THERAPEUTIC REGIMENS
The goal of SC insulin therapy is to replace the normal basal (overnight, fasting, and
between meals) as well as bolus or prandial (mealtime) insulin.
In the nondiabetic individual, the pancreas secretes boluses of insulin in response to
snacks and meals. Between meals and throughout the night, the pancreas secretes small
amounts of insulin that are sufficient to suppress lipolysis and hepatic glucose output
(basal insulin).
Two methods are used to achieve a similar pattern of insulin release:
Basal-Bolus Insulin Regimens
consisting of once to twice daily doses of basal
insulin coupled with pre-meal doses of rapid or short-acting insulin.
Insulin Pump Therapy
(previously referred to as “continuous subcutaneous infusion
of insulin”)
BASAL-BOLUS INSULIN REGIMENS (MULTIPLE DAILY INJECTIONS)
The regimen that most closely mimics physiological insulin release, besides the use of an
insulin pump, is the use of a once-daily basal insulin such as insulin glargine or insulin
detemir to provide basal insulin levels throughout the day, along with doses of regular
insulin, insulin lispro, insulin aspart, or insulin glulisine before meals
The long-acting insulin can be given at bedtime, or, alternatively, in the morning.
If patients skip a meal, they omit a premeal bolus; if they choose to eat a larger meal than
usual, they increase the premeal bolus. Similar dose adjustments can be made to
accommodate snacks, exercise patterns, and acute illnesses.
INSULIN PUMP THERAPY
The use of an insulin pump is the most precise way to mimic normal insulin secretion. It
consists of a battery-operated pump and a computer that can program the pump to deliver
predetermined amounts of insulin from a reservoir to a subcutaneously inserted catheter
or needle.
These systems are portable and designed to deliver various basal amounts of insulin over
24 hours as well as meal-related boluses.
LD250216
10
Most patients using an insulin pump prefer to use the rapid-acting insulin analogs in their
pump. For meal coverage, the rapid-acting insulin can be given 0 to 15 minutes before
eating.
ADVERSE REACTIONS
HYPOGLYCEMIA
Most serious and common adverse reaction to overdose.
Long-term diabetics often do
not produce adequate amounts of counterregulatory hormones (glucagon, epinephrine,
cortisol, GH) that normally provide effective defense against hypoglycemia.
Rapid-acting insulin analogs
(lispro, aspart, glulisine) are associated with lower
incidence of severe hypoglycemic episodes as compared with regular insulin.
Long-acting insulin analogs
(glargine, detemir) are associated with lower risk of
nocturnal hypoglycemia than NPH insulin.
Hypoglycemia is rapidly relieved by glucose administration. In a case of mild
hypoglycemia in a patient who is conscious and able to swallow,
orange juice, glucose
or any sugar-containing beverage
or food may be given. If more severe hypoglycemia
has produced unconsciousness or stupor: 20-50 mL of 50 % glucose solution by IV
infusion over 2-3 min. If IV therapy is not available: 1mg
glucagon
SC or IM.
