Multiple Insulin Injection Regimen Research Articles

Visually controlled pulsatile release of insulin from chitosan poly-acrylic acid nanobubbles triggered by focused ultrasound

Insulin therapy is the most effective way to control the blood glucose value of diabetic patients. The most effective administration route for insulin is subcutaneous injection because bioavailability for non-injection administration is low and unstable. However, patients often need a multiple daily insulin injection regimen to control basal and postprandial blood glucose, which causes various complications. Controlled pulsatile drug release technology using ultrasound as an external stimulus source is a very promising method to avoid multiple injections of insulin. However, most of the drug-loaded microbubbles used for ultrasound-mediated treatment have a short half-life, which limits their use in controlled pulsatile drug release. More importantly, how to control insulin release is still a challenge. In this paper, chitosan poly-acrylic acid nanobubbles as drug carriers of insulin were prepared to achieve a visually controlled pulsatile release of insulin triggered by focused ultrasound. The experimental results in vivo demonstrated that nanobubbles were stable enough to achieve long-term visualization for 7 days after intramuscular injection in rats. Under the guidance of ultrasound imaging, it is visible to find the position and observe the gray values change of nanobubbles. Thus, when triggered by focused ultrasound, the amount of insulin could be accurately pulsatile released from nanobubbles. In vivo experiments in rats showed that the visually controlled pulsatile release of insulin could be achieved for a long time, up to 3 consecutive days. The blood glucose level could be repeatedly reduced by focused ultrasound irradiation with just one injection. Our research provided a promising way for visually controlled pulsatile release of insulin, which would significantly reduce the injection frequency of insulin.

Time-Action Profile of Technosphere Insulin in Children with Type1 Diabetes.

Technosphere insulin (TI) is aninhaled dry powder ultra-rapid-acting insulin. This report describes the results of the first study of TI in children with type1 diabetes (T1D). Pharmacokinetics (PK) of TI and the effect of TI on circulating glucose concentrations were evaluated in a single-arm study that enrolled children ages 8-17years with T1D for more than 1year, on a stable multiple daily insulin injection (MDI) regimen, and meeting pre-defined pulmonary function testing criteria (at least 70% predicted). To assess PK, subjects received an individualized single preprandial dose of TI (4-12U, in 4-U increments) via oral inhalation, basedon their usual meal-time subcutaneously injected rapid-acting insulin dose and meal content. Serum insulin and blood glucose were measured at -30 to 250min relative to dosing. Twenty-seven children with T1D participated in this single-dose PK study. Mean subject age was 13.3years (59% female; 81.5% White). Meanserum insulin Cmax (maximum concentration) was 77.3, 119.15, and 207.7µU/mL for doses of 4, 8, and 12U, respectively. Tmax occurred at 10.5, 13.9, and 14.6min post-dose for 4, 8, and 12U.Glucose lowering 30-60min post-dose was consistent with the PK profile. Serum insulin rapidly increased post-dose and returned to baseline by 120min. The data suggests the PK of TI in youth with T1D ages 8-17years was similar to that seen in previous adult studies. ClinicalTrials.gov identifier, NCT02527265.

Dual-basal-insulin regimen for the management of dawn phenomenon in children with type 1 diabetes: a retrospective cohort study.

