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Harold — too old for treatment
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Pract Diab Int May 2002 Vol. 19 No. 4 Copyright © 2002 John Wiley & Sons, Ltd. 123 LETTERS TO THE EDITOR Harold – too old for treatment Sir, although most of my working life was devoted to paediatric practice, I have had type 2 diabetes for 16 years, treated with insulin for 3 years. I am now aged 79 years. My experience in diabetic care therefore derives from this large but intimate experience of one case so I am clearly interested in Harold’s problems. If his diabetes is of recent onset then his insulin sensitivity has fallen significantly, accompanied by an increasing fall in β-cell reserve, a situation commonly observed in the elderly type 2 diabetic patient. Oral hypoglycaemic agents should be accompanied by reduced CHO intake, which, for such an aged patient, is unkind. Harold should be managed using insulin therapy – Humilin M2 insulin is suggested. The diet in the care home is likely to be reasonably constant in calorie content but there will be some variation so his insulin dose will have to be gauged from his food intake and exercise. The diabetes nurse specialist from the diabetic clinic should teach one or two carers to measure Harold’s blood glucose concentration before breakfast, before lunch (likely to be his largest meal) and before bed. The insulin dose should vary against the blood glucose concentration at these times; the largest dose (6–10 units) before breakfast, and 6 units before his evening meal. A blood glucose of less than 6 mmol/l before bed requires extra CHO, e.g. biscuits, toast, or chocolate, to avoid hypoglycaemia during sleep. I strongly advise that insulin treatment is the best way to manage diabetes in patients over 70 years of age, with routine review by the clinic nurse. I have written this answer before reading the ‘expert’ comments. WILLIAM HAMILTON MD FRCP(G&E) DPH DCH, 81 Woodend Drive, Glasgow G13 1QF, UK Injection sites for insulin Sir, the March 2002 edition of Practical Diabetes International con- tained a supplement devoted to the administration of insulin by subcutaneous injection. Figure 1 detailed some injection sites and yet again the abdominal injection site was depicted as a relatively small area below the umbilicus. This diagram is like so many oth- ers in diabetes texts showing a relatively small area of the anterior abdominal wall as being suitable for subcutaneous insulin injection. A complication of insulin injection into the same area is lipo- hypertrophy and a recent report (1) has described a high preva- lence of lipohypertrophy in children and adolescents.This, in part, is due to patients injecting the same area repeatedly. Presumably they do this as Healthcare Professionals still propagate the myth that in the anterior abdominal wall the area for injection is limited to a small area below the umbilicus. The whole of the anterior abdominal wall should be designated as ideal for insulin injection. Frequently one comes across patients who are surprised when informed that they are allowed to inject insulin above their umbilicus! The larger the area available for injection the less the possibility for repeated injection into the same area with resultant lipohypertrophy. Unfortunately diagrams such as figure 1 in the supplement prop- agate one of the unhelpful myths about insulin administration. DR JAMES D WALKER, Consultant Physician Reference 1. Kordonouri O, Lauterborn R, Deiss D. Lipohypertrophy in Young Patients with Type 1 Diabetes. Diabetes Care 2002; 25: 634 Reply Sir, we fully agree with Dr Walker that the whole of the anterior abdominal wall can be used for insulin injection and thank him for highlighting this important issue. D KYNE-GREZBALSKI, L WOOD, J WILBOURNE CONFERENCE NOTICE FEND Federation of European Nurses in Diabetes Seventh Annual Conference ‘Effective European Coalitions Defending Diabetes’ 30-31 August 2002 Hilton Hotel, Budapest, Hungary Cost: j 225. To register contact: Stina Wallenkrans, 9747 Husebacken, S-44497 Svenshogen, Sweden. Tel/Fax: +46 303 774111; Email: [email protected] or print off the registration form from the FEND website on www.FEND.org
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Transcript of Harold — too old for treatment
Pract Diab Int May 2002 Vol. 19 No. 4 Copyright © 2002 John Wiley & Sons, Ltd. 123
L E T T E R S T O T H E E D I T O R
Harold – too old for treatmentSir, although most of my working life was devoted to paediatricpractice, I have had type 2 diabetes for 16 years, treated withinsulin for 3 years. I am now aged 79 years. My experience indiabetic care therefore derives from this large but intimateexperience of one case so I am clearly interested in Harold’sproblems.
