Use Of Regular Insulin Research Articles

Chinese herbal medicine decreases incidence of hepatocellular carcinoma in diabetes mellitus patients with regular insulin management.

Type 2 diabetes mellitus (DM) is an independent risk factor for hepatocellular carcinoma (HCC), while insulin is a potent mitogen. Identifying a new therapeutic modality for preventing insulin users from developing HCC is a critical goal for researchers. To investigate whether regular herbal medicine use can decrease HCC risk in DM patients with regular insulin control. We used data acquired from the Taiwanese National Health Insurance research database between 2000 and 2017. We identified patients with DM who were prescribed insulin for > 3 months. The herb user group was further defined as patients prescribed herbal medication for DM for > 3 months per annum during follow-up. We matched the herb users to nonusers at a 1:3 ratio according to age, sex, comorbidities and index year by propensity score matching. We analyzed HCC incidence, HCC survival rates, and the herbal prescriptions involved. We initially enrolled 657144 DM patients with regular insulin use from 2000 to 2017. Among these, 46849 patients had used a herbal treatment for DM, and 140547 patients were included as the matched control group. The baseline variables were similar between the herb users and nonusers. DM patients with regular herb use had a 12% decreased risk of HCC compared with the control group [adjusted hazard ratio (aHR) = 0.88, 95%CI = 0.80-0.97]. The cumulative incidence of HCC in the herb users was significantly lower than that of the nonusers. Patients with a herb use of > 5 years cumulatively exhibited a protective effect against development of HCC (aHR = 0.82, P < 0.05). Of patients who developed HCC, herb users exhibited a longer survival time than nonusers (aHR = 0.78, P = 0.0001). Additionally, we report the top 10 herbs and formulas in prescriptions and summarize the potential pharmacological effects of the constituents. Our analysis indicated that Astragalus propinquus (Huang Qi) plus Salvia miltiorrhiza Bunge (Dan Shen), and Astragalus propinquus (Huang Qi) plus Trichosanthes kirilowii Maxim. (Tian Hua Fen) were the most frequent combination of single herbs. Meanwhile, Ji Sheng Shen Qi Wan plus Dan Shen was the most frequent combination of herbs and formulas. This large-scale retrospective cohort study reveals that herbal medicine may decrease HCC risk by 12% in DM patients with regular insulin use.

743: EVALUATION OF REGULAR INSULIN 10 UNITS VERSUS 5 UNITS FOR THE TREATMENT OF HYPERKALEMIA

Introduction: Hyperkalemia is a common problem faced in the intensive care unit (ICU) and emergency department. Traditionally, regular insulin 10 units IV has been used in combination with dextrose to shift potassium intracellularly to prevent cardiac abnormalities. Available literature supports the use of different insulin regimens based on a patient’s weight, renal function, and diabetes status. Currently, our institution has a hyperkalemia order set that includes varying regular insulin doses, dextrose, and scheduled lab draws for potassium and glucose. The purpose of this study was to compare the efficacy and safety of regular insulin 5 units and 10 units for the treatment of hyperkalemia. Methods: This was a single-center, retrospective, cohort study of ICU and emergency department patients who received regular insulin 10 units or 5 units IV push for hyperkalemia treatment. The primary outcome was the decrease in potassium in mmol/L after insulin administration. Secondary outcomes included the incidence of hypoglycemia, rate of order set utilization, and incidence of inappropriate omission of dextrose. Results: Forty-three patients were included in the study, with 21 receiving 10 units and 22 receiving 5 units. Patients who received 5 units of insulin had worse renal function (serum creatinine 5.6 mg/dL vs 3.5 mg/dL) and lower glucose values prior to insulin (glucose 133.7 mg/dL vs 184.8 mg/dL) compared to those who received 10 units. Both groups had similar potassium levels upon presentation, 6.19 mmol/L in insulin 5 unit group compared to 6.20 mmol/L in the 10 unit group. Average decrease in potassium levels was 1.1 mmol/L with 5 units and 1.0 mmol/L with 10 units. Two patients in each group experienced hypoglycemia after insulin administration. Both groups had similar rates of dextrose orders omitted and need for additional units of insulin within 24 hours. Conclusions: The potassium lowering effects were not different between groups based on the units of insulin received. Regular insulin 10 units did not result in a higher incidence of hypoglycemia or a need for less additional insulin orders. This study demonstrated that the use of regular insulin 5 units had similar outcomes compared to the use of 10 units for the treatment of hyperkalemia.

