Insulin Treatment Regimes

There are several different types of insulin treatment regime.

Once-daily Insulin

This regime is only used in elderly or infirm people, where the aim is to prevent hypoglycaemia. Good control of blood glucose cannot be achieved with only one injection of insulin. The types of insulin used are either an intermediate cloudy lente preparation such as Human Monotard® or a long-acting type like Humulin® Zn. The type of person for whom this regime might be recommended is someone elderly who has Type 2 diabetes.

Twice-daily Insulin

Free-mixed or pre-mixed preparations may be used, combining short-acting, clear insulins or fast-acting insulin analogues with intermediate-acting isophane or lente cloudy insulins. This is the most popular and commonly used regime, with the injections usually given before breakfast and before the evening meal. However, there are limitations, and snacks may need to be eaten between meals and before going to bed to avoid hypoglycaemia. This is because of the way the short and longer-acting insulins work and the timing of the peaks of their activity, which may enable some 'gaps' in optimal cover to occur. Free mixing of the insulins, which is usually recommended for people with Type 1 diabetes on this regime, allows for greater flexibility in insulin cover as doses can then be adjusted. Pre-mixed combinations are more likely to be suitable for those with Type 2 diabetes.

Multiple Daily Injections

These consist of three doses of short-acting, clear insulin (or three of rapid-acting such as lispro), injected half an hour before each main meal, combined with one injection of intermediate-acting cloudy insulin (isophane or lente), given at about 10 p.m. to last through the night and into the following day. The pattern is intended to reflect that which occurs in normal health, and these regimes may be used to treat both types of diabetes, but are particularly suitable for those with Type 1 syndrome. If a pen device is used, as is commonly the case, it is known as the Basal Bolus regime. Multiple injections, coupled with frequent checking of blood glucose levels, form the basis of 'tight' control of glycaemia. An advantage of this regime is that it can be adapted to allow for greater flexibility in the timing of meals, and eating occasional larger or smaller meals can be accommodated, both by means of adjusting insulin doses.

One practical disadvantage, apart from having to self-administer four injections each day, is the possible need to test the effect of each dose by monitoring blood glucose levels. Blood glucose tests maybe carried out on rising in the morning (to check the effect of the cloudy insulin given the previous night), and then two hours after each meal to monitor the clear insulin doses. In practice, once a person has settled into the Basal Bolus regime and if he or she has a regular, daily routine (in terms of size of meals and their timing), it may be possible to reduce the number of blood glucose tests. By carrying out fewer tests but at different times on consecutive days, it is possible to obtain a reasonably good picture of what is happening to blood glucose levels. However, frequent testing is usually necessary when the desired aim is to achieve tight control of glycaemia. The main drawback with multiple injection regimes and one which is, understandably, a cause of anxiety, is that there is an increased incidence of hypoglycaemia.

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