Handling of the dawn phenomenon (DP) with multiple daily insulin injection (MDII) regimen is a real challenge. We aimed to demonstrate the effectiveness of a dual-basal-insulin (a long-acting glargine and an intermediate-acting neutral protamine Hagedorn (NPH)) regimen for the management of DP in children with type 1 diabetes mellitus (T1DM). The primary efficacy outcome was to overcome morning hyperglycemia without causing hypoglycemia during the non-DP period of the night. Retrospective cohort study. Charts of 28 children with T1DM (12 female; 42.8%, mean age 13.7 ± 2.1 years) treated with MDII were retrospectively reviewed. The median duration of diabetes was 4.5 years (range 2-13.5 years). DP was diagnosed using a threshold difference of 20 mg/dL (0.1 mmol/L) between fasting capillary blood glucose at 3 a.m. and prebreakfast. NPH was administered at midnight in addition to daily bedtime (08.00-09.00 p.m.) glargine (dual-basal-insulin regimen). Midnight, 03:00 a.m., prebreakfast and postprandial capillary blood glucose readings, insulin-carbohydrate ratios, and basal-bolus insulin doses were recorded the day before the dual-basal-insulin regimen was started and the day after the titration of the insulin doses was complete. Body mass index standard deviation scores (BMI SDS) at the onset-3rd-12th month of treatment were noted. Before using dual basal insulin, prebreakfast capillary blood glucose levels were greater than those at midnight and at 03:00 a.m. (F = 64.985, p < 0.01). After titration of the dual-basal-insulin doses, there were significant improvements such that there were no statistically significant differences in the capillary blood glucose measurements at the three crucial time points (midnight, 03.00 a.m., and prebreakfast; F = 1.827, p = 0.172). No instances of hypoglycemia were reported, and the total daily insulin per kilogram of body weight did not change. The BMI SDS remained steady over the course of the 1-year follow-up. In this retrospective cohort study, the dual-basal-insulin regimen, using a long-acting glargine and an intermediate-acting NPH, was effective in overcoming early morning hyperglycemia due to insulin resistance in the DP. However, the effectiveness of the dual-basal-insulin regimen needs to be verified by prospective controlled studies using continuous glucose monitoring metrics or frequent blood glucose monitoring.

Diabetes and COVID-19: A Tale of 2 Pandemics.

Diabetes and COVID-19: A Tale of 2 Pandemics.

880-P: Insulin Regimen and Glycemic Control in People with Type 2 Diabetes Mellitus

Type 2 diabetes mellitus (T2DM) is a progressive disease with many patients requiring insulin treatment. Basal insulin (BI) is often added first followed by escalation to a multiple subcutaneous insulin injection (MSI) regimen. However, many patients with T2DM struggle managing the MSI regimen. As a result, their glycemic control remains poor after starting MSI. Our study investigates whether switching back to BI alone would improve glycemic control. Patients with T2DM and A1C ≥9.0% on MSI regimen seen in our clinic over two years were included in this analysis. Main study outcome was the A1C after ≥3 months of switching back to BI as compared to continuing MSI. We found 24 patients who were switched from MSI to BI and compared them with 58 patients who were continued on MSI (see Table). There were no significant differences at baseline between the two groups. On follow-up, the BI group had a mean change in A1C (%) of -1.6 ± 2.0 compared to -0.7 ± 1.5 in the MSI group. In addition, the daily dose of prescribed insulin on follow-up was lower in the BI group at 46 ± 14 units/day compared to 90 ± 70 units/day in the MSI group. Hypoglycemia rates were also lower in the BI group at 12% compared to 20% in the MSI group. We conclude that simplification of insulin regimen may improve A1C and decrease the risk of hypoglycemia in patients poorly controlled on MSI regimen. The improved glycemic control is likely related to improved adherence and lower risk of errors. Disclosure A. Arunachalam: None. R. Garg: None.

399 Simple basal insulin regimen in women with mild gestational diabetes

Approximately 30% to 40% of women with gestational diabetes (GDM) receive insulin therapy, and the multiple daily insulin injection (MDI) regimen with a combination of basal and prandial insulin is generally used, as in cases of prepregnancy diabetes. We developed a simple insulin injection (SII) regimen, in which one or two injected doses of basal insulin are used, for women with mild GDM who require insulin therapy. The present study explored whether or not the SII regimen is as effective as the MDI regimen in preventing fetal macrosomia in women with mild GDM. In this retrospective study, we included singleton pregnant women with GDM in a tertiary perinatal care center. Insulin therapy was indicated if glucose control did not reach the target values under diet therapy. At the beginning of the insulin therapy, we used one daily injection of NPH insulin (10 to 20 units) before breakfast and added another injection of NPH insulin at bedtime, if necessary. If the control still did not reach the target values, we switched to an MDI regimen with additional prandial insulin aspart injection. We compared the glucose control levels, gestational weight gain (GWG), and perinatal outcomes between the diet-alone, SII, and MDI groups. Among 397 women with GDM, 66%, 15%, and 19% were in the diet-alone, SII, and MDI groups, respectively. There were no significant differences in the glucose control, maternal GWG, or perinatal outcomes among the groups (Table). Among the 34% of women with GDM requiring insulin therapy, 44% had a well-controlled condition with the SII regimen without any increase in the GWG or adverse perinatal outcomes. In women with mild GDM requiring insulin therapy, nearly half can maintain good control with this simpler insulin regimen.

