Tag Archives: Lente
Patient recommendations for the perioperative period
Ideally, a patient with diabetes who is scheduled for surgery should discuss their perioperative management with the diabetes care provider prior to the surgical preparation. Often, patients receive insufficient or inaccurate recommendations from the anesthesia and/or operative team. Many times older patients with type 1 diabetes are assumed to have type 2, and are thought to be safe temporarily without basal insulin. Iatrogenic diabetic ketoacidosis is fairly common due to omission of insulin during the perioperative period. In contrast, if hospital professionals have a poor understanding of the differences in insulin requirements between insulin-resistant patients with type 2 diabetes (very large doses) and insulin-sensitive type 1 patients (sometimes very small doses), all patients with diabetes might receive similar insulin doses for the same blood sugar level. This is seen in the outmoded “sliding scale” insulin orders using regular insulin, which is not recommended.
Type 1 Diabetes
• Patients should never be advised to omit a dose of basal insulin. If the basal insulin is NPH or Lente, due to the potential for hypoglycemia during the peak action, the dose may be adjusted:
If NPO:
■ If basal insulin is glargine or another peakless insulin, do not change the dose. This insulin should already be adjusted to fasting glucose levels.
■ If basal insulin is NPH or Lente, give the usual night time dose; decrease the morning dose by 30%.
■ Use short-acting insulin only to correct hyperglycemia (if the patient does not have individualized instructions, 15% of total daily dose 4 to 6 hours apart is a good starting point).
If on clear liquids:
■ No change in the basal insulin.
■ Use short-acting insulin to correct hyperglycemia (as above).
■ Recommend a combination of carbohydrate-free and carbohydrate-containing beverages, aiming for 50 g to replace one meal.
Type 2 Diabetes
Packing
If the patient takes oral diabetes medication, they should continue to take it until a strict NPO situation is necessary. If a potential exists for renal compromise during or after the procedure, metformin should be discontinued until after a postprocedure creatinine level less than 1.4 mg/dl. Patients who take insulin should be given the same insulin-adjustment guidelines as type 1 patients.
Travel
Patients with diabetes are able to safely travel as long as a few precautions are taken. High and low blood sugars can occur due to changes in meal timing and content. Medication adjustments may be necessary for a minority of travelers. In order to control diabetes during travel, patients must have adequate monitoring supplies, medications, and knowledge regarding the foods that will be available and a method of estimating carbohydrate content.
Foot Care
Travel often includes using public transportation, sightseeing, and other activities that cause more wear and tear than usual on already vulnerable feet. Foot problems during travel are so common that a new term has been coined by the podiatry community — “Diabetic Holiday Foot Syndrome.” Patients with diabetes should be prepared to walk more than they usually do in a typical day. Encourage travelers to wear athletic or other walking shoes, to limit friction on skin by wearing socks, to examine feet frequently (especially in the middle of the day to detect early problems), and to carry supplies for minor foot problems such as blisters or abrasions. Patients with neuropathy will not be able to detect early skin problems and must actively seek them by examining their feet frequently.
Regardless of the mode of travel, people with diabetes should have the following items in a “carry-on” bag, easily accessible:
• all the insulin and syringes you will need for the trip
• all oral medications (an extra supply is a good idea)
• blood glucose testing supplies (include extra batteries for your glucose meter)
• urine ketone strips if using an insulin pump or history of diabetic ketoacidosis
• other medications or medical supplies, such as glucagon, antidiarrhea medication, antibiotic ointment, antinausea drugs
• personal ID and diabetes identity card
• a well-wrapped, air-tight snack pack of crackers with cheese or peanut butter, a juice box, and some form of sugar (hard candy or glucose tablets) to treat low blood glucose.
Airline Security
The American Diabetes Association has worked closely with the Transportation Security Administration to ensure that people with diabetes are treated fairly in light of recent increases in airport security. A full set of recommendations can be found at www.diabetes.org. In general:
• Notify the security screener that you have diabetes and are carrying your supplies with you.
• Make sure your insulin vials, insulin pens, jet injectors, and insulin pump are accompanied by a professionally printed pharmaceutical label identifying the medication (insulin), which is usually on the outside of the box.
• Lancets, blood glucose meters, blood glucose test strips can be carried through the security checkpoint.
• Notify screeners if you are wearing an insulin pump, and request that they visually inspect the pump rather than removing it from your body.
