Changes in a patient's activity, medical condition, or nutrition, or sometimes unknown factors, can result in the need to modify the basic insulin dosages and/ or program. This is recognized through pattern management, which uses the patient's blood glucose records to identify "problem" glycemia times and then adjust the dose of insulin that is active at that time. This is second nature to most patients and physicians. However, two aspects need highlighting. First, dosage changes should be made based on several days of SBGM; an inescapable characteristic of type 1 diabetes is variable blood sugars, and making a fundamental change in the insulin program because of a few days of surprising values is ill advised. Alternatively, if an event has occurred that explains the change in glycemia and is ongoing—the patient started a new sport or exercise program, went on a diet, etc.—it makes little sense to wait before making adjustments. Second, a key principle in blood sugar management is that the patient's blood glucose value now affects what it will be several hours from now. Stated another way, patients know that how they start the day in terms of glycemia affects their glucose values for the rest of the day. Thus, if the patient's log shows high or low blood glucose values throughout the day, change only the overnight insulin to optimize the fasting blood glucose level. Observe what happens to the blood glucose values later in die day, then, if necessary, change the insulin coverage one shot at a time (coverage for lunch, then supper, then bedtime) until day-long glycemia is optimized.
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