Morphometric characteristics of the brain in patients with type 1 diabetes mellitus on diff erent modes of basic bolus insulin therapy

Objective— to study the morphometric characteristics of the brain in patients with type 1 diabetes mellitus (DM) receiving insulin therapy in diff erent modes, taking into account the variability of glycemia.Material and methods.120 patients with type 1 diabetes, living in Tomsk and the Tomsk Region, were examined. All patients were divided into 2 groups: group 1 — patients receiving insulin in the base-bolus regimen of multiple insulin injections (MII), group 2 — using pump insulin therapy by continuous subcutaneous infusion of insulin using a wearable dispenser (CSII). Patients took this therapy for at least 6 months before inclusion in the study. All patients underwent a general clinical examination, testing of cognitive functions using the Montreal scale (MoCA test), continuous monitoring of blood glycemia (CMG) using iPro™ 2 Professional Continuous Glucose Monitoring (Medtronic, USA), FreeStyle Libre (Abbot, USA) in for 14 days, standard magnetic resonance imaging (MRI) on a 1.5 Tesla apparatus in axial, sagittal and coronal projections using T2, TE, T1, and using programs that suppress the signal of free water. We processed the results of MRI using Free Surfer (USA) and recon-all segmentation algorithm. Statistical analysis was performed using the R-system software package.Results.It was found that in both groups with type 1 diabetes there was a decrease in cognitive functions. It has been shown that CSII is associated with the best completion of the MoCA test. In addition, it has been reported that more frequent episodes of diabetic ketoacidosis and increased glycated hemoglobin (HbA1c) are the main causes of cognitive impairment in this group of patients. Changes in the morphometric parameters of the brain are interconnected with glycemic variability.Conclusion.In patients with type 1 diabetes, cognitive impairment associated with acute and chronic hyperglycemia was verifi ed. Morphometric features of brain changes are more dependent on glycemic variability. CSII helps improve cognitive function.

Systems of continuous subcutaneous insulin infusion to maintain metabolic compensation for type 1 diabetes mellitus among children and adolescents

BACKGROUND: Insulin pumps (IP) are a widespread treatment for type 1 diabetes mellitus (T1D) in children because of its several advantages over multiple insulin injection regimens (MII). However, the long-term effectiveness of continuous subcutaneous insulin infusion (CSII) in achieving and maintaining sustained metabolic compensation remains controversial.&#x0D; OBJECTIVE: To determine the factors affecting the long-team effectiveness of CSII in children and adolescents with T1DM in real clinical practice.&#x0D; METHODS: Data of 239 children and adolescents treated with CSII for 3 years were examined during the registration of patients receiving insulin pump therapy in Saint-Petersburg was formed. HbA1с level changes over time were analysed before switching to CSII and were assessed depending on sex and age, baseline HbA1с level and factors as the frequency of using continuous glucose monitoring (CGM), temporary transitions from CSII to MII with injection pens and use of bolus calculators (BC).&#x0D; RESULTS: The final HbA1с value showed no significant changes as compared with the HbA1с level before switching to CSII (baseline, 7.821.46%; final, 7.931.30%). Approximately 42% of patients had HbA1с level of 7.5%. Better results were observed in the 4.57-year age group, where 67% of patients had HbA1с level of 7.5%; in 1218-year age group, only 35% of patients reached the target HbA1с level. Majority of patients with baseline HbA1с level of 7.5% remained within the target level during the final examination, whereas only 23% of patients with HbA1с level of 7.5% before switching to CSII reached the target level. Better glycaemic control was also observed in patients treated with CSII regularly, as compared to patients who periodically switched to MII with the injection pen (p0.05). HbA1с appeared to be lower in the group of 1218-year-old adolescents who used CGM regularly, as compared to the group not treated with CGM (p0.05).&#x0D; CONCLUSION: Children and adolescents treated with CSII for 3 years did not experience a significant improvement in metabolic control. However, the influence of factors in maintaining the metabolic control, such factors as the patients age, initial HbA1с level, CGM use and frequency, and the presence or absence of changes in insulin therapy regimen is observed.

