Intermediate acting insulin given at bedtime: effect on blood glucose concentrations before and after breakfast.

Francis, Alice J.; Home, Philip; Hanning, I.; Alberti, K. G. M. M.; Tunbridge, W. M. G.

doi:10.1136/bmj.286.6372.1173

Cited by 66 publications

(28 citation statements)

References 26 publications

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“…There are other ways to counteract the dawn phenomenon, such as moving the evening delayed-action insulin from the pre-evening meal to bedtime, thereby extending insulin action (57). However, peaking of intermediate-acting insulin action about 4 -6 h after injection produces a higher risk of nocturnal hypoglycemia than with pump therapy; this result was demonstrated in a recent study where substituting nighttime CSII for bedtime isophane reduced the total number of hypoglycemic episodes (58).…”

Section: Management Of the Dawn Phenomenon Bymentioning

confidence: 99%

Continuous Subcutaneous Insulin Infusion at 25 Years

2002

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Continuous subcutaneous insulin infusion (CSII) is used in selected type 1 diabetic subjects to achieve strict blood glucose control. A quarter of a century after its introduction, world-wide use of CSII is increasing. We review the evidence base that justifies this increase, including effectiveness compared with modern intensified insulin injection regimens and concern about possible complications. Review of controlled trials shows that, in most patients, mean blood glucose concentrations and glycated hemoglobin percentages are either slightly lower or similar on CSII versus multiple insulin injections. However, hypoglycemia is markedly less frequent than during intensive injection therapy. Ketoacidosis occurs at the same rate. Nocturnal glycemic control is improved with insulin pumps, and automatic basal rate changes help to minimize a prebreakfast blood glucose increase (the “dawn phenomenon”) often seen with injection therapy. Patients with “brittle” diabetes characterized by recurrent ketoacidosis are often not improved by CSII, although there may be exceptions. We argue that explicit clinical indications for CSII are helpful; we suggest the principal indications for health service or health insurance–funded CSII should include frequent, unpredictable hypoglycemia or a marked dawn phenomenon, which persist after attempts to improve control with intensive insulin injection regimens. In any circumstances, candidates for CSII must be motivated, willing and able to undertake pump therapy, and adequately psychologically stable. Some diabetic patients with well-defined clinical problems are likely to benefit substantially from CSII and should not be denied a trial of the treatment. Their number is relatively small, as would therefore be the demand on funds set aside for this purpose.

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Section: Management Of the Dawn Phenomenon Bymentioning

confidence: 99%

Continuous Subcutaneous Insulin Infusion at 25 Years

2002

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“…In these patients, fasting plasma glucose levels are proportional to hepatic glucose production (22). On the other hand, when intermediate acting insulin is given at bedtime rather than in the evening, morning plasma insulin levels are higher and hyperglycemia is reduced (26). These data rise the possibility that a change from conventional to pump therapy with an appropriate basal insulin delivery rate would provide higher insulin levels in the morning, reducing hepatic glucose production and fasting hyperglycemia.…”

mentioning

confidence: 95%

Continuous Subcutaneous Insulin Infusion Therapy Decreases Insulin Resistance in Type 1 Diabetes*

Yki‐Järvinen

Koivisto

1984

The Journal of Clinical Endocrinology & Metabolism

122

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The influence of continuous sc insulin infusion therapy for 6 weeks on sensitivity to insulin (euglycemic clamp technique) and hepatic glucose production (3-[3H]glucose technique) was measured in 10 type 1 diabetic patients whose mean duration of diabetes was 8 yr. Mean diurnal blood glucose fell from 8.5 +/- 0.8 (SEM) mmol/liter to 6.0 +/- 0.6 mmol/liter (P less than 0.05) and glycosylated hemoglobin from 10.5 +/- 0.4% to 8.7 +/- 0.3%. Insulin requirements declined by 23% from 47 +/- 4 U/day prepump to 36 +/- 2 U/day after 6 weeks of pump therapy (P less than 0.01). During the insulin clamp, plasma insulin was maintained at approximately 90 mU/liter and plasma glucose at approximately 5.0 mmol/liter in all studies. The rate of glucose metabolism in diabetic patients during conventional therapy (4.65 +/- 0.41 mg/kg X min) was 35% lower than in normal subjects (7.20 +/- 0.42 mg/kg X min, n = 14, P less than 0.001). After 6 weeks of pump therapy, total glucose uptake increased by 27% to 5.90 +/- 0.60 mg/kg X min, P less than 0.05 vs. prepump). This was still 18% lower than in the normal subjects (P less than 0.05). Basal hepatic glucose production in the diabetic patients during conventional therapy (3.07 +/- 0.14 mg/kg X min) was 70% higher than in the normal subjects (1.79 +/- 0.07 mg/kg X min, n = 7, P less than 0.001). After 6 weeks of pump therapy, hepatic glucose production fell to 2.48 +/- 0.19 mg/kg X min (P less than 0.05), which was still 40% higher than in the normal subjects (P less than 0.01). Basal hepatic glucose production was directly related to the fasting plasma glucose level (r = 0.67, P less than 0.001) and inversely proportional to fasting insulin concentration (r = -0.48, P less than 0.05) in the diabetic patients. Specific tracer insulin binding to erythrocytes in the diabetic patients (19.4 +/- 1.5%) was comparable to that in the normal subjects (19.6 +/- 1.2%) and remained unchanged during pump therapy. Thus the improved metabolic control resulting from pump therapy is associated with enhancement in sensitivity to insulin, and reduction in basal hepatic glucose production.

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“…NPH insulin given at dinner will often have a peak effect in the middle of the night, resulting in nocturnal hypoglycemia, while failing to prevent morning hyperglycemia. To overcome this, the evening dose of NPH insulin may be given at bedtime instead of with dinner [37]. Even bedtime NPH insulin, however, often does not eliminate nocturnal hypoglycemia or correct fasting hyperglycemia.…”

Section: Basal Insulinsmentioning

confidence: 95%

Intensive diabetes management in pediatric patients

2001

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Intensive diabetes management requires frequent home glucose monitoring, multiple daily insulin injections or chronic subcutaneous insulin infusion, and adjustments of insulin doses in response to changes in blood glucose levels, food intake, and exercise. It also requires a periodic review of previous glucose results to recognize patterns of hyper- or hypoglycemia. The goals of intensive management are age dependent. In young children, avoidance of severe hypoglycemia is the major goal. In older children and adolescents, lowering hemoglobin A(1c) becomes an increasingly important goal. In children of all ages, the ability to have a flexible lifestyle and meal plan is often a priority. This article provides a brief overview of the rationale for implementing intensive diabetes management in pediatric patients, and practical guidelines for implementation.

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Intermediate acting insulin given at bedtime: effect on blood glucose concentrations before and after breakfast.

Cited by 66 publications

References 26 publications

Continuous Subcutaneous Insulin Infusion at 25 Years

Continuous Subcutaneous Insulin Infusion at 25 Years

Continuous Subcutaneous Insulin Infusion Therapy Decreases Insulin Resistance in Type 1 Diabetes*

Intensive diabetes management in pediatric patients

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