Managing fluctuating illness
This section refers, for example, to relapsing conditions such as connective tissue disease, predisposition to recurrent infections (eg UTI or patients with previous foot ulceration), chronic obstructive airways disease or asthma where recurrent steroid courses may be used.
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Learn by glucose responses during previous relapses: if 150% of usual insulin dose was required before, it is a good starting point for a future relapse to achieve glucose control more quickly and thus limit the duration of present relapse.
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If an episode of illness results in hyperglycaemia (espcially if hospitalised as a result) ensure that an educational session is held in recuperation in order to plan treatment strategy for a similar recurrence.
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Ensure that patient is able to monitor and has information and resources to respond to hyperglycaemia (ie if on oral therapies and supplementary insulin is likely to be required ensure the patient has a disposable pen available at home and has had instruction in its use when well).
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During an acute illness it is ‘tempting’ to suggest recurrent small corrective short-acting insulin adjustments, however this is rarely an effective strategy unless the total of additional corrective insulin doses in the first 24 hour period is added into the ‘usual’ therapy for the second day of illness and repeated until stable control without the need for corrections is achieved.
For subsequent illness exacerbation where steroid course is required plan to use 32 + 24 as soon as blood glucose levels rise on starting steroids (usually 12-24 hrs after first dose if oral).
Example:
Patient on twice daily Mixtard 30, 24 units am, 16 units pm is commenced on 30mg prednisolone for infective exacerbation of COPD and experiences hyperglycaemia as a result.
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Day 1 plan
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usual mixtard doses with additional ‘prn’ 4 hourly actrapid insulin if blood glucose greater than 12
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Actual Day 1 insulin
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mixtard 30, 24 + 16 and 3 additional 4 unit doses of actrapid
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Day 2 plan
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mixtard 30, 30 + 22 (ie usual dose plus yesterdays 12 extra units) with additional prn doses of actrapid as on day 1 if blood glucose greater than 12
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Actual Day2 insulin
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mixtard 30 , 30 + 22 and 1 additional 4 unit dose
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Day 3 plan
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mixtard 30 32 + 24 with additional ‘prn’ 4 hourly actrapid insulin if blood glucose greater than 12
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Actual Day 3 insulin
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mixtard 30 32 + 24, no additional insulin required as is now at target
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Day 7
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glucose levels fall below 6, reduce doses to 28 + 20
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Day 8
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glucose levels still below 6, reduce back to 24 + 16
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