[Insulin therapy of Type I diabetes].
Since the controlled long-term study DCCT has clearly demonstrated that the progression of diabetic late complication is highly dependant on metabolic control an adaptation of insulin therapy became mandatory. In the eighties first successful attempts were made with the so-called Basis-Bolus-Principle (regular insulin before meals and depot-insulin at bedtime), the dosis being adapted depending on blood sugar tests. Near normoglycemia could only be achieved by a very strict time-schedule concerning meal-times and quantity of meals and still was accompanied by an increase of severe hypoglycemia. Only with the so-called functional insulin therapy it was possible to reach the goal of normoglycemia and maintaining the flexibility of patients as well as to reduce the risk of hypoglycemia. This type of therapy is based on the optimized adaptation of the daily insulin substitution to the physiological need of insulin. The pre-requisite is a separate substitution of basal and prandial insulin requirement. The basal substitution is divided in two to three injections of depot-insulin. Prandial insulin is injected according to the amount of desired carbohydrate content of the meal. Furthermore, high blood glucose values are immediately corrected by regular insulin given s. c. or i. m. To learn the basic knowledge of functional insulin therapy, special training is required in which the individualized rules have to be determined by self-experiments. This training is based on evening ambulatory sessions of 1 1/2 hours weekly during four weeks and then two further follow me seminars. The whole course takes three months. More than six years of experience with diabetic outpatient clinic at the university hospital of Basel have revealed that about 60% of type I diabetics were able to learn this therapy and preferred it to the conventional intensive insulin treatment. The secret of success of the functional insulin therapy is due to the self-determination of the therapy promoting a creative handling with the different kind of insulin treatment. The excellent experiences of this therapy oblige to offer this treatment to all type I diabetics. Being the achilles-heel of each insulin treatment, special efforts must be undertaken to reduce the risk of hypoglycemia. An increased risk of hypoglycemia exists with a duration of diabetes for more than ten years, or with a severe hypoglycemic attack in the past, furthermore with impaired renal function, loss or reduction of hypoglycemia awareness and with near-normo-glycemic blood glucose regulation. In this situation, a special training of strategies preventing hypoglycemia is indicated. As by avoiding low blood glucose values the awareness of hypoglycemia could be improved, it is mandatory to make special efforts to reduce or avoid low blood glucose values [< 3 mmol]. It is important that in determining the target of blood sugar regulation the risk of hypoglycemia has to be considered. In case of increased risk of hypoglycemia the target of blood sugar must be elevated. The goal of a good metabolic control while minimizing the risk of hypoglycemia and of increased flexibility in daily life can only be reached by special efforts of the teamwork between physician, diabetes nurse and dieticians with the diabetic patient. Different sorts of problems and recommendations of insulin treatment are discussed in a supplement.
Berger
W
W
Abteilung Endokrinologie, Diabetologie und Klinische Ernährung, Kantonsspital Basel.
D000328:Adult; D000368:Aged; D001786:Blood Glucose; D003922:Diabetes Mellitus, Type 1 / Q000097:blood / Q000188:drug therapy*; D005260:Female; D006442:Glycated Hemoglobin; D006801:Humans; D007004:Hypoglycemic Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D007328:Insulin / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance; D011247:Pregnancy; D011254:Pregnancy in Diabetics / Q000188:drug therapy; D011788:Quality of Life
D001786:Blood Glucose; D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents; D007328:Insulin