulin stage
2. Find the pattern of blood glucose problem (column)
3. Identify time of day (row) pattern occurs
4. Where the column and row intersect, see recommended changes
5. See notes for additional considerations
Insulin Pattern Adjustments
• Adjust insulin from 2-3 day BG pattern
• Determine which insulin is responsible for pattern
• Adjust insulin by 10% or 2 U, whichever is greater
• Adjust PM/BT N for 3 AM hypoglycemia or hyperglycemia
Notes
a. Evaluate nocturnal hypoglycemia; check 3 AM BG
b. Consider increasing mid-morning snack
c. Consider increasing afternoon snack
d. Consider increasing bedtime snack
e. Consider giving injection 45 minutes before meal
f. Consider decreasing carbohydrate at breakfast
g. If post AM increase, increase AM snack
h. Consider Insulin Stage 3A
i. Consider Insulin Stage 4A
j. Consider adding exercise
k. Evaluate if previous exercise is causing hypoglycemia
l. Consider decreasing mid-morning snack
m. Consider decreasing afternoon snack
n. Consider decreasing bedtime snack
Impaired Glucose Homeostasis
At Diagnosis
Impaired fasting glucose (IFG), fasting
plasma glucose 110-125 mg/dL,
and/or 2 hr OGTT value 140-199 mg/dL
Establish food and Exercise Plan
Assess Nutritional Needs
• HbA1c, SMBG, lipid profile, albuminuria
• Food history or 3-day food record (meals and smacks with time and
snacks with times and portions)
• Nutrition adequacy
• Height/weight/BMI
• Weight goals/eating disorders
• Exercise times, duration, and type
Determine Nutritional Goals
• SMBG and HbA1c within target range
• Weight, BP, and lipids in acceptable range
• Consistent carbohydrate intake
Design Food Plan
Set meal and snack times
Set consistent carbohydrate intake at meals and snacks to meet BG targets
Design Exercise Plan
• Encourage regular exercise based on cardiovascular fitness age, weight,
history
• Low intensity warm-up and cool-down
50-75% maximum aerobic capacity for 20 minutes, 3 times/week
Refer patient for nutrition and diabetes education
Follow-up
Medical: Within 3 months
Nutrition: As meeded
4-2