In all insulin regimens, the timing of the insulin dose in relation to food intake must be based on the type of insulin given and it’s onset of action. If this balance is not taken into account, the result will be:
Since the primary defect
in type 1 diabetes is insulin deficiency, treatment involves replicating, as
much as possible, physiological insulin secretion by the pancreas. In other
words, continuous basal release with additional boluses released in proportion
to the size and type of meal consumed. Basal insulin requirements may vary due
to physical stress, hormonal changes, illness, physical activity, and level
of physical fitness. Designing an effective insulin regimen involves working
with the patient to find a regimen that provides adequate coverage and flexibility
in regard to meals, physical activity, schedule, other medications, and psychological
factors.
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Insulin injection regimens range from one or two injections per day (conventional insulin therapy) to multiple (3-4) daily injections (intensive insulin therapy). The selection of insulin regimen depends on the level of glycemic control required and patient's ability to comply.
Conventional insulin therapy for type-1, usually involves one injection of short acting insulin in the morning before breakfast and another before the evening meal or at bedtime. This type of therapy may include intermediate acting insulin or doses of regular or rapid-acting insulins mixed with intermediate-acting insulin or premixed formulations at one or both injection times. Single dose therapy may be useful for patients that are: poorly controlled type-2, poorly motivated or disable with limited ability to comply with more complicated regimens.
Over the past few years,
research has shown a benefit from tight control of blood sugar in reducing
the complications of diabetes. Intensive insulin therapy with multiple insulin
injections throughout the day is now commonly used to manage type-1 diabetes. Studies
have shown that 3 or 4 injections a day provide the best blood sugar control
and reduce or delay eye, kidney, and nerve damage caused by diabetes. Intensive
insulin therapy allows better insulin coverage, reducing the risk of nighttime
hypoglycemia and morning hyperglycemia, the latter due to the normal release
of cortisol and growth hormone early in the day. For most patients with type
1 diabetes, achieving adequate blood glucose control requires using intensive
therapy. With a 3 injection regimen, insulin is injected in the morning before
breakfast, before the evening meal, and at bedtime, or before each meal. In
a 4 injection regimen, insulin is injected in the morning before breakfast,
before lunch, before the evening meal, and at bedtime.
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For a person with either type 1 or type 2 diabetes, the beginning dose and schedule of insulin administration is based on an assessment of the individual’s insulin deficiency and suspected insulin resistance, and on the person’s preference for eating times and amounts of carbohydrates, exercise, and waking and sleep patterns. Insulin requirements for persons with type 1 diabetes, who are within 20% of ideal body weight, range between one half and 1 unit per kilogram of body weight per day. During illness, insulin requirements rise for persons with either type 1 or type 2 diabetes, sometimes to several hundred units per day, depending on the extent of insulin deficiency and resistance. Insulin requirements for pregnant women with pre-existing diabetes gradually increase during the second and third trimesters of pregnancy.
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