Subcutaneous regular insulin use for the management of diabetic ketoacidosis in resource limited setting.

The standard recommendation of insulin therapy for patients with DKA is the administration of slow continuous intravenous (IV) regular insulin. Currently subcutaneous insulin is being recommended as an alternative treatment of DKA in mild and moderate cases in resource-limited settings. The purpose of this study was to assess the effectiveness and safety of six-hourly subcutaneous regular insulin use for the treatment of DKA among children with type one diabetes mellitus. A retrospective cohort study was conducted among 224 DKA episodes which occurred in 161 children who were treated at St. Paul's Hospital Millennium Medical College in Addis Ababa, Ethiopia, from November 2015 to November 2020. Majority (68.8%) of the episodes occurred in newly diagnosed cases. The median time for urinary ketones clearance was 24h. DKA severity was found to be the only significant predictor of time to DKA resolution. Only 13 (5.8%) were treated at the pediatric intensive care unit (PICU), and 27 (12.1%) developed complications during management. No death or neurological complications observed. The six-hourly subcutaneous regular insulin use was found to be safe and effective alternative to slow IV insulin infusion for the treatment of DKA in a non PICU setting. As it resulted in minimum morbidity and no mortality, we recommend its use in the treatment of DKA irrespective of its severity. It can also decrease the health care cost and patients' inconvenience.

Clinical Experience with U-500 Regular Insulin by Multiple Daily Injections and Continuous Subcutaneous Insulin Infusion.

The effectiveness of U-500 regular insulin was assessed in patients with type 2 diabetes who were previously treated with U-100 insulin. A retrospective chart review was conducted on all patients who were prescribed U-500 insulin between January 2012 and December 2013. The primary outcome measure was change in glycosylated hemoglobin (A1C) 1 year after switching from U-100 insulin to U-500 regular insulin. Secondary outcomes included change in body weight, total daily insulin dose, number of daily injections, and episodes of hypoglycemia. Sixty-six patients met inclusion criteria: U-500 regular insulin via multiple daily injections (MDI; n = 36) or continuous subcutaneous insulin infusion (CSII; n = 30). The A1C in patients using MDI decreased by 1.8%, whereas patients using CSII experienced an A1C decrease of 0.63% after 1 year of U-500 regular insulin use. There was an increase of 3.1 + 0.73 kg in body weight in both the MDI and CSII groups, which was significant (P < 0.001). Confirmed hypoglycemia with a blood glucose of 51-70 mg/dL occurred in 51 patients (77%), but there were no episodes of severe hypoglycemia requiring treatment assistance. The use of U-500 regular insulin in MDI and CSII patients can improve glycemic control, and it does not increase the frequency of hypoglycemia when compared with U-100 insulin hypoglycemic incidence reported in the literature.

Knowledge of inpatient diabetes among sixth-year medical students

Results 82% of students performed the initial management of acute coronary syndrome correctly. However, only 68% of them hit the proper management of diabetes in the same patient, 18% of students opted for the maintenance of oral antidiabetic during hospitalization. In another patient assessed with COPD only 23% of students indicated insulin properly, another 43% recommended the sole use of regular insulin in sliding scale for diabetes management and about 36% did not initiate any form of treatment. Hyperglycemia in patients not known to have diabetes is less likely to be recognized.