• Advise screeners if you experience symptoms of a low blood glucose level and are in need of medical assistance.
• The above protocol applies only to travel within the 50 United States and is subject to change. International passengers should consult their individual air carriers for applicable international regulations.
Dealing with Time Zone Changes
Time zone changes are not usually problematic unless the change increases the risk of hypoglycemia. The risk of hypoglycemia is increased if insulin is taken and carbohydrate is not consumed during the time the insulin peaks. People taking oral agents, basal/bolus insulin, or using insulin pumps typically do not need to make major adjustments during travel. Those who take pre-mixed insulin, intermediate-acting insulin, or a combination of intermediate-acting and short-acting insulins may need to make some adjustments.
Adjusting Insulin for Travel
Newer insulins have made travel much less of a burden for insulin-treated diabetes. If a peakless basal insulin is used, the timing of the injection need not be changed since it has no relationship to food intake. If the patient expects to be asleep during the time of the usual injection, the time could safely be adjusted by up to 2 hours per day until reaching a convenient local time to take the injection. Depending on the length of the trip and the difference in time zone, another option would be to premeasure the insulin and keep the syringe at the bedside, set an alarm and take the injection at the same time as at home. Short-acting insulin should be taken to cover meals and correct hyperglycemia as usual.
Older basal and premixed insulins are more difficult to adjust, since they do influence meal times. The more time zones the patient crosses, the more complicated the adjustment will be. In general, traveling East shortens the day, and less insulin may be needed. Traveling West lengthens the day, and more insulin (additional injections) may be needed. In general, patients will be safe taking the usual dose the morning of travel, if two daily injections are taken, the larger dose is usually (not always) taken in the morning, to control meal-related glucose excursions during the day. When traveling to another time zone, the patient should be advised to take the usual dose the morning of travel, and to adjust amounts the rest of the day. For example, if traveling West, take half the evening dose with a meal at the usual (home) time, and the remaining half with another meal at the local dinner time.
It should be apparent that the basal/bolus regimen is less complicated and people who travel extensively should be offered this regimen if they are still taking intermediate-acting or premixed insulin.
Patient guide to sick day management
Type 1 Diabetes
What is a sick day? Any day that you are not feeling well, having trouble eating your usual meals, or are experiencing a medical procedure or extreme emotional upset.
Why are sick days important? Diabetes is affected not only by what you eat and the insulin you take, but also by other hormones in the body. Hormones that work against insulin usually increase during illness or stress, causing the insulin you take to work less effectively. This is why illness and stress cause the blood sugar to rise. Diabetic ketoacidosis is a severe, life-threatening complication of diabetes that commonly occurs during illness or severe stress. This develops due to a lack of adequate insulin to fight the stress-related hormones.
What can I do ? The MOST important thing you can do during a sick day is to take your insulin. Even if you cannot eat, your body needs at least the insulin you take during a usual day, maybe even more. You should adjust your insulin as follows:
• Identify your longest-acting insulin. This is probably either glargine (Lantus), NPH, or Lente. Take your usual dose of this insulin, the same number of times during the day.
• Identify your shortest-acting insulin. This is probably lispro (Humalog), aspart (Novolog), or regular insulin. If you are not eating, do not take your usual doses of the short-acting insulin. Take the short-acting insulin as follows:
Add together your total daily dose of all insulin.
How many units of long-acting and short-acting insulin do I take in a typical day? units
Figure out 15% of this number (with a calculator, multiply your total daily dose x 0.15). If the result is a fraction, round up to the nearest unit. This is your “sick day dose”.
My “sick day dose” is: units of short-acting insulin.
When blood sugar is over 150 mg/dl, take this dose of short-acting insulin, at least 4 hours apart.
What should I eat? If you are able to, eat the way you usually do. If you are unable to eat normally, it is important to make sure you get enough fluid and carbohydrate (sugar).
Drink 4-6 ounces (4 ounces is half a cup) of fluid without calories every 30 minutes.
This fluid could include water, unsweetened hot or cold tea, or diet soft-drinks. This fluid is important to prevent dehydration.
Eat or drink 50 g of carbohydrate every 4 hours. To find the carbohydrate content in food/fluids, look at the nutritional label. Note the serving size, and the total carbohydrate.
For example, one can of (non-diet) soda contains 12 ounces and 43 g of carbohydrate. This carbohydrate (sugar) will provide you with energy to fight your illness, and help to prevent low blood sugar.
