This woman is on three injections of short and / or intermediate acting insulin each day, with a split-evening dose. She wants to start a family, but consistently has had quite high blood glucose levels in the early afternoon, despite numerous attempts to normalise her control in anticipation of becoming pregnant. Clearly she could decrease the amount that she eats, but this would not be ideal during pregnancy. See if you can adjust her insulin doses to improve her glycaemic control.
This 45 year old man was diagnosed as having diabetes at the age of 14. He is currently on a regimen of combined short and / or intermediate acting insulin preparations four times per day. As you can see from his home monitoring blood glucose measurements, he tends to higher blood glucose values overnight but has a low blood glucose in the mid-morning. Try using the simulator to see how you could redistribute his insulin doses to improve his overall control.
This man is a relatively newly diagnosed insulin-dependent (type 1) diabetic patient. He has had problems
maintaining his blood glucose profile on two and more recently three injections per day; so currently he is controlled on four injections per day. He tends to quite high blood glucose levels in the middle of the day, despite not eating excessively. Try and see if you can reduce his mid-day blood glucose levels.
It has taken a lot of effort to stabilise this girl's blood glucose profile. However, she still often goes 'hypo' in the middle of the day, especially between breakfast and lunch. She is on a slightly unusual regimen taking a short acting
insulin preparation three times per day, with an intermediate acting preparation twice a day - at lunchtime and before bed. Can you improve her glycaemic control, and get rid of her 'hypo' at 10:00am? Hint: For a start try increasing the carbohydrate content of her breakfast....
This overweight 58 year old insulin-dependent (type 1) diabetic patient has had major problems losing weight. She is quite sensitive to insulin. Unfortunately, the more insulin she takes the more she wants to eat. She also smokes and is at great risk of suffering a heart attack or stroke. See if you can decrease her carbohydrate intake - adjusting her insulin regimen accordingly - to try and help her reduce weight without going 'hypo'.
This man often wakes with 'sweats' and feeling profoundly unwell in the middle of the night. However, his blood sugars are quite respectable when he gets up at 7:30am. In such a situation he needs to measure his blood glucose when he wakes in the middle of the night, feeling unwell. Clearly injecting so much insulin before he goes to bed isn't a good idea. Try adjusting his bedtime insulin and see if you can stop him going 'hypo'.
This 18 year old insulin-dependent diabetic patient has just left home for the first time to go to University. He isn't a very good cook and hasn't been taking good care of himself. He feels pretty awful most mornings and even getting an early night hasn't helped. He tends to quite low blood sugars in the morning, at times being at risk of going 'hypo'. See if you can adjust his insulin regimen so that his blood sugars don't run quite so low in the morning.
This 50 year old insulin-dependent diabetic women has quite high blood sugars throughout most of the day, especially after lunch. She is adamant that she can't change her diet - she attends a lot of business lunches and dinners. She also refuses to inject any more frequently than two times per day. See if you can adjust the doses of her insulin injections to improve her glycaemic control, without compromising her lifestyle.
This 34 year old insulin-dependent diabetic man (diagnosed as a boy aged 8) has impaired renal function as a result of diabetic nephropathy. He tends to run very high blood glucose levels overnight, which will be contributing to the appearance of his diabetic complications. See if you can reduce his night time blood sugar levels without changing his diet which he "loves". Also try adding in a single long-acting insulin preparation before bed, instead of his existing intermediate-acting doses before lunch and bed.
This 35 year old insulin-dependent diabetic man recently switched to using an insulin pen, injecting three 'shots' of short-acting insulin before breakfast, lunch and supper and taking a single dose of long-acting insulin before going to bed. However, he hasn't quite yet got full control of his blood sugars, still tending towards high blood glucose levels overnight. How might you improve his control, adjusting his existing insulin doses.
This gentleman normally eats well. However in anticipation of a lunchtime business function where he knew he would be eating a lot, he cut back on his breakfast. Unfortunately, he had a bit of a trip to make to attend the function and forgot to adjust his insulin as well. As a result he found himself going 'hypo' at around 7:30am. Try using the simulator to find out by how much he would have needed to reduce his morning insulin doses to avoid this predictable event?
This newly diagnosed insulin-dependent (type 1) diabetic young man is on a twice daily regimen of short- and intermediate-acting insulin injections with a split-evening dose. On this regimen he still finds himself having wide 'swings' in his blood glucose profile - his blood sugars being fine one minute and just a few hours later he finds himself going 'hyper' (too high). See what happens if you switch him over to a 'pen' regimen, with short-acting injections before each meal and a long-acting dose injected before going to bed.
This elderly man is on two 'shots' of short- and intermediate-acting insulin twice a day, with a split-evening dose. His blood sugars are very good and he prides himself on maintaining tight control. However, he is not adverse to a round or two of golf, and on 'golf mornings' has noticed that his blood sugar can fall slightly low. He doesn't want to take any more snacks, and as the golf is going to become a regular feature of his day, how should he adjust his morning insulin to avoid mid-morning 'hypos'?