Assessment of satisfaction, impact and emotional stress in elderly diabetics without satisfactory control of disease

Materials and methods We performed a historical case-control study of diabetic patients in the Endocrinology Department of a Brazilian tertiary hospital who were treated between June and December 2014. We include patients over 60 yrs. of age, of both sexes, with HbA1c ≥ 8.5% using oral hypoglycemic agents and insulin. Patients were submitted to BPAID (Problems Ares in Diabetes – Brazil) and DQOL (Diabetes Quality of Life) questionnaires, both validated in Portuguese. The first evaluates emotional stress related to DM in 20 questions. On the second, we use the variables “impact” and “satisfaction” to evaluate quality of life. There were 33 issues. We divided the patients into two groups, according the mean of score BPAID (39.45). There are no pre-defined cutoff point for this BPAID questionnaire. The higher the final score, the greater the stress related to DM. Results Forty-five patients were included. There were no differences between the groups for age, gender, education, race, religion, smoking and alcohol. There was no difference in HbA1c (10.75% vs. 9.98%, p=0.09) in the moment of interview. However, the HbA1c levels was greater in the year preceding study in patients with the worst stress scores (10.87% vs. 9.31%, p=0.023). Number of medicines used, dose of Insulin UI/kg, number of daily insulin injections or use of Regular insulin, weight, presence of hypoglycemia, blood pressure levels, or presence of chronic complications associated were not different. Patients with higher levels of stress presented greater negative impact of diabetes on quality of life compared to patients with lower levels of stress (p<0.001). Results were similar with respect to the degree of satisfaction (p<0.001).

U-500 Regular Insulin Use in Hospitalized Patients

U-500 is a potent insulin used in patients with severe insulin resistance. This study aimed to describe the inpatient insulin requirements, insulin regimens, and glycemic control of hospitalized patients using U-500. A retrospective chart review of adult patients using U-500 insulin at home who were admitted to Cleveland Clinic hospitals between 2001 and 2011 was performed. Two groups were compared: those who were given U-500 while hospitalized (Group A) and those who were switched to a different insulin regimen (Group B). The percentages of hypoglycemia days and hyperglycemia days were calculated as the number of days with the respective event divided by the length of stay (LOS) in days for each patient. There were 61 patients, 59% of which were male, with a median body mass index (BMI) 38.4, age 60.8 years, hemoglobin A1c 8.9% or 74 mmol/mol, and LOS 5.0 days. The majority (66%) remained on a U-500-based insulin regimen, while the rest were switched to a combination of long-, intermediate-, short- and/or fast-acting insulin. The endocrinology service was consulted for 61% of patients. Glucose levels were not significantly different between the 2 groups. Group B was given less insulin in the hospital compared to their home regimen. Group A had more frequent hypoglycemia days (mean ± SD: 15.3 ± 21.3 vs. 2.8 ± 6.4%) and more frequent severe hyperglycemia days (16.8 ± 21.8 % vs. 6.3 ± 9.8%) than Group B. This study suggests that there is a subset of patients on U-500 at home who might be managed on conventional insulin in the hospital. Patients who remain on U-500 in the hospital tend to continue with a high insulin dose requirement, which might predispose them to more frequent hypoglycemia.

Association between antidiabetic drugs and psoriasis risk in diabetic patients: Results from a nationwide nested case-control study in Taiwan

The risk of psoriasis in diabetic patients has rarely been explored. We sought to investigate the association between antidiabetic therapies and psoriasis. The incidence of psoriasis was compared between a representative diabetic cohort and a matched nondiabetic cohort. We next conducted a nationwide cohort study with 1,659,727 diabetic patients using the National Health Insurance Research Database of Taiwan 1997 through 2011. Multivariate conditional logistic regression was used for nested case-control analyses. Incidence rates of psoriasis among diabetic patients and nondiabetic matched control subjects were 70.2 (95% confidence interval [CI] 59.5-80.9) and 42.3 (95% CI 39.5-45.5) per 100,000 person-years, respectively (P < .0001). Frequent insulin use was associated with higher risk of incident psoriasis (adjusted odds ratio 1.29, 95% CI 1.18-1.42) after adjusting for comorbidities, disease duration, and number of hospital visits. Among diabetic patients without history of insulin use, frequent use of thiazolidinedione was associated with lower risk of psoriasis (adjusted odds ratio 0.87, 95% CI 0.77-0.99). The National Health Insurance Research Database did not contain information regarding disease severity, diet, body mass index, lifestyle, or family history. Among diabetic patients, regular insulin use is associated with psoriasis development. Frequent use of thiazolidinedione may be associated with modest reduction in psoriasis risk.

