However, discontinuation is not recommended because data suggest that the insulin may be altering the immune system to retard beta-cell destruction. Traditional once-daily or twice-daily insulin regimens are no longer recommended for most patients with type 1 diabetes who have little or no endogenous insulin production. However, twice-daily insulin injections may be effective for at least a short period in patients with newly diagnosed type 1 diabetes who are still producing a significant amount of insulin Table 3.
Twice-daily administration of NPH insulin and regular insulin usually works adequately while endogenous insulin is still being produced. Two thirds of the total daily insulin dose may be given 20 to 30 minutes before breakfast, and one third of the dose may be given 20 to 30 minutes before the evening meal. As an estimate, NPH insulin and regular insulin can be given in a ratio for the breakfast dose and a ratio for the evening-meal dose. As more complete insulin deficiency develops, this regimen becomes less effective.
As noted in Table 2 and Figure 1 , 19 the peak of action for NPH or lente insulin creates several problems. The morning administration of a large dose of intermediate-acting insulin with regular insulin results in hyperinsulinemia at midday.
If lunch is delayed even a short time in patients who maintain reasonable glycemia after breakfast, hypoglycemia ensues.
To avoid this problem, many patients require a midmorning snack, even when lunch is not delayed. For patients on this regimen, a lack of hypoglycemia, even after a long delay to the midday meal, strongly suggests extremely high morning glucose levels. In many patients, especially those who are young and thin, the morning insulin tends to dissipate by late afternoon, resulting in high glucose levels before the evening meal. This particular issue was not as great a problem with bovine and porcine insulins, 2 because they had longer durations of action than the human insulins used today.
Perhaps an even greater problem is maintenance of nocturnal glycemic control when an intermediate-acting insulin is injected with the evening meal Figure 1. Idealized insulin effect provided by an insulin regimen consisting of two injections per day arrows of short-acting regular insulin Reg and intermediate-acting insulin NPH or Lente.
Adapted with permission from Skyler JS. Insulin treatment. In: Lebovitz HE, ed. Therapy for diabetes mellitus and related disorders. Alexandria, Va. For any flexible diabetes therapy to be effective, the basal and mealtime components must be identified. The basal component restrains hepatic glucose production, keeping it in equilibrium with tissues that are obligate glucose consumers such as brain tissue. Mealtime insulin stimulates peripheral glucose uptake while inhibiting hepatic glucose output.
Basal insulin may be provided as 1 bedtime intermediate-acting insulin with or without morning intermediate-acting insulin, 2 ultralente insulin, usually administered twice daily, or 3 insulin pump therapy.
Dosing can be determined only by assessing the blood glucose level after the insulin administered at mealtime has dissipated and food has been digested. It is important to determine if the blood glucose level is maintained within the target range after breakfast. For example, if the glucose level before the midday meal is consistently elevated and the glucose level two hours after the meal is usually within the target range, the basal component in the morning may be too low.
If the blood glucose level before the midday meal is above the target range and the glucose level two hours after the meal is also usually high, the mealtime insulin component is probably insufficient, or perhaps the basal and mealtime insulins need adjustment to a larger dose.
One popular solution to the problem of nocturnal insulin replacement is to delay administration of the intermediate-acting insulin until bedtime 1 , 2 , 16 Figure 2. When mealtime insulin is only administered twice at morning and evening meals , mealtime flexibility is not significantly improved.
Idealized insulin effect provided by an insulin regimen consisting of injections arrows of short-acting regular insulin Reg and intermediate-acting insulin NPH or Lente before breakfast, short-acting insulin Reg before the evening meal and intermediate-acting insulin NPH or Lente at bedtime. When regular insulin is used at mealtimes, some physicians prefer using bedtime intermediate-acting insulin as the only basal insulin. An injection of regular insulin is also given before the midday meal.
Other physicians prefer administration of a small dose of intermediate-acting insulin in the morning, a larger dose at bedtime and doses of insulin at mealtimes when needed 16 Figures 3 and 4. Perhaps more importantly, if insulin lispro is used as the mealtime insulin, a minimum of two injections of intermediate-acting insulin is required.
