Components Of The Physiologic Insulin Regimen

Insulins are divided for practical purposes into two broad categories, basal and bolus, based on their pharmacokinetics. Physiologic insulin replacement attempts to mimic normal insulin secretion patterns, and is used to meet an individual's total daily insulin requirement that consists of the sum of basal, prandial, and correction dose insulin requirements (13-15).

Basal insulin refers to exogenous insulin per unit of time necessary to prevent unchecked gluconeogenesis and ketogenesis. It provides a constant background level of insulin that controls BG overnight while the patient sleeps and between meals when they are not eating and the meal bolus insulin action has waned. When dosed appropriately, basal insulin should not cause hypoglycemia if/when the patient does not eat or ingests less food than was anticipated during a meal. In treating DM1, basal insulin needs will most commonly be met by: injection of once daily insulin glargine; once or twice daily insulin detemir; or by rapid-acting or regular insulin delivered subcutaneously via an insulin pump.

The term bolus insulin incorporates both prandial and correction doses of insulin. Bolus insulin is preferentially provided as one of the rapid-acting insulin analogs, e.g., aspart, glulisine and lispro, or may be provided as short-acting regular insulin. Prandial or meal insulin refers to insulin which covers the postmeal glycemic excursion. Efforts are made to match meal insulin doses to anticipated carbohydrate intake, which will be achieved either by a consistent carbohydrate meal plan or by "carbohydrate counting." The latter refers to counting the number of grams of carbohydrate to be taken in a meal and calculating an appropriate dose of insulin to take with the food. An individualized carbohydrate to insulin ratio is based upon an estimate of known insulin sensitivity. (Further details are discussed below in the section on pattern management.)

Correction- or supplemental-dose insulin is used to treat hyperglycemia that occurs before or between meals despite administration of routine daily doses of basal and prandial insulin, and is taken in addition to these standing doses. When the patient with diabetes is ill or stressed, total daily insulin requirements commonly increase. This increase in insulin requirement is a result of release of insulin counter-regulatory hormones, predominantly cortisol and catecholamines, and to a lesser extent glucagon and growth hormone, which

Table 1 Salient Features of Insulin Preparations (18,34,122)

Category

Generic

Brand name

Time to onset Time to peak

Duration of action

Special considerations

Basal insulins

Long acting (preferred)

Glargine LantusĀ®

Detemir

LevemirĀ®

2^11ir

2 hr

No pronounced peak

No pronounced peak

20-24 hr

6-24 hr

Usually once daily dosing. If antihyperglycemic action wanes in hours prior to administration of once daily shot, dose twice daily If low total daily insulin requirement (<0.1 unit/ kg/day) or antihyperglycemic action wanes in hours prior to administration of once daily shot, dose twice daily

Intermediate acting

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