What else should I do during a sick day?
• Check your urine for ketones. When the body produces ketones (detectable in the urine) and your blood sugar is high, it means you are not taking enough insulin to stay in control during your illness.
If you have ketone strips, make sure they are not expired
If you do not have ketone strips, get some at the pharmacy (available without a prescription)
Check your urine for ketones several times daily while you are sick. If you are taking enough insulin and fluids, ketone levels should not be more than “small”
• Call your diabetes care provider (primary care physician, nurse practitioner, or diabetes educator) if:
You vomit (throw up) even once; ask for an antinausea medication. Suppositories work best if you are having trouble keeping food down. A prescription may need to be called in to your pharmacy. This could prevent a hospital stay.
You have an obvious infection. You may need an antibiotic.
Your illness lasts longer than 2 days
Your blood sugar is over 400 mg/dl, two times in a row, after you have taken your sick day dose of insulin and it should have had an effect.
You have “moderate” to “large” amounts of ketones in your urine and a blood sugar over 200 mg/dl for more than 8 hours, even after taking your sick day dose of insulin.
You feel very sick or are in pain.
You have abdominal pain, shortness of breath or trouble breathing, your family notices a fruity odor in your breath, or you become extremely sleepy or woozy.
Your diabetes care provider is:
Name:____________________________________________________________________
Office number:_____________________________________________________________
Emergency contact information:________________________________________________
What is a sick day? Any day that you are not feeling well, having trouble eating your usual meals, or are experiencing a medical procedure or extreme emotional upset.
Why are sick days important? Diabetes is affected not only by what you eat and the insulin you take, but also by other hormones in the body. Hormones that work against insulin usually increase during illness or stress, causing the insulin you take to work less effectively. This is why illness and stress cause the blood sugar to rise. Severe high blood sugar requiring hospitalization can occur if proper care is not taken during illness.
What can I do? When you are sick, even if you are unable to eat normally, you must take your diabetes medication. If you take only pills for your diabetes, you need these even if you are unable to eat. Metformin (Glucophage), a common diabetes medication, can cause stomach upset if not taken with meals. If this happens to you, stop taking the metformin until you are able to eat again.
If you take insulin (either alone or in combination with diabetes pills), you still need to take it while you are sick. Even if you can not eat, your body needs at least the insulin you take during a usual day, maybe even more. You should adjust your insulin as follows:
• Identify your longest-acting insulin. This is probably either glargine (Lantus), NPH, or Lente. Take your usual dose of this insulin, the same number of times during the day.
• Identify your shortest-acting insulin. This is probably either lispro (Humalog), aspart (Novolog), or regular insulin. If you are not eating, do not take your usual doses of the short-acting insulin. Take the short-acting insulin as follows:
Add together your total daily dose of all insulin.
How many units of long-acting and short-acting insulin do I take in a typical day?_ _units
Figure out 15% of this number (with a calculator, multiply your total daily dose x 0.15). If the result is a fraction, round up to the nearest unit. This is your “sick day dose”.
My “sick day dose” is: _units of short-acting insulin.
When blood sugar is over 150 mg/dl, take this dose of short-acting insulin, at least 4 hours apart.
What should I eat? If you are able to, eat the way you usually do. If you are unable to eat normally, it is important to make sure you get enough fluid and carbohydrate (sugar).
• Drink 4-6 ounces (4 ounces is half a cup) of fluid without calories every 30 minutes. This fluid could include water, unsweetened hot or cold tea, or diet soft-drinks. This fluid is important to prevent dehydration.
• Eat or drink 50 g of carbohydrate every 4 hours. To find the carbohydrate content in food/fluids, look at the nutritional label. Note the serving size, and the total carbohydrate. For example, one can of (non-diet) soda contains 12 ounces and 43 g of carbohydrate. This carbohydrate (sugar) will provide you with energy to fight your illness, and help to prevent low blood sugar.
What else should I do during a sick day?
• If you normally take insulin, check your urine for ketones. When the body produces ketones (detectable in the urine) and your blood sugar is high, it means you are not taking enough insulin to stay in control during your illness.
if:
If you have ketone strips, make sure they are not expired
If you do not have ketone strips, get some at the pharmacy (available without a prescription)
Check your urine for ketones several times daily while you are sick. If you are taking enough insulin and fluids, ketone levels should not be more than “small” Call your diabetes care provider (primary care physician, nurse practitioner, or diabetes educator)
You vomit (throw up) even once; ask for an antinausea medication. Suppositories work best if you are having trouble keeping food down. A prescription may need to be called in to your pharmacy. This could prevent a hospital stay.
