AJUSTE DE DOSE DE INSULINA EM PACIENTE DIABÉTICO TIPO I

Paciente, sexo M, 22 anos.
Diabético tipo I desde 7 anos de idade, chega ao consultório com queixa de crises hipoglicêmicas todos os dias. Solicita ajuste de dose da insulina NPH.
Dúvida 1) Como deve ser feito o acompanhamento da glicemia e insulinoterapia?
Clinical monitoring of glucose
- Clinical monitoring of blood glucose levels by  high-precision DCCT*-aligned methods of  haemoglobin A1c (HbA1c) should be performed every 2–6 months,  depending on:
• achieved level of blood glucose control
• stability of blood glucose control
• change in insulin dose or regimen.
- Site-of-care measurement, or before-clinical-consultation measurement, should be provided.
- HbA1c results should be communicated to the person with type 1 diabetes after each measurement. The term ‘A1c’ can be used for simplicity.
- Total glycated haemoglobin estimation, or assessment of glucose profiles, should be used where haemoglobinopathy or haemoglobin turnover invalidate HbA1c measurement.
- Fructosamine should not be used as a routine substitute for HbA1c estimation.
- Continuous glucose monitoring systems have a role in the assessment of glucose profiles in adults with consistent glucose control problems on insulin therapy, notably:
• repeated hyper- or hypoglycaemia at the same time  of day
• hypoglycaemia unawareness, unresponsive to conventional insulin dose adjustment.