This insulin-dependent diabetic teenager has been admitted to hospital three times in the past couple of months in diabetic ketoacidosis. She only has three meals per day but is very insulin resistant and tends to run consistently very high blood sugars. How might you adjust her regimen to generally reduce her blood glucose levels? Hint: For a start, try increasing her intermediate-acting insulin doses - can you see how much more insulin she requires to better control her blood sugars?
This insulin-dependent diabetic man regularly monitors his blood sugars. He is a bus driver and knows that if he ever went 'hypo' he could end up losing his job. However, he is overweight - something which he and his doctors wish to tackle. Reducing his dietary intake might prove difficult, unless his insulin regimen could be adjusted accordingly. Try and see if you can reduce the carbohydrate content of some of this man's snacks while at the same time decreasing the amount of insulin he injects.
This young man is on a slightly unusual therapeutic regimen, eating a fair amount during the day but taking his largest injection of insulin just before bed. This isn't ideal because firstly it doesn't control his blood sugars as tightly as one might wish, and secondly if he were to miss a meal or snack he would run the risk of going "hypo" overnight. How might you redistribute the existing insulin doses that this young man injects to tighten his control?
This young insulin-dependent diabetic man tends to high blood sugars towards the end of the day. He doesn't take large snacks, but eats big meals for lunch and supper. He is on a split-evening dose insulin regimen - taking his short-acting injection before supper and his intermediate-acting injection before bed. See if you can devise a way of reducing his evening blood glucose levels without sending him 'hypo'.
This man appears to be have some reasonable glycaemic control although the blood sugar he records before going to bed just precedes a mild hyperglycaemic peak. However, he wakes in the morning with headaches suggesting nocturnal hypoglycaemia. As such the patient may be running low blood sugars overnight. Can you improve Jonathan's overnight glycaemic control?
This young woman hopes to start a family soon. She has been attending her diabetic clinic regularly in an attempt to improve her glycaemic control. However, she still runs relatively high blood glucose levels - especially towards the end of the day. She is on a slightly curious insulin regimen, injecting herself four times per day with short- and / or intermediate-acting insulin preparations. The patient is willing to monitor her blood glucose regularly. See if a different insulin regimen might improve her
This man is a travelling salesman who often finds himself on the road and only able to take meals at certain times. He obviously carries some snacks with him in the car for emergencies - but nevertheless his glycaemic control can be quite variable. In this case he had very little to eat (and therefore left off most of his insulin) till lunchtime. Thereafter he had a large supper. Would you have injected any insulin before lunch? Use the simulator to find out what effect this might have....
This woman is quite overweight and tends to eat large amounts of food. She also finds it difficult to maintain tight glycaemic control despite being on four insulin injections per day. How might you set about reducing some of the swings in her blood glucose profile, as well as generally bringing down some of her blood glucose levels. Do note that the patient is relatively resistant to the effects of insulin.
This patient is on twice daily pre-mixed (biphasic) insulin injections. She maintains reasonable glycaemic control with this regimen but is thinking of starting a family and would like to tighten her glycaemic control even further. If she were to try this, she would obviously need to do so cautiously, in consultation with her doctor. See what happens if you gradually increase her injected insulin doses in small steps....
This young man has reasonable glycaemic control although the simulation does suggest a slight dip in his blood glucose profile at around 9am. This is most probably due to his injecting insulin at 6:15am, but not taking anything to eat till 7:05am. Furthermore, his main breakfast seems to come later at around 8:30am. Also some patients benefit from having split-evening injections - taking their short-acting preparation before supper with their intermediate acting preparation before bed. See what happens if you try this for James....
This young man's blood glucose profile appears very well controlled. He is on a three time daily short- and intermediate-acting insulin regimen with a split-evening dose. That is he takes the short-acting component before supper and the intermediate-acting component before going to bed. The alternative is to combine these two injections into a single injection before supper. Try simulating this, and see why this option - although reducing the number of injections - does not provide such ideal glycaemic control....
This girl has had a number of urinary tract infections - diabetes can predispose to these because glucose in the urine can nourish bacteria there. Use the advanced Fluxes option to see the different glucose fluxes within the model. Focus particularly on the renal excretion curve. As the blood sugar rises above the renal threshold of glucose - glucose starts to flow from the kidneys into the urine - as a waste product. Try improving this girl's glycaemic control to stop this happening....
This young woman is on a twice daily insulin regimen, injecting a biphasic preparation which has a premixed 30% to 70% ratio of short vs intermediate acting insulin. While this doesn't permit quite as much flexibility in selecting a dose - it does save on having to mix insulin in the syringe. Use the simulator to see what would happen if you switched this woman onto other biphasic preparations with, say, premixed 10/90, 20/80, 40/60, or 50/50 percent
This woman tends to higher blood sugars in the afternoon. Her renal threshold of glucose (RTG) is currently set at 'low'. Her RTG represents the blood glucose level at which glucose begins flowing from the kidneys into the urine (being excreted) - as a waste product. As her RTG rises so blood glucose levels will rise higher before glucose starts to be excreted into the urine. Using the advanced Fluxes option to monitor the renal excretion of glucose - increase the RTG from 'low' to 'normal' or 'high' and see the effect on this woman's blood glucose profile - as you try to improve her metabolic control.