You have an obvious infection. You may need an antibiotic.
Your illness lasts longer than 2 days
Your blood sugar is over 400 mg/dl, two times in a row, after you have taken your sick day dose of insulin and it should have had an effect.
You have “moderate” to “large” amounts of ketones in your urine and a blood sugar over 200 mg/dl for more than 8 hours, even after taking your sick day dose of insulin.
You feel very sick or are in pain.
You have abdominal pain, shortness of breath or trouble breathing, your family notices a fruity odor in your breath, or you become extremely sleepy or woozy.
Your diabetes care provider is: Name:___________________
Office number:______________
Emergency contact information:.
Insulin and insulin analogs
Insulin is frequently initiated when maximum dose of single or combined oral agents fail to control glucose levels. Diabetes is a progressive disease with continuing loss of β-cell function — patients should be informed that this is the natural history and they have not personally failed. Insulin and insulin analogs are available in a number of long-, intermediate-, and short-acting preparations and in an inhaled form, recently approved by the FDA for use in patients with type 1 or type 2 diabetes.
When initiating the older patient on insulin, the advantages and concerns of treatment need to be reviewed. Aspects such as physical, mental, and visual problems must be carefully assessed; practical and safe glucose targets must be established based on the individual patient’s needs and capabilities. Insulin therapy must be individualized based on each patient’s glucose levels, prognosis related to coexisting medical conditions, and treatment goals.
Insulin is often initially used in combination with one or more oral agents. Basal insulin — intermediate- or long-acting — is initially started at bedtime and slowly increased to reach safe morning glucose targets and, if required, a second dose and/or additional fast-acting insulin is added during the day. Complex multiple-dose insulin regimens should be avoided unless essential. A wide variety of insulins is available, from very rapid-acting to very long-acting and premixed combination preparations.
The greatest risk of insulin therapy is hypoglycemia, and evidence suggests that frail older adults are at higher risk of serious hypoglycemia than are healthier, more functional older adults. A practical approach to improve benefit and reduce risk when using insulin therapy includes
■ Continuation of use of oral agents. There is evidence that it will enhance effectiveness of residual insulin, reduce glycemic variability, and may help with weight control.
■ Use of basal insulin early [neutral protamine Hagedorn (NPH) or glargine]. With a starting dose of 10 units bed time (HS) (5 units if frail) or up to 0.25 units/kg weight, then titrating weekly or biweekly to a goal of fasting blood glucose of 120 to 140 mg/dL.
■ Use of insulin analogs in patients who require prandial insulin because it may reduce the likelihood of hypoglycemia in those with variable food intake or unpredictable digestion/ absorption.
Time for supervised practice for those with motor or visual problems should be provided and can improve the accuracy of insulin administration. The patient’s insulin injection technique should be observed on a regular basis to detect a need for adaptive strategies such as additional lighting, magnification, and premixed syringes. Elderly subjects often make errors when trying to mix insulin on their own. The accuracy of insulin injections may be improved in older patients when they are treated with premixed insulin. Family members, home care nurses, and visiting nurses can assist with implementing these techniques at home.
Physician and educator attitudes are important factors in the acceptance of insulin therapy. Discussing the benefits and potential challenges of insulin therapy may help patients decide about whether to take insulin or not. The need of insulin can be presented as the treatment for the patient’s particular stage of diabetes. This approach may help overcome patient resistance to insulin use (i.e., fear of injection, pain, lipohypertrophy complexity of regimens, etc.). In addition, it is important to recognize and address the provider’s resistance related to lack of time and resources to supervise treatment, skepticism about the effectiveness of insulin, and perceived cardiovascular risk. Finally, understanding medical limitations associated with insulin use (weight gain and risk for hypoglycemia) may help overcome these barriers and target therapy more appropriately.
