• Schedules and doses individualized according to blood glucose levels and carbohydrate content of meals
• Blood glucose self-testing
• Before each meal
• Periodically 1–2 hr after meals
• Before or after intensive exercise
• Occasionally at 3 A.M.
• Frequently during illness
• Hemoglobin A_1c (HbA_1c ) measurement twice a year (four times a year if glycemic goals not met; monthly during pregnancy)
• Test for ketoacids in urine or blood during illness
• Anticipated meal carbohydrate intake
• American Diabetes Association goals
• Preprandial capillary whole blood glucose levels: 90–130 mg/dl
• Postprandial peak capillary whole blood glucose levels: < 180 mg/dl
• HbA1c values < 7.0% (nondiabetic range, ~4.0%–6.0%)
• Goals difficult to achieve with current therapeutic tools
• Long-acting insulin to provide 24-hour basal supply, plus short-acting insulin before meals (each = ~50% of average total daily dose)
• Average total daily dose = 0.6–0.7 units per kg body weight
• Insulin requirements increased by weight gain and increased caloric intake and during adolescence, late pregnancy, illness
• Insulin delivery
• Subcutaneous injection in the abdomen
• Produces most consistent absorption rates
• Continuous subcutaneous insulin infusion (CSII) via external pump
• Use rapid-action or regular insulin
• Provides smooth basal delivery and more predictable coverage for meals
• Inhaled insulin
• Can be used for meals together with injected basal insulin
• Contraindicated for smokers and those with lung disease
• Test pulmonary function before initiating and annually thereafter

• Rapid acting
• Regular, crystalline zinc insulin (CZI)
• Onset of action: 0.5–1.0 hr
• Duration of action: 6–8 hr
• Peak action: 2–4 hr
• Inhaled insulin
• Onset of action: 15–30 min
• Duration of action: 6–8 hr
• Peak action: 1.5–2 hr
• Very rapid acting
• Lispro, aspart, glulisine
• Onset of action: 5–15 min
• Duration of action: 4–6 hr
• Peak action: 1–2 hr
• Intermediate acting
• NPH
• Onset of action: 1–2 hr
• Duration of action: 10–14 hr
• Peak action: 4–8 hr
• Long acting
• Detemir
• Onset of action: 2–3 hr
• Duration of action: 9–24 hr
• Peak action: variable modest peak: 6–10 hr
• Glargine
• Onset of action: 1.5–3 hr
• Duration of action: 20–24 hr
• Peak action: no peak

• Adjunct to insulin for patients who fail to achieve glycemic control with insulin alone
• Inject subcutaneously before meals
• Dose: 15 µg initially, titrate upward as necessary to 30–60 µg
• Reduce preprandial insulin by 50% initially

• Diet controlled for carbohydrate intake and tailored to activity levels
• Exercise regimen to maintain lean muscle mass

• Ketoacidosis
• Caused by insulin deficiency resulting in extremely high plasma glucose and ketoacid levels
• Symptoms: nausea; vomiting; dehydration; hyperventilation; depressed mentation or decreased consciousness
• Treatment: 0.9% saline I.V. immediately for volume repletion; potassium repletion; rapid-acting insulin, 0.1–0.15 U/kg S.C. q. 1–2 hr, after serum potassium rises to 4.0 mEq/L, if below normal initially
• Hypoglycemia
• Caused by missed meals, insulin dosage errors, exercise, alcohol, drugs
• Symptoms: palpitations, tremulousness, anxiety, sweating, blurred vision, dizziness; can cause confusion, seizures, coma
• Treatment: simple carbohydrates p.o.; glucagon, 1 mg S.C. or I.M.

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Best References

American Diabetes Association: Diabetes Care 29(suppl 1):S4, 2006 [PMID 16373931]

Diabetes Control and Complications Trial Research Group: N Engl J Med 329:977, 1993 [PMID 8366922]

Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Diabetes Care 26(suppl 1):S5, 2003 [PMID 12502614]

Hirsch IB: Am Fam Physician 60:2343, 1999 [PMID 10593324]

Umpierrez GE, et al: Diabetes Care 27:1873, 2004 [PMID 15277410]

February 2007