Lege Artis Medicinae

[Insulin dose titration in type 1 diabetes mellitus: A blessing or a curse?]

TAKÁCS Róbert

JUNE 15, 2012

Lege Artis Medicinae - 2012;22(05)

[INTRODUCTION - Knowing the pharmacokinetic properties of different insulins, useful treatment algorithms can be set up for the majority of our insulin-treated patients. When planning either a human or an analogue basal-bolus regimen, the first task is to determine the daily insulin requirement, followed by determination of the optimal rate of basal and bolus insulins. CASE REPORT - In a 33-year old, moderately obese man with type 1 diabetes who received 180 U daily insulin doses, accumulated hypoglycaemic episodes with neuroglycopenic symptoms occured. After cessation of the original insulin therapy and starting an analogue basal-bolus treatment regimen, both the carbohydrate metabolism and the overall quality of life of the patient have significantly improved. Optimal metabolic control was achieved by a basal insulin ratio above 50%. CONCLUSION - Using elements of the analogue basal-bolus regimen - one of the state-of-the-art forms of insulin treatment - at the appropriate dose and dose ratio, it is possible to comply with the therapeutic requirements of our age. However, if this weapon is used inappropriately, it might actually harm patients.]

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[INTRODUCTION - The choice of insulin combination therapy in children with type 1 diabetes mellitus is determined basically by the diet as well as the age of the patient. However, life rhythms of individual children are widely different. As a consequence, insulin therapy must be tailored to individual needs, by chosing the optimal one from the available insulin products with different efficacy curves. The aim is, of course, to maintain near-normoglycaemia for years or decades. CASE STUDY - The author presents the case of a 10-year-old girl with diabetes for 4 years, whose insulin treatment has involved a number of combinations. Good metabolic balance could be obtained by premixed insulin preparations for more than two years. However, subsequent intensive treatment with human insulins had poor results. This was primarily due to the fact that the child had a rather hectic daily schedule and eating habits, although she ate - appropriately for her age - six meals per day. After changing the ratios of the meals while maintaining her six-mealsper- day regime, an analogue glargine/glulisine combination therapy was induced, with a significant increase in the basal/ bolus ratio. This treatment was successful: HbA1c level got to the target range, without changes - theoretically caused by the rapid analogue - in hypo- and hyperglycaemic periods before and after small meals, respectively. CONCLUSION - During the time of remission, treatment with premixed human insulin can maintain good metabolic balance even for years, while saving (at least) two pricks per day. Insulin treatment intensified by analogue insulins (glulisine/glargine) may be attempted in prepubertal children needing six meals a day, provided their lifestyle raises problems. Glargine, given in an increased ratio, can compensate the hyperglycaemic effect of minimised small meals.]

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