TABLE Insulin Preparations
| Preparations | Onset | Peak | Duration | Indication |
| Insulins (Humulin, Novolin) | ||||
| Short acting | — | — | — | — |
| Regular | 0.5-1 hr | 2-3 hr | 6-12 hr | Prandial |
| Intermediate acting | ||||
| NPH | 1-1.5 hr | 4-12 hr | 8-12 hr | Basal |
| Lente (intermediate acting) | 1-2.5 hr | 8-12 hr | 10-24 hr | Basal |
| Long acting | ||||
| Ultralente | 4-8 hr | 16-18 hr | 36 hr | Basal |
| Insulin analogs | — | — | — | — |
| Rapid acting | — | — | — | — |
| Insulin aspart (NovoLog) | 30min | 1-3 hr | 3-5 hr | Prandial |
| Insulin lispro (Humalog) | 15 min | 0.5-1.5 hr | 3-5 hr | Prandial |
| Insulin glulisine (Apidra) | 15 min | 0.5-1.5 hr | 3-5 hr | Prandial |
| Long acting | — | — | — | — |
| Insulin glargine (Lantus) | 1-2 hr | — | 22-24 hr | Basal |
| Insulin detemir(Levemir) | 1-2 hr | — | 14-24 hr | Basal |
| Premixed combination insulin/analogs | — | — | — | — |
| NPH and regular insulin mix (70/30 or 50/50) | 30 min | 2-12 hr | 24 hr | Mixed |
| NPH and insulin analog mix (NPH and lispro | ||||
| 75/25, NPH and aspart 70/30) | ||||
Abbreviation: NPH, neutral protamine Hagedorn (insulin).
Action Times
People may respond to preparations of insulin and insulin mixtures differently, so it is important to find the types of insulin that work best for you. Each type of insulin has a different action time, a term that describes the length of time it takes to begin acting and how long its effect lasts. The action times of insulin are due to the following three features:
■ onset: the length of time it takes for insulin to reach the blood and begin lowering blood glucose levels
■ peak time: the time during which insulin is at its maximal strength in lowering blood glucose levels
■ duration: the length of time in which insulin continues to lower blood glucose
Before you got diabetes, your pancreas made the insulin you needed to keep your blood glucose in the normal range. The pancreas made a small amount of insulin throughout the day and night that was released in a steady stream. This is the basal insulin level. When you ate and your blood glucose level began to rise, the pancreas released a burst, or bolus, of insulin.
Insulin doses are planned to work as much like the body as possible. Rapid- and short-acting insulins are bolus insulins. Intermediate- and long-acting insulins are basal insulins. Most people with diabetes take both a basal and a bolus insulin.
| Insulin type | Onset (hours) | Peak (hours) | Duration (hours) |
| Rapid acting
Human lispro or human aspart |
Within 15 minutes | 1 to 2 | 3 to 4 |
| Short acting
Human regular |
0.5 to 1.0 | 2 to 3 | 3 to 6 |
| Intermediate acting
Human NPH Human lente |
2 to 4
3 to 4 |
4 to 10 4 to 12 | 10 to 16 12 to 18 |
| Long acting
Human ultralente Insulin glargine |
6 to 10 2 to 4 | — | 18 to 24 20 to 24 |
The first type of insulin that was made available is known as regular insulin. Regular insulin is short acting and must be injected several times throughout the day. Regular insulin begins working rapidly and is used up fairly quickly by the body. As shown in the table on insulin action times, regular insulin begins to act within an hour. Rapid-acting insulin, lispro insulin and insulin aspart, go to work within minutes. An intermediate-acting insulin, NPH (neutral protamine Hagedorn), contains a molecule known as a protamine, which slows down how fast the body absorbs insulin. Because the insulin reaches the blood more slowly, the onset, peak, and duration times are longer. By using a slower-acting insulin, you can get by with fewer injections each day. For example, a mixture of NPH and regular insulin injected at breakfast can last until dinnertime. You may not need an injection at lunchtime.
People who are allergic to the prota-mine in NPH can consider using lente, another intermediate-acting insulin. An even longer-acting insulin, ultralente, provides a continuous level of insulin with a less pronounced peak. In some people, human ultralente insulin may really act more like an intermediate insulin. Insulin glargine is the newest long-acting insulin. It has no peak and works well with rapid-acting insulin taken before meals. Whenever you change insulins, you need to figure out how quickly the new insulin works in your body.
All insulins used for injections have added ingredients. These prevent bacteria and molds from growing and help keep insulin from spoiling. Intermediate- and long-acting insulins also contain ingredients that prolong their action times. If you think you may be experiencing an allergic reaction to your insulin preparation, talk to your provider.
