Insulin Treatment Update
Stuart J. Brink
New England Diabetes and
Endocrinology Center, Waltham, MA and Tufts University School of Medicine,
Boston MA, USA
Insulin treatment has been revolutionized by adapting DCCT goals,
utilizing new blood glucose monitoring advances, applying multidose
intensified insulin regimens, pumps & analogs. The DCCT established the
importance of overall glycemic control to decrease or prevent long term
hyperglycemia complications. Studies in Australia, England, Belgium,
Germany & Sweden document
the importance of improving control even in the very young but always with
caveats about also minimizing hypoglycemia. Hemoglobin A1c testing
standardized vs DCCT provides a means of stratifying risks. Goals for
keeping A1c <8% & perhaps <7% demand individualized treatment,
ongoing education, parental involvement and ongoing adjustment. Advances in
blood glucose monitoring allow more accurate, less painful home/school
monitoring but adds expense. New monitors allow microliter sampling of
capillary blood as well as interstitial monitoring. Continuous and soon,
noninvasive monitoring brings us closer toward a goal of semi-automatic
insulin delivery systems or implantable mechanical artificial pancreases.
Insulin algorithms using rapid acting analogs (Humalog® & Novolog®)
improve post-prandial glycemia & decrease hypoglycemia. Overlapping doses of either NPH (or
lente) insulins with analog bolus algorithms or inhaled insulin (Exubera®)
mimic insulin pump treatment. Longer-lasting insulin analogs (Lantus® &
Detimer®) with fewer insulin peaks offer better basal insulin delivery with
decreased nocturnal hypoglycemia. Knowledge about carbohydrate counting
promotes flexibility, active sports participation & more physiologic
insulin balance when used in a multidsiciplinary individualized approach.
Education empowering the child, teen & family to reach daily pre and
postprandial glycemic targets, A1c goals & better psychosocial
adjustment to long term diabetes mellitus demands can be adopted in all
parts of the world with the prediction that short and long term diabetes
associated complications will drastically be reduced.