Increased Glycemic Variability Is Independently Associated With Length of Stay and Mortality in Noncritically Ill Hospitalized Patients

OBJECTIVETo investigate the association between glycemic variability (GV) and both length of stay (LOS) and 90-day mortality in noncritically ill hospitalized patients.RESEARCH DESIGN AND METHODSThis study retrospectively analyzed 4,262 admissions to the general medicine or surgery services during a 2 year period. Patients with point-of-care glucose monitoring and a minimum of two glucose values per day on average were selected. GV was assessed by SD and coefficient of variation (CV). Data were analyzed with linear and logistic multivariate regression analysis in separate models for SD and CV. Analysis was performed with generalized estimating equations to adjust for correlation between multiple admissions in some individual cases.RESULTSAfter exclusions, 935 admissions comprised the sample. Results of adjusted analysis indicate that for every 10 mg/dL increase in SD and 10–percentage point increase in CV, LOS increased by 4.4 and 9.7%, respectively. Relative risk of death in 90 days also increased by 8% for every 10-mg/dL increase in SD. These associations were independent of age, race, service of care (medicine or surgery), previous diagnosis of diabetes, HbA1c, BMI, the use of regular insulin as a sole regimen, mean glucose, and hypoglycemia occurrence during the hospitalization.CONCLUSIONSOur results indicate that increased GV during hospitalization is independently associated with longer LOS and increased mortality in noncritically ill patients. Prospective studies with continuous glucose monitoring are necessary to investigate this association thoroughly and to generate therapeutic strategies targeted at decreasing GV.

Lower rate of cardiovascular complications in patients on bolus insulin analogues: a retrospective population-based cohort study.

BackgroundFew studies are available evaluating the impact of rapid-acting insulin analogues on long-term diabetes outcomes. Our aim was to compare the use of rapid-acting insulin analogues versus human regular insulin in relation to the occurrence of diabetic complications in a cohort of diabetic patients through the analysis of administrative databases.MethodsA population-based cohort study was conducted using administrative data from four local health authorities in the Abruzzo Region (900,000 inhabitants). Diabetic patients free of macrovascular disease at baseline and treated either with human regular insulin or rapid-acting insulin analogues were followed for a maximum of 3 years. The incidence of diabetic complications was ascertained by hospital discharge claims. Hazard ratios (HRs) and 95% CIs of any diabetic complication and macrovascular, microvascular and metabolic complications were estimated separately using Cox proportional hazard models adjusted for patients’ characteristics and anti-diabetic drug use. Propensity score matching was also used to adjust for significant difference in the baseline characteristics between the two treatment groups.ResultsA total of 2,286 patients were included: 914 receiving human regular insulin and 1,372 rapid-acting insulin analogues. During the follow-up, 286 (31.3%) incident events occurred in the human regular insulin group and 235 (17.1%) in the rapid-acting insulin analogue group. After propensity score-based matched-pair analyses, rapid-acting insulin analogues users had a HR of 0.73 (0.58–0.92) for any diabetes-related complication and HRs of 0.73 (0.55–0.93) and 0.55 (0.32–0.96) for macrovascular and metabolic complications respectively, as compared with human regular insulin users. No difference between the two groups was found for microvascular complications.ConclusionsOur findings suggest that the use of rapid-acting insulin analogues is associated with a lower risk of cardiovascular and metabolic complications compared with human regular insulin use.

