DAFNE basics



Blood glucose testing and targets
Target blood glucose
  • Before breakfast: 5.5-7.5
  • Before other meals: 4.5-7.5
  • Before bed: 6.5-8.0.
Testing guidelines
  • Test before meals and before bed
  • Only test at other times if likely to affect management, e.g. snack with no QA in body; illness; hypo.
Hypo guidelines
When to treat hypo:
  • when BG<3.5 mmol/l.

Immediate hypo treatment 1.5-2 CPs:
  • 100-120ml Lucozade
  • 150-200ml fruit juice or cola
  • 5-6 dextrose tabs
  • 4 jelly babies.
Sustained hypo treatment:
  • add 1 slower-acting CP if 1-2hr until next meal
  • add 2 slower-acting CP if >2hr until next meal.

Glucagon:
  • on coming round, 2 rapid-acting CP followed by 4 slower-acting CP
  • if no response within 10 min, call ambulance
Snack guidelines
Less than 1 CP:
  • no extra QA.

1+CP, <1hr before a meal
  • add snack QA to meal QA
  • don't correct at mealtime for above-target BG.
1+CP, 1-2hr before meal:
  • either snack QA separate from meal QA
  • or add snack QA to meal QA and don't correct for above-target BG at mealtime.

1+CP, >2hr before meal:
  • QA with snack, separate from meal QA
Ratios:
  • generally 1:1 with snacks
  • but use meal ratios if large snack (>4CP) or shortly after a meal.
Testing and correction:
  • BG not required at time of snack if previous QA still active
  • if no active QA and BG off target - correct as normal.
Illness guidelines
Check BG and ketones

Sip sugar free fluids (at least 100 ml/hr)
No ketones (or trace)
(<1.5 mmol/l on Optium)
Blood glucose in target or slightly high

Minor illness
Test BG and ketones every 4-6hr
Usual QA:CP when eating
Use corrections (larger QA doses may be needed)
May only need BI if not eating
May need QA corrections even if not eating
Usual BI but may need to increase by 1-2 units if unwell >1 day
Ketones present
(>1.5 mmol/l on Optium)
Blood glucose elevated (usually >13 mmol/l)

Severe illness
Test BG and ketones every 2 hr
Calculate total daily dose from previous day
Ketones + or ++
(1.5-3 on Optium)

10% of TDD every 2 hr
plus usual QA if eating
plus usual BI.
Ketones +++ or ++++
(>3 mmol/l on Optium)

20% of TDD every 2 hr
plus usual QA if eating
plus usual BI.
Contact hospital as emergency if unable to keep fluids down, or continual vomiting, or unable to control BG or ketone levels. Never stop BI insulin.
Glycaemic index
High GI - cannot be matched with QA insulin
  • glucose
  • Lucozade
  • cola drinks
  • jelly sweets
  • boiled sweets
  • dextrose tablets
  • fruit juice
Low GI - do not need QA insulin
  • lentils, beans, pulses
  • barley
  • cherries (dubious)
  • grapefruit (low GL rather than GI)
  • nuts
  • fructose
Medium GI - everything else can be covered with QA insulin
Insulin adjustment
Typical QA insulin ratios
  • morning: 1-3 units per CP
  • midday: 1-2 units per CP
  • evening: 1-2 units per CP

Adjusting insulin ratios
  • wait 48hr for a pattern unless overnight hypo
  • reduce BI immediately after overnight hypo
  • adjust BI by 10-20%
  • adjust QA by 1/2 a ratio
Corrections
  • adjustments for high or low BG
  • add QA if BG above target and no QA active in body and no recent snack uncovered by QA
  • reduce QA if BG below target but not hypo before meal or snack
  • 1 unit QA typically lowers BG by 2-3 mmol/l
Alcohol guidelines
CP content
  • standard wine & spirits - 0
  • sweet wine & sherry - 0.5 per glass
  • standard beer & cider - 1 per pint
  • strong beer - 1.5 per pint
  • Low alcohol beer - 2 per pint
  • Sweet cider - 2 per pint
  • Alcopops - 2 per bottle
  • Liqueurs - 0.5 per small glass or measure.
Covering CPs in drinks
  • ignore 1 CP
  • for subsequent CPs - typically 0.5 QA for each CP, but depends on personal experience.

Avoiding hypos
  • ignore 1-2 units of alcohol
  • if more - either eat extra CPs, or reduce BI
  • for Lantus, extra CPs may be preferable to reducing BI

Consider exercise
  • Dancing, sex, sport may increase hypo risk.
Exercise guidelines
Avoid exercise if significant hyperglycaemia or ketosis
  • if BG>13 mmol/l, exercise will probably not cause it to fall
  • check for ketones and consider QA
  • if ketones present, do not exercise until BG<13 mmol/l

If exercise <45 min:
  • BG <7 - take 2-3 CPs depending on intensity
  • BG 7-10 - take 1-2 CPs depending on intensity
  • BG 10 - optimum
  • BG 10-13 - no extra CPs - is insulin running out? - retest after 30 minutes
  • BG >13 - see above
Intense exercise or prolonged exercise < 4 hr:
  • 30-50% reduction in QA prior to exercise
  • extra CPs may be needed

Prolonged exercise >4 hr:
  • reduce BI and QA pre-exercise by 50%
  • reduce any insulin during exercise by 50%
  • reduce insulin immediately after exercise by 30-50%
  • snacks may be needed
  • reduce BI by 10-20% in evening and possibly next morning.