Idealized insulin effect provided by a multiple-dose regimen consisting of injections arrows of short-acting insulin Reg before meals and basal intermediate-acting insulin NPH or Lente twice daily. Idealized insulin effect provided by a multiple-dose regimen consisting of injections arrows of rapid-acting insulin Lispro before meals and basal intermediate-acting insulin NPH or Lente twice daily.
Ultralente Insulin as the Basal Insulin. Recently, ultralente insulin programs have become more popular 2 Figures 5 and 6. Idealized insulin effect provided by a multiple-dose regimen consisting of injections arrows of short-acting insulin Reg and long-acting insulin Ultralente.
Idealized insulin effect provided by a multiple-dose regimen consisting of injections arrows of rapid-acting insulin Lispro and long-acting insulin Ultralente. Persistent fasting hyperglycemia may be treated by increasing the dose of ultralente insulin that is given at the evening meal. However, this approach may not be effective in some patients, because nocturnal hypoglycemia may occur without any improvement in fasting hyperglycemia as a result of the dawn phenomenon.
Occasionally, patients do best with ultra-lente insulin given in the morning and NPH insulin administered as the other basal component at bedtime. The advantage of this regimen is that early-morning insulin resistance can be better targeted with the bedtime NPH insulin. Any flexible diabetes therapy regimen is based on predetermined actions to be taken in response to self-monitoring of blood glucose levels or an unusual situation that can affect glycemia.
Patients with type 1 diabetes need to be taught an action plan that takes into account all components necessary to correct glycemia. This plan would cover any changes in mealtime insulin dose, as well as lag time, food intake especially carbohydrate consumption and physical activity. Unfortunately, action plans for flexible diabetes therapy continue to be confused with sliding-scale insulin therapy, which refers to a retrospective correction of hyperglycemia with short-acting insulin without regard to caloric intake or physiologic insulin delivery.
An insulin supplement is a temporary dose of regular insulin that is administered to prevent or correct a blood glucose level outside of the target range. A supplement may be used if premeal hyperglycemia is present, a particularly large meal is anticipated or usual physical activity is not going to be performed.
For supplementation using regular insulin or insulin lispro, the lag time must be considered. Regular insulin or insulin lispro should be used with caution at bedtime.
Table 4 represents a sample plan for the administration of insulin lispro before meals in conjunction with a flexible diabetes therapy program using either twice-daily ultra-lente insulin or insulin pump therapy as the basal insulin component.
A plan for the management of outpatient surgery in a patient with type 1 diabetes is presented in Table 5. Test for urinary ketones; if levels are moderate or large, increase fluid intake and consider giving additional insulin. Because the blood glucose level is 90 mg per dL above the target value, an additional 3 units of lispro should be administered. The plan should be individualized for each patient. If NPH insulin is used, give 50 percent of the usual dosage at the usual time.
If ultralente insulin is used, give the entire daily dose at the usual time. For an early-morning procedure, withhold the insulin dose until after surgery unless the blood glucose level is higher than mg per dL See converting from long-acting insulin to NPH for more. Patients at high risk for hypoglycemia e. Toujeo to twice-daily NPH Daily dose remains the same. Lantus and Tresiba have similar glucose-lowering effects.
Lantus has a similar effect to Tresiba. The recommendations presented here are based on the fact that Tresiba has similar glucose-lowering effects as Lantus. Also, there are many variations of insulin therapy. You will need to work out your specific insulin requirements and dose regimen with your medical provider and diabetes team.
Self assessment quizzes are available for topics covered in this website. To find out how much you have learned about Treatment of Type 1 Diabetes , take our self assessment quiz when you have completed this section. The quiz is multiple choice. Please choose the single best answer to each question. At the end of the quiz, your score will display. All rights reserved. Ninety-nine percent of patients used both regular and intermediate-acting NPH or Lente insulin min before breakfast and again in the evening.
Ten percent of the patients used only regular insulin at supper but used intermediate-acting insulin at bedtime.
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