Sliding Scale Insulin—Time to Stop Sliding

IN MOST TEACHING HOSPITALS IN THE UNITED STATES, PRImary care first-year residents and medical students learn about sliding scale insulin (SSI), usually from a senior resident. The more experienced resident explains how to prescribe regular insulin every 4 to 6 hours without any scheduled basal or mealtime (prandial) insulin. For the typical patient who is too sick to eat, this results in a roller coaster effect on blood glucose variability due to poor matching of insulin with individual blood glucose patterns. Unfortunately, for the patient who is able to eat, insulin scheduled to be administered based on a bedside capillary glucose measurement is actually administered long after the meal is consumed. Although there are often challenges with hospital logistics in terms of timing of insulin administration in relation to actual food intake, the SSI orders typically do not mention the relationship of the insulin injection as it pertains to a meal, even though at one time, the resident was taught that regular insulin is mealtime insulin. Even worse, SSI, as used here, does not account for the basic principles of insulin therapy. Certainly, SSI has evolved considerably since first described by Joslin more than 70 years ago. For decades, insulin doses were based on the amount of glycosuria (fractional urine glucose testing) for both inpatient and outpatient settings. Although glycosuria is no longer used for this indication, there is still the fundamental problem of clinicians and even health care systems having nonstandardized definitions of SSI. Usually, SSI involves use of regular insulin or a rapid-acting insulin analogue provided without any other scheduled short-acting or long-acting insulin, but there are variations. For example, in one recent study, SSI was defined as regular insulin provided prior to meals and at bedtime based on bedside blood glucose testing or every 6 hours for the patient who is not eating. Both clinicians and patients often refer to the use of SSI as the addition of insulin to previously scheduled prandial insulin. So how can the merits or inadequacies of SSI be discussed when they cannot even be defined? Strategies that do not mimic normal insulin secretion (nonphysiologic regimens such as basal insulin at bedtime only) can also result in different patient outcomes based on the type of diabetes. With the more common type 2 diabetes mellitus manifested by insulin resistance and relative insulin deficiency, long periods of insulin deficiency or even insulin stacking (when insulin doses are injected at times too close together, resulting in an overlap of action of the insulin) will usually not result in any metabolic crisis. However, in patients with type 1 diabetes mellitus, who generally are not resistant to insulin and have complete insulin deficiency, SSI is more apt to result in clinically significant hyperglycemia, ketosis, ketoacidosis, or hypoglycemia. No data are available for how often this happens but experienced clinicians have observed this repeatedly over the years. Perhaps the lack of major clinical crises when SSI is used in type 2 diabetes mellitus helps to fuel its acceptance in our medical culture. Surprisingly, there are not more clinical trials assessing the efficacy and safety of SSI. One randomized controlled trial reported superior glycemic control of a more physiologic basal-bolus (replacing both background and mealtime) insulin therapy compared with SSI, but the SSI group received a much lower dose of daily insulin (12.5 U/d vs 42 U/d for basal-bolus), potentially biasing the results. Nevertheless, inpatient diabetes therapy has gained interest this decade due to both interventional and observational studies, suggesting that hyperglycemia in hospitalized patients can result in deleterious outcomes. There is also increasing literature to support that hypoglycemia in the inpatient setting, especially for critically ill patients, is more dangerous than originally appreciated. Appropriate insulin nomenclature includes 3 components: basal insulin (inhibits hepatic glucose production overnight and between meals), prandial (also called bolus or mealtime) insulin (promotes glucose disposal into muscles from food consumption), and correction-dose insulin. This latter component is often confused with SSI, yet it is quite different. Correction-dose insulin is usually administered as an addition (or supplement) to the usual dose of mealtime insulin as a specific algorithm based on total daily dose of insulin or patient weight. SSI is defined (for the purpose of this Commentary) as it is used in the traditional sense: an

Standardization as a Mechanism to Improve Safety in Health Care

A growing body of literature shows that when patterns of care are widely divergent, clinical outcomes suffer and, as a result, safety may be compromised. A multispecialty group at Luther Midelfort, Mayo Health System (LM, MHS) initiated efforts to reduce variance in the clinical practice patterns of providers. The pilot initiative, which entailed standardization of a sliding-scale insulin protocol, served as a template throughout the LM, MHS for reducing variance and enhancing safety. A single sliding-scale insulin protocol for regular insulin use in appropriate patients was intended to decrease the number of hypoglycemic events. A six-week comparison revealed that in the protocol-driven standardized sliding-scale insulin group, two episodes of hypoglycemia occurred in 134 dosages administered versus 20 hypoglycemic events in 519 dosages administered in the traditional group (1.49 versus 3.85%, p < .04). Subsequent 30-month data months revealed a reduction in hypoglycemic episodes from 2.95% to 1.1%. A reconciliation of medications initiative focused on clarifying, correcting, and specifying the medications patients were consuming at different intervals of their hospitalization and then amending the data in the medical record. In a seven-month chart audit, errors per 100 admissions decreased from 213 to fewer than 50 errors. Standardization efforts to increase uniformity of practice are worth considering in other practice areas to increase safety and possibly reduce costs.