Signs of a local allergic reaction to insulin:
► dents under the skin at injection sites
► redness at injection sites, either persistent or temporary
► groups of small bumps, similar to hives
► swelling at injection sites
Premixed Insulin
You might be advised to take a mixture of regular or rapid-acting and NPH insulin in one injection. You can mix them yourself. Or you may be able to buy the insulin already mixed. Mixtures of regular and NPH insulins come in various combinations that make them more convenient and easier to handle. For example, you can buy a 50/50 mixture of NPH and regular insulin, or you can buy a mixture that contains 30 percent regular insulin and
Rapid- or short-acting insulins can both be used for bolus doses of insulins. But many people find rapid-acting insulins more convenient.
Rapid-acting insulins can be used by people with either type 1 or type 2 diabetes. The faster action of these insulins makes it easier to time insulin with food. In other words, you can match the rise in blood glucose from food absorption to the rise in insulin in your blood from the rapid-acting insulin.
Rapid-acting insulins are in a form that the body can absorb right away without having to break it down. With regular insulin, the body needs to reduce the insulin protein chain to a smaller size before it can be absorbed and go to work. It can take over 30 minutes from the time regular insulin is injected until it starts working on cells. With rapid-acting insulins, this time is cut in half, so there’s less room for error. It goes to work almost as fast as naturally produced insulin does.
This rapid-acting insulin may give you a lot more flexibility. You can count the carbohydrates in your meal and take insulin to cover that amount. If you eat an extra helping at a meal, you can take care of the carbohydrates with a booster shot right away. You may even be able to wait until you know how much carbohydrate you’ve eaten to inject these insulins. Also, because rapid-acting insulins don’t remain in the body as long as regular insulin does, you may experience fewer episodes of hypoglycemia. Ask your provider whether you could benefit from using a rapid-acting insulin.
| Insulin type | Onset | Peak | Duration |
| Made by body | Immediate, when needed | 30 to 60 minutes | 2 to 3 hours |
| Human lispro, human aspart | Within 15 minutes after injection | 1 to 2 hours | 3 to 4 hours |
| Human regular | 30 to 60 minutes | 2 to 3 hours | 3 to 6 hours |
Crossing time zones can confuse your insulin schedule. You may need to make a new plan for timing your insulin injections. You may also need to adjust your total daily insulin dose. When traveling east, you get a shorter day and need less insulin. When traveling west, you get more hours in a day and need more insulin. Keep your watch on your home time until the first morning after you arrive in a new time zone. Check your blood glucose level more often than usual. For more on insulin and traveling.
70 percent NPH. Preparations containing intermediate- and rapid-acting insulins are also available. Premixed insulins can also be useful for people with eyesight or dexterity problems that make drawing different amounts of insulin from two different bottles difficult. You may want to discuss assistive devices for people with impaired sight with your doctor or diabetes educator.
Even though you can buy mixtures of insulin or can mix them yourself, make sure to talk to members of your health care team before you make any changes in the insulin you take. Never mix types of insulin without the okay from your provider. Mixing insulin with lente or ultra-lente insulin can be more complicated than mixing with NPH. These longer-acting insulins can interfere with rapid-and short-acting insulins and lead to unpredictable results. Rapid-acting and regular insulins are not always readily absorbed by the body when mixed with slower insulins. If your injection schedule calls for taking both regular and lente insulin at the same time, try to inject them immediately after mixing. Glargine cannot be mixed in the same syringe with other insulins. If you have any questions or notice that you don’t get the response you expect from the bolus insulin, talk to your provider. You may need to increase the amount of regular insulin in the mixture or switch to a rapid-acting insulin.
Before you leave your diabetes care provider’s office, be sure you understand the following:
■ what type of insulin you will be taking and the name of the insulin
■ the symptoms of high and low blood glucose that could indicate a problem with your insulin doses
■ where you should inject it
■ whether you need to prepare any mixtures
■ how often to give yourself injections
■ the best times of the day to take your insulin
■ how to store your insulin
Don’t be afraid to take notes or ask questions about anything that’s not clear. Even if you have taken insulin before, you might want to review your insulin schedule on a return visit, especially if you are experiencing any difficulties. You might also want to go over any changes in your schedule that were recommended. Make sure you understand how to time injections with mealtimes. Go step-by-step through a typical day. Also talk about how to adjust for an unusual day. What happens if you oversleep, get sick, travel across time zones, or plan to be unusually active?