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Insulin
Principles of insulin therapy
Frequently used regimens
- Two injections daily of a mixture of short and intermediate-acting insulins (before breakfast and the main evening meal)
- Three injections daily using a mixture of short and intermediateacting insulins before breakfast; short-acting insulin alone before an afternoon snack or main evening meal; intermediate-acting insulin before bed; or variations of this
- Basal-bolus regimen of short-acting insulin 20–30 min before main meals (e.g. breakfast, lunch and the main evening meal); intermediate or long-acting insulin at bedtime
- Basal-bolus regimen of rapid-acting insulin analog immediately before main meals (e.g. breakfast, lunch and main evening meal); intermediate- or long-acting insulins at bedtime, probably before breakfast and occasionally at lunchtime
- Insulin pump regimes are regaining popularity with a fixed or variable basal dose and bolus doses with meals
None of these regimens can be optimized without frequent assessment by BG monitoring
Daily insulin dosage
Daily insulin dosage varies greatly between individuals and changes over time. It therefore requires regular review and reassessment
Dosage depends on many factors such as
- Age
- Weight
- Stage of puberty
- Duration and phase of diabetes
- State of injection sites
- Nutritional intake and distribution
- Exercise patterns
- Daily routine
- Results of BG monitoring (and glycated hemoglobin)
- Intercurrent illness
Guideline on dosage
- During the partial remission phase the daily insulin dose is often <0.5 IU/kg per day
- Prepubertal children (outside the partial remission phase) usually require 0.7–1.0 IU/kg per day
- During puberty, requirements may rise substantially above 1 IU/kg per day
The ‘correct’ dose of insulin is that which achieves the best attainable glycemic control for an individual child or adolescent
Distribution of insulin dose
The distribution of insulin dose across the day shows great individual variation
- Children on twice-daily regimens often require more (perhaps two-thirds) of their total daily insulin in the morning, and less (perhaps one-third) in the evening
- On this regimen approximately one-third of the insulin dose may be short-acting insulin and approximately two-thirds may be intermediate-acting insulin, although these ratios change with greater age and maturity of the young person
- On basal-bolus regimens, night-time intermediate-acting insulin may represent 30–50% of total daily insulin: 50–70% as rapid or short-acting insulins divided up between three to four pre-meal boluses (when using rapid-acting insulin for pre-meal boluses, the proportion of basal insulin may be higher)
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