Maternal metabolic control and perinatal outcome in women with gestational diabetes treated with regular or lispro insulin: comparison with non-diabetic pregnant women

Objective: To compare maternal glucose levels and neonatal outcome, achieved in women with gestational diabetes (GDM) receiving either regular insulin or insulin lispro, with those of a control group of non-diabetic pregnant women. Study design: We enrolled 49 pregnant women with GDM, randomly allocated to the treatment with either insulin lispro ( n=25) or regular insulin ( n=24), and 50 pregnant women with normal GCT, matched for age, parity, pre-pregnancy weight and BMI, who formed the control group. All the women were caucasian, non-obese, with a singleton pregnancy and delivered term live born infants. Women of both groups were requested to perform a blood glucose profile (consisting of nine determinations: fasting/pre-prandial, 1 and 2 h post-prandial) every week from the time of diagnosis to 38 weeks (study subgroups) or every 2 weeks from 28 to 38 weeks’ gestation (control group). Results: Overall pre-prandial blood glucose values in diabetic women were significantly higher than those of controls; at the 1 h post-prandial time point, blood glucose values of GDM women receiving insulin lispro were similar to those of controls, whereas in the regular group they were significantly higher. Overall, both the lispro and regular insulin obtained optimal metabolic control at the 2 h post-prandial time point, although near-normal blood glucose levels 2 h after lunch could be observed only in the lispro group. There were no statistically significant differences between the groups in neonatal outcome and anthropometric characteristics; however, the rate of infants with a cranial–thoracic circumference (CC/CT) ratio between the 10th and the 25th percentile was significantly higher in the group treated with regular insulin in comparison to the lispro and control groups. Conclusions: Fasting/pre-prandial and 1 h post-prandial maternal blood glucose levels in non-diabetic pregnant women fell well below the currently accepted criteria of glycemic normality in diabetic pregnancies. In women with GDM, the use of insulin lispro enabled the attainment of near-normal glucose levels at the 1 h post-prandial time point and was associated with normal anthropometric characteristics; the use of regular insulin was not able to blunt the 1 h peak post-prandial response to a near-normal extent and resulted in infants with a tendency toward the disproportionate growth. Insulin lispro can be regarded as a valuable option for the treatment of gestational diabetes.

Relato de um paciente brasileiro com síndrome de Wolfram

To report a case of a patient diagnosed with Wolfram Syndrome and brachydactyly type E. Wolfram Syndrome is characterized by the presence of diabetes mellitus, diabetes insipidus, atrophy of the optic nerve, alterations of the urinary tract, deafness and neurologic and psychiatric disorders. However, not all manifestations are present at diagnosis, indicating the necessity of long-term follow-up of these patients. This long-term follow-up should be extended to the patients' closest relatives, having in mind the increased risk of occurrence of psychiatric disorders and diabetes mellitus among the heterozygous carriers of Wolfram Syndrome. Male, white patients, only child of non-consanguineous parents, was healthy until four years of age, when he presented with polydipsia and polyuria, being diagnosed with diabetes mellitus type I. Since then, he has needed regular insulin use, but has followed an inadequate diet due to socioeconomic problems. He was evaluated by the genetic service when he was 11 years old. Brachydactyly was observed on physical examination. In the course of the complementary investigation, bilateral atrophy of the optic nerve was observed; the visual evoked potential and the electroretinogram were compatible with extensive optic nerve injury. Both retinas were normal. The presence of insulin-dependent diabetes mellitus together with atrophy of the optic nerve is a sufficient criterion for the diagnosis of Wolfram Syndrome. The molecular investigation confirmed the diagnosis of Wolfram Syndrome. The aim of the present report is to alert physicians about the association between diabetes mellitus and monogenic syndromes, such as Wolfram Syndrome.