Assessment of type i diabetes mellitus compensation degree in children and adolescents of Perm Krai

Aim. To assess the dependence of carbohydrate metabolism state in children and adolescents with type I diabetes mellitus (DM) in Perm Krai on patients age, disease duration, way of insulin administration (regimen of multiple insulin injections or insulin pump therapy), complications available.&#x0D; Materials and methods. The study enclosed 451 children and adolescents, living in Perm Krai, who were hospitalized for type 1 DM to Endocrine Unit of Regional Childrens Clinical Hospital during 2016-2017. Glycated hemoglobin level (HbA1c), daily insulin requirement, availability and character of complications were assessed in these patients.&#x0D; Conclusions. The state of decompensation more often is connected with the disease duration for more than 5 years and adolescent age. There was detected a feedback between the physical development level and the duration of disease and number of chronic complications. The period of development of type 1 DM chronic complications depends on patients age, sex and compensation of disease. The degree of compensation of the disease is higher when using insulin pump therapy or regimen of multiple injections of ultrashort analogs of insulin in combination with basal analogs.

The role of proper insulin injection technique training FOR achieving of good glycaemic control

Inappropriate injection technique leads to incorrect insulin dosing, increased pain and impaired glucose control in patients with diabetes. This review examines in detail the results of two clinical studies, the Glycemic Impact of Insulin Injection Technique (GIIIT) and the UK Lipo Study (UKLS) that examined the effect of teaching patients proper injection techniques to achieve good glycemic control.&#x0D; The GIIIT study included patients with type 1 and type 2 diabetes (1870 years) who were on a regimen of multiple daily insulin injections. They were categorised into three groups: those that received structured injection technique training using 4-mm injection needles (TN), those that received injection technique training (T) and control (C). The UKLS study included 75 patients who received structured training to reduce the risk of developing lipohypertrophy.&#x0D; Initially, deviations from proper insulin injection technique were observed in a majority of patients in both the studies. In the GIIIT study, 6 months after training under TN and T conditions, HbA1c decreased by 1%, with no observable changes under the C condition. The daily insulin dose was increased by 6 IU in all conditions. Overall, the use of 4-mm short needles reduced post-injective pain in all patients. In the UKLS study, for 6 months, the variability of glycemia and frequency of unexplained hypoglycaemia decreased as the daily dose of insulin decreased by an average 6 IU; in addition, HbA1c level decreased from 8.6% to 8.2%. Six months after the training, both studies noted a decrease in or disappearance of lipohypertrophy in the patients.&#x0D; These results indicate that proper injection technique training improves glycemic control in patients with diabetes.

Efficacy and safety of adding single dose insulin glargine in patients with type 2 diabetes uncontrolled by oral hypoglycemic drugs

Abstract:&#x0D; Unfortunately, a Significant number of type 2 diabetic patients on oral hypoglycemic agents are not achieving the desired and recommended target of glycemic control in terms of reduction of HbA1c and fasting plasma glucose, this is largely because most of them are reluctant to use insulin injections for many reasons, mainly the painful injection, fear of hypoglycemia or inability to adapt to a complex regimen of multiple insulin injections. it has been recommended by many diabetes associations ( the American diabetes association(ADA) and the European association for the study of diabetes(EASD) ), in their algorithm of management of hyperglycemia in patients with uncontrolled diabetes (HbA1c &lt; 7 %) to add a basal ( long acting) insulin to their oral drug regimen as a more simple initial step of adding insulin that is acceptable by most patients and capable of achieving target glycemic levels. insulin glargine is the preferred long acting insulin analogue for its pharmacodynamic properties (peakless action profile with low incidence of hypoglycemia and longer duration of action) , furthermore, its pen formulary makes it less painful than conventional human insulin syringe injections.

