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Insulin Treatment Regimes

SINGLE-DOSE REGIMENS (i.e. one shot daily of insulin): In someone with Type 1 diabetes, there are no insulins that can reliably act for a 24-hour period. Overall glucose control (as assessed by Hgb A1c) will never be optimal, and this regime is almost never successful. Its use dates back to the early days of diabetes management, when it was not as clear that multiple dose regimes were better, and monitoring of the blood was crude, without the use of a HgbA1c test, or even blood glucose testing at home.

TWICE-DAILY REGIMENS (i.e. two shots of insulins daily): There are two basic regimes using twice-daily insulin.

  1. The first consists of a short- and intermediate-acting insulin (R and N, or Toronto and NPH) before breakfast, along with a short- and intermediate-acting insulin before supper. This regime, generally speaking, does not offer adequate control and has certain disadvantages. By giving an intermediate-acting insulin before supper, its action often peaks in the middle of the night, and may not fully last until morning. This can cause hypoglycemia during sleep and hyperglycemia upon waking.

  2. The other twice-daily insulin regime that is often used is a mixture of short- and intermediate-acting insulins in the morning, and an intermediate-acting insulin at bedtime. Unfortunately it too rarely achieves good glucose control. Intermediate-acting insulin taken in the morning usually doesn't last through the early evening hours. There is no insulin left to handle the glucose rise from eating supper. Significant hyperglycemia can then occur after supper, and it will not be controlled until the peak action of the next insulin dose (given at bedtime). This peak would occur the next morning, and the individual would have been exposed to elevated glucose levels for several hours.

MULTIPLE DAILY INJECTIONS: In view of the findings of the nine-year study of the Diabetes Control and Complications Trial (DCCT), tighter glucose control should be attempted in every individual for whom it is feasible. This is usually achieved by insulin regimes of three or four injections per day.

  1. The three-injections-per-day regimen consists of short- and intermediate-acting insulin (R and N or Toronto and NPH) in the morning, a short-acting insulin (R or Toronto) before supper, and an intermediate-acting insulin at bedtime (N or NPH).

  2. A four-shot-daily regimen consists of a short-acting insulin given before each meal (accounting for three shots), and an intermediate-acting insulin at bedtime. Almost all new Type 1 diabetes patients are treated with this type of regimen, and many existing Type 1 patients are switching to it.

Both regimens offer equally good glucose control. There are advantages of a four-shot regimen, including some leeway in timing of the meals and the ability to adjust insulin doses prior to the meal.

INSULIN PUMPS: also known as continuous subcutaneous insulin infusion. This provides an alternative to multiple daily injections for achieving tight glucose control. The patient wears an external pump which delivers insulin from a syringe or reservoir through a plastic tube placed in the skin. The tube, or "catheter" can be changed every one to two days. The individual can program the pump to give insulin automatically in a basal (continuous) mode, as well as additional dosages before meals. This allows a person to maintain excellent glucose control.

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