Glucose control assessment levels
- Adults with type 1 diabetes should be advised that maintaining a DCCT-harmonised HbA1c below 7.5% is  likely to minimise their risk of developing diabetic eye, kidney or nerve damage in the longer term.
- Adults with diabetes who want to achieve an HbA1c down to, or towards, 7.5% should be given all appropriate support in their efforts to do so.
- Where there is evidence of increased arterial risk  (identified by a raised albumin excretion rate, features  of the metabolic syndrome, or other arterial risk factors),people with type 1 diabetes should be advised that approaching lower HbA1c levels (for example, 6.5% or lower) may be of benefit to them. Support should be
- given to approaching this target if so wished.
- Where target HbA1c levels are not reached in the individual, adults with diabetes should be advised that  any improvement is beneficial in the medium and long term, and that greater improvements towards the target level lead to greater absolute gains.
- Undetected hypoglycaemia and an attendant risk of unexpected disabling hypoglycaemia or of hypoglycaemia unawareness should be suspected in adults with
type 1 diabetes who have:
• lower HbA1c levels, in particular levels in or approaching the normal reference range (DCCT harmonised < 6.1%)
• HbA1c levels lower than expected from self-monitoring results.
- Where experience or risk of hypoglycaemia is significant  to an individual, or the effort needed to achieve target levels severely curtails other quality of life despite optimal use of current diabetes technologies, tighter blood glucose control should not be pursued without balanced discussion of the advantages and disadvantages. Note: A new chemical standard for HbA1c has been developed by the International Federation of Clinical Chemistry (IFCC). This reads lower by around 2.0% (units), and will be the basis of primary calibration of instruments from 2004 onwards. However, this does not preclude the use of DCCT-harmonised levels, and views from patient organisations and professional bodies at a recent Department of Health meeting (July 2003) are that all
- HbA1c reports should be DCCT aligned, pending some internationally concerted policy change.  
Insulin regimens
- Adults with type 1 diabetes should have access to the types (preparation and species) of insulin they find allow them optimal well-being.
- Cultural preferences need to be discussed and respected in agreeing the insulin regimen for a person with type 1 diabetes.
- Multiple insulin injection regimens, in adults who prefer them, should be used as part of an integrated package of which education, food and skills training should be integral parts.
- Appropriate self-monitoring and education should be used as part of an integrated package to help achieve optimal diabetes outcomes.
- Meal-time insulin injections should be provided by injection of unmodified (‘soluble’) insulin or rapid-acting insulin analogues before main meals.
- Rapid-acting insulin analogues should be used as an alternative to meal-time unmodified insulin:
• where nocturnal or late inter-prandial hypoglycaemia is a problem
• in those in whom they allow equivalent blood glucose control without use of snacks between meals and this  is needed or desired.
- Basal insulin supply (including nocturnal insulin supply) should be provided by the use of isophane (NPH) insulin or long-acting insulin analogues (insulin glargine). Isophane (NPH) insulin should be given at bedtime. If rapid-acting insulin analogues are given at meal times or the midday insulin dose is small or lacking, the need to give isophane (NPH) insulin twice daily (or more often) should be considered.
- Long-acting insulin analogues (insulin glargine) should be used when:
• nocturnal hypoglycaemia is a problem on isophane (NPH) insulin.
• morning hyperglycaemia on isophane (NPH) insulin results in difficult daytime blood glucose control.
• rapid-acting insulin analogues are used for meal-time blood glucose control.
- Twice-daily insulin regimens should be used by those adults who consider number of daily injections an important issue in quality of life.
• Biphasic insulin preparations (pre-mixes) are often the preparations of choice in this circumstance.
• Biphasic rapid-acting insulin analogue pre-mixes may give an advantage to those prone to hypoglycaemia at night.
Such twice daily regimens may also help:
• those who find adherence to their agreed lunch-time insulin injection difficult
• adults with learning difficulties who may require assistance from others.
- Adults whose nutritional and physical activity patterns vary considerably from day to day, for vocational or recreational reasons, may need careful and detailed review of their self-monitoring and insulin injection regimen(s). This should include all the appropriate preparations, and consideration of unusual patterns and combinations.
- For adults undergoing periods of fasting or sleep following eating (such as during religious feasts and fasts or after night-shift work), a rapid-acting insulin analogue before the meal (provided the meal is not prolonged) should be considered.
- For adults with erratic and unpredictable blood glucose control (hyper- and hypoglycaemia at no consistent times), rather than a change in a previously optimised insulin regimen, the following should be considered:
• resuspension of insulin and injection technique;
• injection sites;
• self-monitoring skills;
• knowledge and self-management skills;
• nature of lifestyle;
• psychological and psychosocial difficulties;
• possible organic causes such as gastroparesis.  
- Continuous subcutaneous insulin infusion (or insulin pump therapy) is recommended as an option for people with type 1 diabetes provided that:
• multiple-dose insulin therapy (including, where appropriate, the use of insulin glargine) has failed;* and
• those receiving the treatment have the commitment and competence to use the therapy effectively.
- Partial insulin replacement to achieve blood glucose control targets (basal insulin only, or just some meal-time insulin) should be considered for adults starting insulin therapy, until such time as islet B-cell deficiency progresses further.
- Clear guidelines and protocols (‘sick-day rules’) should be given to all adults with type 1 diabetes to assist them in adjusting insulin doses appropriately during intercurrent illness.
- Oral glucose-lowering drugs should generally not be used in the management of adults with type 1 diabetes.  
Dúvida 2) Como manejar os quadros de hipoglicemia?
Adults with type 1 diabetes should be informed that any available glucose/sucrose-containing fluid is suitable for the management of hypoglycaemic symptoms or signs in people who are able to swallow. Glucose-containing tablets or gels are also suitable for those able to dissolve or disperse these in the mouth and swallow the products. When a more rapid-acting form of glucose is required, purer glucose-containing solutions should be given. Adults with decreased level of consciousness due to hypoglycaemia who are unable to take oral treatment safely should be:
• given intramuscular glucagon by a trained user (intravenous glucose may be used by professionals skilled in obtaining intravenous access).
• monitored for response at 10 minutes, and then given intravenous glucose if the level of consciousness is not improving significantly.
• then given oral carbohydrate when it is safe to administer it, and placed under continued observation by a third party who has been warned of the risk  of relapse.
Adults with type 1 diabetes should be informed that some hypoglycaemic episodes are an inevitable consequence of insulin therapy in most people using any insulin regimen, and that it is advisable that they should use a regimen that avoids or reduces the frequency of hypoglycaemic episodes while maintaining as optimal a level of blood glucose control as is feasible. Advice to assist in obtaining the best such balance from any insulin regimen should be available to all adults with type 1 diabetes. When hypoglycaemia becomes unusually problematic or of increased frequency, review should be made of the following possibly contributory causes:
• inappropriate insulin regimens (incorrect dose distributions and insulin types).
• meal and activity patterns, including alcohol.
• injection technique and skills, including insulin resuspension.
• injection site problems.
• possible organic causes including gastroparesis.
• changes in insulin sensitivity (the latter including drugs affecting the renin-angiotensin system and renal failure).
• psychological problems.
• previous physical activity.
• lack of appropriate knowledge and skills for self-management.
Hypoglycaemia unawareness should be assumed to be secondary to undetected periods of hypoglycaemia (< 3.5 mmol/litre, often for extended periods, commonly  at night) until these are excluded by appropriate monitoring techniques. If present, such periods of hypoglycaemia should be ameliorated. Specific education on the detection and management of hypoglycaemia in adults with problems of hypoglycaemia awareness should be offered. Nocturnal hypoglycemya (symptomatic or detected on monitoring) should be managed by:
• reviewing knowledge and self-management skills.
• reviewing current insulin regimen and evening eating habits and previous physical activity.
• choosing an insulin type and regimen with less propensity to induce low glucose levels in the night hours, such as:
– isophane (NPH) insulin at bedtime.
– rapid-acting analogue with the evening meal.
– long-acting insulin analogues (insulin glargine).
– insulin pump.
Adults with type 1 diabetes should be informed that late post-prandial hypoglycemia may be managed by appropriate inter-prandial snacks or the use of rapid-acting insulin analogues before meals. Where early cognitive decline occurs in adults on long-term insulin therapy, normal investigations should be supplemented by the consideration or investigation of possible brain damage due to overt or covert hypoglycaemia, and the need to ameliorate this.


Referência Bibliográfica: National Institute for Health and Clinical Excellence (NICE). Type 1 diabetes: Diagnosis and management of type 1 diabetes in children, young people and adults. NICE Clinical Guidelines CG15.