САХАРНЫЙ ДИАБЕТ И БЕРЕМЕННОСТЬ. ЧАСТЬ II. ТЕЧЕНИЕ, ТАКТИКА ВЕДЕНИЯ ПАЦИЕНТОВ

Background: diabetes mellitus is one of the most widespread diseases in the world and one of those which lead to complications. One of the factors, which influence the clinical course of diabetes mellitus and its complications is pregnancy. Aim: to study the peculiarities of diabetes mellitus clinical course and its complications in pregnancy as well as the management of diabetes mellitus in pregnant women depending on the gestational age, clinical course of diabetes mellitus and its complications. Material and methods: 34 sources of literature by native and foreign authors on the studied subject have been analyzed. Results: it has been established that the clinical course of diabetes mellitus in pregnancy is labile and contributes to the development of vascular complications in a mother. Strict control of glycaemia, the introduction of a regimen of multiple insulin injections have a positive effect on the clinical course of pregnancy and birth of a healthy child. Conclusion: the application of intensified insulin therapy in pregnant women with diabetes mellitus, improved management and treatment of pregnant women, application of modern technologies have given opportunities to improve pregnancy outcomes in a mother and a child: the frequency of severe forms of gestosis, hydramnion, premature birth, perinatal mortality has decreased.

Acute Mononeuropathy as the first presentation of Pediatric Type 1 Diabetes Mellitus: a case report

Background: Prevalence of neuropathy in Diabetes in the pediatric age group is very low. Moreover, it is often a late complication of diabetes mellitus (DM) and usually related to the duration of diabetes, poor glycemic control and advanced age. We present here an interesting case of motor neuropathy as a first manifestation of Type 1 diabetes in an adolescent. Case presentation: A previously fit fourteen years old girl presented with sudden onset right foot drop. There was a history of osmotic symptoms and weight loss over the preceding last few months before presentation. Investigations revealed Type 1 diabetes mellitus. So, our patient was started on Multiple Daily Insulin Injection Regimen (MDI) as per protocol and the foot drop recovered within a period of two months. Conclusion: Mononeuropathy as a first presentation of diabetes is extremely rare. It is extremely important to assess the blood glucose in patients with peripheral neuropathy. Normalizing blood glucose levels leads to rapid neuronal recovery.

Comparison between a multiple daily insulin injection regimen (basal once-daily glargine plus mealtime lispro) and continuous subcutaneous insulin infusion (lispro) using continuous glucose monitoring in metabolically optimized type 1 diabetes patients: A randomized open-labelled parallel study

Background and objectiveAdvantages of continuous subcutaneous insulin infusion (CSII) over multiple daily injections with glargine (MDI/G) are still uncertain. We compared CSII vs. MDI/G therapy in unselected patients with type 1 diabetes using continuous glucose monitoring (CGSM). The primary end-points were glycaemic control and quality of life (QOL). MethodsA total of 45 patients with long-term diabetes and mean HbA1c values of 8.6±1.8% (70.5±15.4mmol/mol), previously treated with MDI/NPH, were switched to MDI/G for 6 months and then, unfulfilling therapy CSII indication, were randomly assigned to CSII or MDI/G for another six months. We evaluated QOL (EsDqol) and glycaemic control by measuring HbA1c levels, rate of hypoglycaemia, ketoacidosis and CGSM data. ResultsAfter the first phase (MDI/NPH to MDI/G) there was a significant improvement in total EsDQOL (99.72±18.38 vs. 92.07±17.65; p<0.028), a 0.5% decrease in HbA1c values (8.4±1.2 vs. 7.9±0.7% [68±9.7 vs. 63±5.5mmol/mol]; p<0.032), an improvement in glycaemic variability (standard deviation 66.9±14 vs. 59.4±16mg/dl; p<0.05), a decrease in insulin requirements (0.87±0.29 vs. 0.80±0.25U/kg; p<0.049), a decrease in number of severe hypoglycaemia episodes (0.44±0.9 vs. 0.05±0.2; p<0.014), and an increase in periods of normoglycaemia measured with CGSM (15.8±10.9% vs. 23±18.4%; p<0.003). Six months after randomization, significant improvements were seen in the HbA1c (7.9±0.7 vs. 7±0.6% [63±5.5 vs. 53±4.5mmol/mol]; p<0.001) and EsQOL (91.66±22 vs. 84.53±1.63; p<0.045) only in the CSII group. The HbA1c value was significantly lower when compared with the MDI/G group (CSII 7±0.6% [53±4.5mmol/mol] vs. MDI/G 7.6±0.9% [59.6±7.7mmol/mol]; p<0.03). ConclusionsIntensive insulin therapy with CSII vs. MDI/G was associated with better levels of HbA1c in patients with long-term type 1 diabetes.

