Insulin & MDIs

Multiple Daily Injections
As often as not, type 1 diabetes is first diagnosed during a bout of diabetic ketoacidosis (DKA) in hospital. During that initial hospital stay, your glucose is lowered, electrolytes balanced and a variety of lab tests are performed to confirm the diagnosis, check for ancillary endocrinological problems and stabilize you prior to sending you home to begin your new life. 
 
Most frequently, the first treatment regime requires injection of insulin by means of “insulin pens.” There are two different kinds of insulin you’ll be using: 
 
Long Acting
This insulin is intended to remain active in your body 24 hours a day to help your body maintain it’s myriad autonomic functions – thinking, breathing, heart action, etc. This injection is given once or twice daily. 
 
Lantus and Levemir are common brands of long-acting insulin. 

Short Acting
This insulin is given in the form of an injection (bolus) before meals to “cover” the amount of carbohydrate you plan to eat. 
 
Humalog, Novolog and Apidra are common brands of short-acting insulin. 

Your endocrinologist at the hospital will make a determination of your approximate insulin needs before discharging you and provide you with a chart outlining proposed amounts of injections to be used once you’ve arrived home. 
 
Following your initial hospital stay, you’ll be finding a personal endocrinologist to track your treatment and progress as time goes by. This can be a very successful method of treating type 1 diabetes and one that a great number of patients have used for many, many years living happy, productive and healthy lives. 
 
There are a few important things to remember: 
● You must perform a finger stick prior to eating in order to know your current glucose. 
● In order to bolus correctly before meals to cover the carbohydrates you’re eating, you MUST count those carbohydrates.

That means that everything you eat requires a pretty accurate count of the actual carbohydrates you’re about to eat. At the very least, read the label on the food and weigh your portion. There are many online resources to help you find accurate carb counts for various foods as well as tools to convert measurements. 
 
You will very likely find some big surprises in terms of carbohydrates. Foods that you thought negligible (watermelon, for example) you quickly realize has a high-carb content. 
 
● Not everyone’s body responds exactly the same way.  
 
You will want to keep track of what you’re eating and your body’s response. Perhaps your acquaintance drinks coffee without concern, but whenever you join in your glucose goes up. Take note. 
 
Additionally, you’ll find that exercise will generally lower your glucose, while illness, stress and a variety of common medications will raise it. 
 
No matter how well-meaning the advice and education you receive, part of your job now is to observe the workings of your own body. 
 
● Be sure to perform a finger stick upon arising.  
 
This “fasting blood sugar” test is important to help you understand how well your long-acting insulin is working through the night. It’s common for glucose to rise when you wake up (the “Dawn” effect), but whatever spike you may experience should go back down before your mid-day meal. 
 
● Don’t skip meals or finger sticks. However busy you may be or however inconvenient it may be, be sure to take the time to check your glucose and eat at regular intervals.  
 
● Be careful about snacks. 
 
● By all means notice your body! It can be quite easy to ignore signs of glucose either rising too high or dropping too low.  
 
Often high glucose will be accompanied with dry mouth, thirst and even nausea. Don’t ignore it. 
 
● Keep a supply of urine test strips to test for ketones. If your glucose is too high, you’re at risk for developing diabetic ketoacidosis that can indeed by life threatening. Don’t take chances. In early stages it can easily be reversed at an emergency room, but having these strips handy will help you keep track of just where you are. 
 
● Feeling angry, woozy, or even drunk may indicate glucose that is too low. Definitely take the time to check your glucose before you drive or perform any sort of task that has any risk. 
 
● Keep a bottle of glucose tabs (available at any drug store) with you for a quick boost in glucose if you find yourself suddenly low. These can be a real life saver and you should always have these or something similar with you. 
 
Insulin/Carb Ratio
The I/C ratio is an approximation of how much insulin your body needs to cover how many carbs. Your endocrinologist will help you with your initial determination, however, you may need to adjust it over time. 
 
For example: 
 
1 unit insulin/25 grams of carbohydrate. (I/C ratio 1:25). 
 
In this case, if you were eating a meal of 50 grams of carbs, you’d need an injection of 2 units of insulin to cover that meal. 
 
Similarly, a meal of 14 grams of carbs, you’d need an injection that was a fraction of a single unit of insulin. 
 
Pens will not allow you to inject fractions of 1 unit of insulin, so you may need to adjust your carbohydrate in order to make allowances for that situation. 
 
Generally, you’ll be safe without having an absolute fraction, but do try to come close to the real amount eaten. 
 
Insulin Needs 
Your endocrinologist will begin your insulin therapy based upon the results of lab tests and some general guidelines. 
 
One of the very best things you can do for yourself is immediately begin a diary that includes: 
 
● Pre-meal glucose. 
● Carbs you ate at each meal. 
● How much you bolused at that meal. 
● Glucose 1-2 hours following that meal. 
 
On a daily basis, make note of: 
 
● Your long-acting insulin injection(s). 
● Your weight. 
● The amount of exercise you undertook. 
● Any other illness and associated medications. 
 
Over a long period of time, you may find your insulin needs changing. Don’t be alarmed, simply notice the adjustments.  
 
Supplies:
 
Always carry with you: 
 
• Insulin pens 
• Test strips 
• Lancet and alcohol wipes 
• Glucometer 
• Glucose tabs (for quickly correcting lows) 
 
Additionally, invest in a medical ID bracelet or pendant that identifies you as a type 1 diabetic. 
 
Always carry identification along with the name and contact information of someone that emergency workers can contact.