Intensified insulin therapy

M/sce/Zaneows-Allergic reactions. Sodium retention and edema may occur, particularly if previously poor metabolic control is improved by intensified insulin therapy. Antibody production. 

Heller SR, Amiel SA, Mansell PU.K. Lispro Study Group. Effect of the fast-acting insulin analogue lispro on the risk of nocturnal hypoglycemia during intensified insulin therapy. Diabetes Care 1999 22(10) 1607-11. 

Gale EA. A randomized, controlled trial comparing insulin lispro with human soluble insulin in patients with Type 1 diabetes on intensified insulin therapy. The UK Trial Group. Diabet Med 2000 17(3) 209-14. 

Hirsch IB. Intensifying insulin therapy in patients with type 2 diabetes mellitus. Am J Med. 2005 118(suppl 5A) 21S-26S. 

Jacqueminet S, Masseboeuf N, Rolland M, et al. Limitations of the so-called intensified insulin therapy in type 1 diabetes mellitus. Diabetes Metab. 2005 31 4S45-4S50. 

The importance and need for intensified insulin therapy in the treatment of insulin-dependent diabetes, however, seems to be not yet fully settled, despite the fact that nearly all clinical studies that compared CSII and/or... 

An improved metabolic control with intensified insulin therapy compared with a conventional treatment was reported by Wolf et al. (1987). A continuous insulin infusion with insulin pump therapy, monitored over 1 year, however, did not exhibit a clear advantage. The management of even preschool children with insulin pump therapy was not associated with an increased frequency or an accelerated rate of development of ketosis (Flores et al., 1984 Brambilla et al., 1987). However, Marshall et al. (1987) reported more abscesses and ketoacidosis in children on CS1I, and an increased risk of developing cutaneous infections was also noted in patients treated by CSII in the Oslo Study (Dahl-Jorgensen et al., 1985). 

No additional effects of intensified insulin therapy were noted with regard to circulating lipids and lipoprotein values (Goldberg et al., 1985), but others reported an increase in HDL cholesterol and apolipoprotein A-l, without changes in serum triglycerides as a result of intensified conventional insulin therapy (ICIT) (Wilson et al., 1985). 

Intensified insulin therapy, started before conception in insulin-dependent women, resulted in normalized blood glucose levels in 88% cases compared with 20% in conventional treatment. The rate of congenital malformation was reduced from 7.1% to 1.1% (Fuhrmann, 1986). 

This chapter deals first with the therapeutic use of insulin and its analogues in TIDM as well as different ways of insulin administration, that is, by conventional intensified insulin therapy with multiple injections (MDl), pump treatment (CSII) and inhalation (INHI). 

Conventional Intensified Insulin Therapy or Multiple Daily Insulin Injections (MDI)... 

In conventional intensified insulin therapy (MDI) using the basal-bolus approach with MDI, continuous basal insulin supply is obtained by once- or twice-daily subcutaneous injections of longer-acting preparations, supplemented by mealtime injections of more rapid-acting formulations. 

What insulin therapy would you consider for AJ to intensify her glucose control ... 

Next to the insulin pump, intensified conventional insulin therapy is the most effective way of imitating the homoeostatic regulation of blood glucose levels by means of several daily injections of clear insulin before meals and basal insulin to suppress gluconeogenesis during the night. 

Buysschaert et al. (1983) reported a better glycaemic control of totally insulin-dependent diabetic patients under continuous insulin infusion compared with conventional insulin therapy (Lager et al., 1983). An improved metabolic control, an increased glucose-disposal rate and an inverse insulin resistance following a more physiological insulin regimen with continuous insulin infusion compared with conventional therapy was also reported (Jarret, 1986). Similar results were observed by Muhlhauser et al. (1987) where an intensified insulin injection therapy performed as routine treatment of Type-1 diabetics significantly lowered HBA) levels (Fig. 13). 

In Type-I diabetes, which is due to the loss of insulin-producing cells as a consequence of autoimmune disorders, substitution of insulin is the most important measure. However, merely to inject one daily dose is not an adequate therapy. Here, the objective is to mimic the daily variations in plasma insulin which are closely related to food intake. One such attempt which has improved microvascular complications is intensified insulino-therapy through multiple daily injections of insulin. Another approach is to develop techniques of islet transplantation and using a bioartificial pancreas. In the case of islet transplantation, tissues will not only respond to changes in blood glucose levels but also to hormones of the entero-insular axis. 

Reeves, M. L., Seigler, D. E., Ryan, E. A., and Skyler, J. S., 1982, Glycemic control in insulin-dependent diabetes meUitus Comparison of outpatient intensified conventional therapy with continuous subcutaneous insulin infusion. Am. J. Med. 72 637-680. 

Hanaire-Broutin H, Melki V, Bessieres-Lacombe S, Tauber JP. Comparison of continuous subcutaneous insulin infusion and multiple daily injection regimens using insulin lispro in type 1 diabetic patients on intensified treatment a randomized study. The Study Group for the Development of Pump Therapy in Diabetes. Diabetes Care 2000 23(9) 1232-5. 

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