Comparison between a multiple daily insulin injection regimen (basal once-daily glargine plus mealtime lispro) and continuous subcutaneous insulin infusion (lispro) using continuous glucose monitoring in metabolically optimized type 1 diabetes patients: A randomized open-labelled parallel study

Background and objectiveAdvantages of continuous subcutaneous insulin infusion (CSII) over multiple daily injections with glargine (MDI/G) are still uncertain. We compared CSII vs. MDI/G therapy in unselected patients with type 1 diabetes using continuous glucose monitoring (CGSM). The primary end-points were glycaemic control and quality of life (QOL). MethodsA total of 45 patients with long-term diabetes and mean HbA1c values of 8.6±1.8% (70.5±15.4mmol/mol), previously treated with MDI/NPH, were switched to MDI/G for 6 months and then, unfulfilling therapy CSII indication, were randomly assigned to CSII or MDI/G for another six months. We evaluated QOL (EsDqol) and glycaemic control by measuring HbA1c levels, rate of hypoglycaemia, ketoacidosis and CGSM data. ResultsAfter the first phase (MDI/NPH to MDI/G) there was a significant improvement in total EsDQOL (99.72±18.38 vs. 92.07±17.65; p<0.028), a 0.5% decrease in HbA1c values (8.4±1.2 vs. 7.9±0.7% [68±9.7 vs. 63±5.5mmol/mol]; p<0.032), an improvement in glycaemic variability (standard deviation 66.9±14 vs. 59.4±16mg/dl; p<0.05), a decrease in insulin requirements (0.87±0.29 vs. 0.80±0.25U/kg; p<0.049), a decrease in number of severe hypoglycaemia episodes (0.44±0.9 vs. 0.05±0.2; p<0.014), and an increase in periods of normoglycaemia measured with CGSM (15.8±10.9% vs. 23±18.4%; p<0.003). Six months after randomization, significant improvements were seen in the HbA1c (7.9±0.7 vs. 7±0.6% [63±5.5 vs. 53±4.5mmol/mol]; p<0.001) and EsQOL (91.66±22 vs. 84.53±1.63; p<0.045) only in the CSII group. The HbA1c value was significantly lower when compared with the MDI/G group (CSII 7±0.6% [53±4.5mmol/mol] vs. MDI/G 7.6±0.9% [59.6±7.7mmol/mol]; p<0.03). ConclusionsIntensive insulin therapy with CSII vs. MDI/G was associated with better levels of HbA1c in patients with long-term type 1 diabetes.