If his diabetes is of recent onset then his insulin sensitivity hasfallen significantly, accompanied by an increasing fall in β-cellreserve, a situation commonly observed in the elderly type 2diabetic patient. Oral hypoglycaemic agents should beaccompanied by reduced CHO intake, which, for such an agedpatient, is unkind. Harold should be managed using insulintherapy – Humilin M2 insulin is suggested.
The diet in the care home is likely to be reasonably constant incalorie content but there will be some variation so his insulin dose
will have to be gauged from his food intake and exercise. Thediabetes nurse specialist from the diabetic clinic should teach oneor two carers to measure Harold’s blood glucose concentrationbefore breakfast, before lunch (likely to be his largest meal) andbefore bed. The insulin dose should vary against the blood glucoseconcentration at these times; the largest dose (6–10 units) beforebreakfast, and 6 units before his evening meal. A blood glucose ofless than 6 mmol/l before bed requires extra CHO, e.g. biscuits,toast, or chocolate, to avoid hypoglycaemia during sleep.
I strongly advise that insulin treatment is the best way tomanage diabetes in patients over 70 years of age, with routinereview by the clinic nurse. I have written this answer beforereading the ‘expert’ comments.
WILLIAM HAMILTON MD FRCP(G&E) DPH DCH, 81 Woodend Drive, Glasgow G13 1QF, UK
Injection sites for insulinSir, the March 2002 edition of Practical Diabetes International con-tained a supplement devoted to the administration of insulin bysubcutaneous injection. Figure 1 detailed some injection sites andyet again the abdominal injection site was depicted as a relativelysmall area below the umbilicus. This diagram is like so many oth-ers in diabetes texts showing a relatively small area of the anteriorabdominal wall as being suitable for subcutaneous insulin injection.
A complication of insulin injection into the same area is lipo-hypertrophy and a recent report (1) has described a high preva-lence of lipohypertrophy in children and adolescents.This, in part,is due to patients injecting the same area repeatedly. Presumablythey do this as Healthcare Professionals still propagate the myththat in the anterior abdominal wall the area for injection is limitedto a small area below the umbilicus.
The whole of the anterior abdominal wall should be designatedas ideal for insulin injection. Frequently one comes across patientswho are surprised when informed that they are allowed to inject
insulin above their umbilicus! The larger the area available forinjection the less the possibility for repeated injection into thesame area with resultant lipohypertrophy.
Unfortunately diagrams such as figure 1 in the supplement prop-agate one of the unhelpful myths about insulin administration.
DR JAMES D WALKER, Consultant Physician
Reference1. Kordonouri O, Lauterborn R, Deiss D. Lipohypertrophy in Young Patients with Type
1 Diabetes. Diabetes Care 2002; 25: 634
ReplySir, we fully agree with Dr Walker that the whole of the anteriorabdominal wall can be used for insulin injection and thank himfor highlighting this important issue.
D KYNE-GREZBALSKI, L WOOD, J WILBOURNE
C O N F E R E N C E N O T I C E
FENDFederation of European Nurses in Diabetes
Seventh Annual Conference
‘Effective European Coalitions Defending Diabetes’30-31 August 2002
Hilton Hotel, Budapest, Hungary
Cost: j225. To register contact: Stina Wallenkrans, 9747 Husebacken, S-44497 Svenshogen, Sweden.Tel/Fax: +46 303 774111; Email: [email protected] or print off the registration form from theFEND website on www.FEND.org