This man is on a very unusual regimen injecting three doses of intermediate acting insulin together with some
short-acting insulin in the afternoon. He has relatively high insulin levels overnight with very little carbohydrate intake to compensate for this, and as a result ends up with low blood glucose levels during the night. He experienced a 'hypo' at 3am - which perhaps isn't surprising given the large amounts of insulin taken at 6pm and 10:30pm. How could he modify his regimen to increase his blood glucose overnight?
This elderly man is on a twice daily regimen of short and intermediate acting insulin preparations. Unfortunately, his eyesight is failing, and although he is on the waiting list for a cataract operation, this could take some time to
come through. He wife heard about premixed (biphasic) insulin preparations and thought this might help him, saving him having to mix the individual preparations within the syringe. Using the simulator can you provide him with such an example, premixed twice daily insulin
This woman is on a four times daily insulin regimen, taking three 'shots' of a short-acting preparation before each of the main meals, with an intermediate-acting preparation before going to bed. She injects using an insulin pen - but hasn't yet managed to stabilise her glycaemic control. She tends to eat a lot more towards the end of the day and so finds herself going markedly
hyperglycaemic overnight. How might you control these extremely raised blood sugar levels during the night, without sending her 'hypo' as a result?
This elderly man often has 'hypos' between breakfast and lunch. This morning he felt himself going 'hypo' at 9am and fortunately by 9:15am managed to get some food down
inside him. He injects his first insulin 'shot' of the day at 6:45am approximately 15 minutes before he starts breakfast. See if you can use the simulator to identify the effect of decreasing his morning dose. Might this help to ensure that he is less prone to mid-morning 'hypos'?
This overweight, insulin resistant man keeps reasonable glycaemic control. Accessing the advanced Fluxes option shows that he has relatively constant glucose production by the liver with just minor excursions in peripheral glucose uptake and in the renal excretion of glucose following each meal. By how much would he need to increase his insulin intake to tighten his glycaemic control even further?
This young woman, who is very overweight, runs reasonably high blood sugars during the course of the day. At present she is only injecting herself twice daily with two 'shots' of intermediate-acting insulin. How might you add in a short-acting insulin preparation to her regimen to tighten her glycaemic control? Alternatively, see if you can decrease her carbohydrate intake - thereby perhaps helping her to lose weight - and at the same time improve her blood glucose control....
This man tends to high blood glucose levels overnight. How might you control these without sending him 'hypo'? Supposing however that he was to take his insulin, as usual at 7:15am, but then skip breakfast and rush off to work. By deleting the entry for breakfast use AIDA to simulate what would happen to his blood glucose profile during the mid-morning. Although AIDA at present does not include exercise, exertion would simply increase peripheral glucose utilisation compounding the mid-morning 'hypo' which would occur....
This man went 'hypo' at 9:30am, and even after taking a sizeable snack at 10am still had a low blood sugar at 10:30am. He also tends to quite high blood glucose levels in the evening. How might you be able to redistribute his current insulin regimen and / or food intake to reduce the risk of him going 'hypo' during the mid-morning while at the same time controlling his nocturnal blood sugars more tightly?
This man has quite reasonable glycaemic control on a three-times daily insulin injection regimen (with a
split-evening dose). Use AIDA to simulate what would happen to his blood glucose profile if he were to forget to take his morning insulin injection - which might leave him at serious risk of diabetic ketoacidosis.
This man has to maintain tight glycaemic control to keep his job, which involves controlling heavy machinery.
Keeping his blood glucose profile within narrow limits is complicated by the fact that he has to do shiftwork. This simulation shows how AIDA can demonstrate the relation between meals and insulin injections for an example patient on an unusual sleep-wake schedule.... See if you can create a new pair of case scenarios for an example patient flying across time zones - say from London to Sydney....
This woman injects herself twice a day with a premixed (biphasic) insulin preparation. However, on this regimen she has not yet achieved tight glycaemic control. What sort of other premixed insulin preparations could be used - perhaps with different premixed short-to-intermediate acting ratios - to improve her blood glucose profile? Try
experimenting with some of the other premixed insulin types which come as standard within AIDA. Hint: you will also have to adjust the dosages.....
This young woman wants to start a family. She is trying to achieve very tight blood glucose control before becoming pregnant. She is currently on a three-times daily regimen
with a split-evening dose. When she becomes pregnant she will need to inject more often than this. See if you can use AIDA to create a new insulin injection regimen with four injections per day. Can you at the same time tighten her glycaemic control any further?
This man is slightly obsessive compulsive when checking his blood sugar levels. He tends to run slightly low first thing in the morning, before breakfast and is concerned
about this. How might he adjust his evening intermediate acting dose to compensate for this. He currently finger pricks himself at least 8 times a day, which apart from being painful, may not be totally necessary. When should he measure his blood sugars to maximise the information he gets back, while keeping the number of finger pricks
down? Hint: Before meals.