GOALS OF INSULIN THERAPY
is made to establishes glycemic goals for the patient before the therapy
The American Diabetes Association recommends the following :
Preprandial plasma glucose : 70-130 mg/dl
Postprandial plasma glucose : <180 mg/dl
HbA1C : <7%
THE REPLACEMENT STRATEGIES
There are two common strategies implemented for insulin therapy
1. Physiologic Insulin Replacement
Insulin is released continously from functional pancreas in order to provide basal amount of insulin and to promote glucose utilization after eating. Physiologic insulin replacement is the administration of exogenous insulin to simply mimic the continous supply of physiologic insulin in body. This is call the bolus/basal concept. The strategies is to inject the body thrice daily/or more with insulin or using the insulin pump. Usually, 50% of the total daily dose required to form basal insulin and the rest at about 10-20% is required for each meal.This strategies allow patients to have flexibility in their mealtimes and achieve better glycemic control.
2. Non-Physiologic Insulin Replacement
For this strategies , the injected insulin do not mimic the continous supply of physiologic insulin. Insulin is given either one or twice daily. For people with type 2 diabetes, in whom basal insulin replacement is not as critical, once or twice daily regimens can still work satisfactorily with reasonable glycemic control achieved.
TYPES OF REGIMENS FOR INSULIN THERAPY
Various factors to be considered to design an appropriate insulin regimens such as type of diabetes, indivudual needs and circumstances. Actives involvement of patient including numbers of injection and self control toward the blood glucose level is needed throughout the therapy.
Once-daily regimen
Long/intermidiate acting insulin is given at bedtime and suitable only for type 2 diabetic patient. It may use with combination of oral hypoglycaemic agent. Usually insulin glargine, NPH and detemir is used. This strategies is rarely used because of the lower insulin coverage.
Twice daily regimen (split mixed and premixed regimen)
A mixture of rapid or short acting with intermidiate insulin is given two times a day(known as biphasic insulin)Two-thirds of the total daily insulin dose is given in the morning before breakfast and one-third of total daily dose is given before dinner. It can be mixture of NPH with insulin aspart/glulisine/lispro. Optimal glycemic control is difficult to achieved.
Multiple Daily Insulin Injection Regimen: Basal plus Prandial Insulin
Many different types of regimens are possible with multiple daily injections. Regular, insulin aspart, glulisine and lispro are used to provide prandial insulin before each meal. NPH, insulin glargine, and insulin detemir are used to provide basal insulin over time.This offers greater flexibility and is the most commonly adopted method when intensified insulin therapy is used to provide optimal glycaemic control.
insulin pump therapy /continuous subcutaneous insulin infusion (CSII)
The insulin used in pumps may be soluble or a fast-acting analogue. Some advantages for this kind of therapy such as patient can activates pre-meal boluses, the pumps can be disconnected up to one hour and they can be pre-programmed. Usually, only type 1 diabetic use this kind of therapy but not it is available for type 2 too. Insulin pumps causes less weight gain, less hypoglycemia, and better control of fasting hyperglycemia due to the dawn phenomenon compared to multiple daily injections. But , the patient need to be very knowledgable to handle the apparatus.
HOW INSULIN THERAPY IS DONE?
Sources:
1.Insulin-Pharmacology,Type of regimen and Adjustment. Available at http://diabetesmanager.pbworks.com
2. Insulin Regimen. Available at http://www.patient.co.uk/doctor/insulin-regimens
3.Insulin Regimen and Therapy. Available at http://www.diabetes.co.uk/insulin/insulin-regimens.html
WHICH REGIMEN FOR WHICH PATIENT??
Type 1 diabetes The options are:
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Type 2 diabetes
In type 2 diabetes, there is a gradual decline in beta cell function, so that
treatment will need regular adjustment. When oral agents are
insufficient options are:
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using once/twice daily intermediate/ long-acting insulin.
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