Determining in‐patient diabetes treatment satisfaction in the UK—the DIPSat study

To measure in-patient diabetes treatment satisfaction and its relationship to in-patient diabetes care. In a cross-sectional study, diabetes in-patient specialist nurses at 58 UK hospitals asked insulin-treated in-patients with diabetes to complete the recently updated Diabetes Treatment Satisfaction Questionnaire for In-patients and a general questionnaire; 1319 in-patients completed these questionnaires. Satisfaction with the general diabetes treatment items in the Diabetes Treatment Satisfaction Questionnaire for In-patients was high, but there were high levels of extreme dissatisfaction with meal choices, meal quality and lack of similarity of hospital meals to normal domestic choices--23% would never or rarely have made similar meal choices at home. Hyperglycaemia or hypoglycaemia was reported for much of the in-patient stay (20% and 7%, respectively) and 26% reported at least one severe hypoglycaemic episode; these groups had lower satisfaction with the timing of medication in relation to meals (P < 0.003). More frequent in-patient hyperglycaemia or hypoglycaemia were associated with significantly poorer overall satisfaction scores and negative well-being scores (both P < 0.0001). Previous experience of a multiple daily insulin injection regimen was associated with more dissatisfaction than other regimens (P < 0.01). Multiple regression models explained 36% of variability in overall treatment satisfaction, with most (22.4%) accounted for by satisfaction with time spent with a diabetes in-patient specialist nurse (P < 0.0001). Self-administration of insulin was independently associated with higher treatment satisfaction (P < 0.006) in this model. The DIPSat programme describes the complex relationships between diabetes in-patient treatment satisfaction and in-patient diabetes care.

Comparison of a Multiple Daily Insulin Injection Regimen (Glargine or Detemir Once Daily Plus Prandial Insulin Aspart) and Continuous Subcutaneous Insulin Infusion (Aspart) in Short-Term Intensive Insulin Therapy for Poorly Controlled Type 2 Diabetes Patients

Aims. To examine the potential differences between multiple daily injection (MDI) regimens based on new long-acting insulin analogues (glargine or detemir) plus prandial insulin aspart and continuous subcutaneous insulin aspart infusion (CSII) in patients with poorly controlled type 2 diabetes. Methods. Patients (n = 119) with poorly controlled type 2 diabetes of a duration exceeding five years were randomly assigned into three groups: Group A treated with CSII using insulin aspart; Group B treated with glargine-based MDI and Group C treated with detemir-based MDI. Results. Good glycemic control was achieved by patients in Group A in a significantly shorter duration than patients in Groups B and C. Total daily insulin, basal insulin dose and dose per kg body weight in Group A were significantly less than those in Groups B and C. Daily blood glucose fluctuation in Group A was significantly less than that in Groups B and C. There were no differences between Groups B and C. Conclusions. Aspart-based CSII may achieve good blood glucose control with less insulin doses over a shorter period compared with glargine or detemir-based MDI. No differences between glargine- and detemir-based MDI were detected in poorly controlled subjects with type 2 diabetes.

Achieving better outcomes in pregnancies complicated by type 1 and type 2 diabetes mellitus

Background: Pregnancy in type 1 and type 2 diabetes mellitus (DM) is associated with an increased rate of adverse outcomes for both mother and fetus. Objective: This article reviews the data available on achieving better outcomes in pregnancies complicated by DM. Methods: Background materials for this article were gathered based on a PubMed search of English-language articles (up to and including August 2007) using the search terms diabetes mellitus, pregnancy, glycemic control, mortality, and morbidity. This review article was based on a presentation given at a satellite symposium entitled “Realising the Value of Modern Insulins: Reaching Further with Rapid-Acting Insulin Analogues” that was convened during the XIXth World Diabetes Congress, December 3, 2006, in Cape Town, South Africa. Results: There is clear evidence that optimized metabolic control, from preconception through pregnancy, can reduce the risk of maternal and fetal complications in women with DM. The risk of fetal congenital abnormalities in pregnant women with DM is intricately related to the level of glycemic control in early pregnancy; thus, strict metabolic targets as close to normal glycosylated hemoglobin (HbA 1c) (ie, 4.0%–6.0%) as possible are recommended. However, these HbA 1c and postprandial plasma glucose targets are challenging for the physician and the patient. The rapid-acting insulin analogues, insulin aspart and insulin lispro, may be useful because they can reduce postprandial hyperglycemia without increasing the risk for hypoglycemia and even provide a small improvement in HbA 1c compared with regular human insulin. In a recent, prospective, randomized controlled study of pregnant women with type 1 DM (N = 322), maternal hypoglycemia, metabolic control, and tolerability, including perinatal outcomes, were compared between those randomized to mealtime insulin aspart or human insulin. The results from this study suggest that insulin aspart is at least as effective and well tolerated as human insulin in basal-bolus therapy with neutral protamine Hagedorn insulin. Overall, 80% of study participants in both groups achieved HbA 1c levels ≤=6.5% in the second trimester. In addition, insulin aspart was associated with lowered postprandial blood glucose levels, as well as reduced risk of hypoglycemia, suggesting that it may offer clinical advantages in this population. Conclusions: Women with DM who are of reproductive age should be identified as members of a high-risk group. Access to specialized prepregnancy clinics should be made available where their DM can be intensively managed throughout pregnancy by a combined obstetrical/endocrine multidisciplinary team. Use of multiple insulin injection regimens, including use of insulin aspart during pregnancy, is both well tolerated and effective and may offer some benefits with respect to postprandial glycemic control.