Profile of patients with diabetes type 1: insulinotherapy and self-monitoring

A study carried out in Londrina - PR, with the cohort of local patients from Brazilian Study on the incidence of Diabetes Mellitus Type 1 (EDID). To know the insulin treatment and the plan for glycemic self-monitoring used by these patients; to verify their knowledge as for what they consider the optimization of these parameters and limitations of use. A survey was conducted with objective questions to 63 patients of the cohort. The average age was 13 years, without gender predominance. It was verified that most of the patients, 79.36%, (n=50) took at least 2 daily applications of insulin. All of them used insulin NPH in one (n=13) or two (n=50) doses. The use of regular insulin, in variable programs, was associated to the NPH in 41.27% (n=26) of the patients (The most frequent insulin type used was human 53.97% (n=34). Of the patients not making use of human insulin, 44.83% (n=13) considered it of high cost and 95.24% (n=60) would make use of it if it was distributed by the Government Unified Health System. As for the monitoring, 63.40% (n=40) took the tests up to 7 times a week, 20.63% (n=13) from 15 to 21 and only 1 patient from 29 to 35 tests. The high cost was the reason for 48.21% (n=27) not to take the tests; 58.73% (n=37) would take the test in the blood and 33.33% (n=21) either in the blood or in the urine if they were given the reactive ribbons. In this cohort of patients, although the human insulin is already adopted as the use of choice, the outline insulin treatment plan is still traditional and the monitoring is far behind the ideal.

Phases of functional, near-normoglycaemic insulin substitution: what are computers good for in the rehabilitation process in type I (insulin-dependent) diabetes mellitus?

We have divided the rehabilitation process in patients with insulin-dependent diabetes mellitus into the following four phases. The basic phase, the so-called ‘phase 0’, provides information about literature, different strategies of treatment and introduces the use of regular insulin as well as blood sugar self-monitoring. During the ‘phase 1’ (i.e. ‘diabetes education common sense’) all the initial information from ‘phase 0’ will be used practically and discussed in depth. After the patient's actual insulin need (U/24 h) has been estimated, initial algorithms for functional insulin use can be defined. And this is the turning point to ‘phase 2’ of the group rehabilitation process, the so-called education in functional insulin use. Initial algorithms should be understood as a preliminary answer to the patient's questions, ‘What is my basal insulin need?’, ‘How much insulin do I need for a particular amount of carbohydrates?’, and ‘What is the hypothetical response of my blood glucose to a particular amount of insulin?’. These algorithms are going to be used and optimised now by the patient (under the supervision of the physician) during the so-called ‘insulin games’ (fasting or 24 h, experimental violation of traditional dietary rules, etc.) to demonstrate (1) how to influence actual glycaemia through immediate correction of blood sugar off blood sugar target (primary adjustment of insulin dosing), and (2) how to optimise algorithms for insulin use (secondary insulin adjustment) in future conditions of different insulin sensitivity. The ‘phase 3’ of individual teaching is an ongoing process of updating the patient's knowledge and practical skills. All these phases (0–3) usually require about 40–50 h of (group) teaching. Functional insulin substitution was proposed for 340 type I diabetic patients. The mean glycosilated haemoglobin decreased to the upper limit of normal range in out-patients under the condition of free diet and remains still in this range despite low frequency of acute complications (Diabetologia 30 (1987) 47–48; p < 0.0001 vs. initial values). Computers are used for experimental purposes in all these phases of the rehabilitation process: (1) for the initial (programmed) information (‘phase 0’), (2) for estimation of initial algorithms (‘phase 1’), (3) as a training computer in the blood sugar simulation process (‘phase 2’), and (4) for statistical evaluation of out-patients' clinical data and for up-dating the patient's knowledge (‘phase 3’), as an ‘artificial diabetes counsellor’. However, computers are still not used by the patient on a routine basis at present.