Insulin Administration , Preparations And Regimens

Starting insulin in patients with Type 1 diabetes
Some patients start treatment with twice-daily insulin injections
using either a mixture containing premixed short and medium
acting insulins twice daily or medium acting insulin alone; 8 units
twice daily, 15 to 30 minutes before meals is a suitable initial dose
for most patients; others will start with a three or four times daily regimen.

Only those who are seriously weakened or ill need
hospital admission and treatment either with intravenous insulin
and fluids or multiple insulin injections.

Many patients who present with acute diabetes enter partial remission soon after
diagnosis, known as the “honeymoon” phase, when a small dose
of almost any insulin is enough to maintain control. The practice
of withdrawing insulin at this stage is not encouraged because
after a few months the need for insulin is almost inevitable.
 
Maintenance regimens
Most Type 1 diabetic patients who want to achieve very good
control will need at least thrice-daily injections. Multiple
injections (three or four times daily) may improve control,
reduce the risk of serious hypoglycaemia, and to some extent
increase flexibility (for example, the timing of the midday
meal) and are often needed in pregnancy. Suitable insulin
regimens are as follows:

Twice daily: short and medium acting insulins or
occasionally medium acting insulin alone are taken twice daily
before breakfast and the main evening meal.
 
Three times daily: the mixture of neutral soluble and medium
acting insulins is taken before breakfast; neutral soluble insulin
alone before the evening meal; medium acting insulin alone
before bedtime. This insulin regimen has the advantage that the
noon injection is not required and is thus favoured by many.

Fasting blood glucose is also improved using this regimen.
Four times daily: neutral soluble insulin alone or a short acting
insulin analogue is taken before each of the three main meals,
and medium acting insulin at bedtime.

(Occasionally the long acting Human Ultratard insulin is used, though this has not
proved to be as advantageous as it should be in theory.)
Sometimes there is a further advantage in adding a medium
acting insulin to the prebreakfast soluble insulin.

For some Type 2 diabetic patients, when control on oral
medication fails, a single daily injection may suffice; the use of
medium acting insulin at bedtime alone has gained popularity
and by lowering fasting blood glucose may achieve an
acceptable profile throughout the day.

This regimen can be usefully combined with concurrent use of metformin. If this
fails, insulin needs to be delivered on a twice daily basis or
more often, as described above. Premixed insulin mixtures are
valuable for many Type 2 diabetic patients.

When changing from one insulin regimen to another some
trial and error by regular blood glucose monitoring is always
needed. In converting a patient to the four times daily regimen
the normal dose should be divided by four and a slight
adjustment made to give more than one-quarter before
breakfast and less than one-quarter before bedtime