Unlocking the opportunity of tight glycaemic control

The long‐term benefits of providing intensive insulin therapy to control blood glucose levels have been demonstrated in people with type 1 or type 2 diabetes mellitus. However, achieving good glycaemic control in clinical practice continues to be a major challenge with only a small proportion of people with diabetes achieving current treatment goals. Some of the reasons for this include ineffectual diet and weight control initiatives, limited efficacy of therapeutic agents or association with excessive adverse events, delayed initiation of insulin therapy and poor patient acceptance and compliance with a regimen of multiple daily insulin injections. New ways of delivering insulin without the need for subcutaneous injections may overcome many of these limitations and thus help in the early adoption of insulin treatment by patients, assist in achieving and maintaining long‐term optimal glycaemic control and improve patients' quality of life.

Dietary management for children and adolescents with diabetes mellitus: personal experience and recommendations.

Diet has traditionally played an important role in diabetic therapy. Over the years, various diets have been proposed, often without scientific evidence. One of the main errors was (is) to speculate that there exists a direct linear correlation between the injection of x units of insulin and the utilization of y grams of glucose. If this were true, one should give more insulin to practice physical activity. In reality, it is the reverse. Dietary recommendations issued over the last few years are the same for diabetic and non-diabetic individuals in order to avoid degenerative diseases. In many countries, the intake of fat is too high, and that of complex carbohydrates too low. The so-called 'Mediterranean diet', in combination with appropriate insulin therapy, may be optimal. This consists mainly of fiber-rich complex carbohydrates (grain), vegetables, fruits, fish, and olive oil. Explanations of this diet should focus on quality rather than quantity of foodstuffs, and should be given by a multidisciplinary team. Prescription of a highly rigid diet has proved ineffective in producing adequate metabolic control, and increases the risk of deviations from the diet. In our experience, the proper use of the two-injection regimen, in countries where the meal schedule allows correct allocation of diet, may lead to 'intensive conventional therapy' and good metabolic control. It is inadequate to systematically assign the multiple-insulin injection regimen to intensified insulin therapy, and the 'conventional' two-injection regimen to a non-intensified insulin therapy. The proper use of the basal-bolus regimen, with increased flexibility in daily life and dietary freedom, cannot always be applied successfully before adolescence. The adjustment of insulin dosage is more complicated than in the twice-daily injection regimen because dose alteration cannot be made only according to sliding scales based on the glycemia measured immediately before the insulin injection. The simplistic use of these non-physiological sliding scales is the main error in the multiple daily insulin injection regimen. The use of fast-acting insulin analogs in the basal-prandial regimen improves post-prandial glycemia at the expense of an increase in pre-prandial glucose levels, if the period between two meals, and therefore two injections, exceeds 3-4 hours, because of the short duration of action. If there are 4-6 or 7 hours between two meals, it is better to use a rapid-acting insulin. Avoid dogmatism--only objective results (good glycosylated hemoglobin and lipid levels, as well as good quality of life) are important.