Evolving approaches to intensive insulin therapy in type 1 diabetes: multiple daily injections, insulin pumps and new methods of monitoring.

Abstract

Ke yW ords. intensive insulin therapy, multiple daily injections, basal-bolus therapy, continuous subcutaneous insulin infusion Type 1 diabetes affects approximately 1 million individuals in the United States, whose management has significantly changed over the last decades. Initially, following the discovery of insulin in the early 1920’s, improvements centered around the purification of insulin formulations. Later came the development of both shortand longer-acting insulin preparations and more recently the availability of the insulin analogues aspart, lispro and glargine, which have added to our ability to deliver physiologic insulin replacement patterns. However, insulin is only one component of therapy. Another critical element has been the development of devices for selfmonitoring blood glucose (SMBG). As these devices have become increasingly accurate and convenient, they have allowed patients to monitor blood glucose more often and accurately, adding a critical component to diabetes management. Much of the impetus to develop better therapies for the management of type 1 diabetes stems from an understanding of the importance of blood glucose control. The association between glycemic control and microvascular complications was established with the publication in 1993 of results from the Diabetes Control and Complications Trial (DCCT), the landmark study which demonstrated the benefit of efforts to achieve excellent glucose control to limit retinopathy and nephropathy [1]. Establishment of this relationship has led to significant changes in management. In this review we will discuss the concepts behind the current management of type 1 diabetes, beginning with a definition of intensive insulin therapy, and the various ways by which it can be achieved. We will then discuss the elements involved in intensive therapy, including essential educational components, glucose monitoring, and the newer monitoring devices that are available.