INSULIN THERAPY - FROM INSULIN-SECRETION TO INSULIN THERAPY

Which insulin for which diabetic?: Besides type 1 insulin-dependent di abetes, insulin therapy may be indicated in certain type 2 patients wh ose glucose regulation is insufficiently controlled by diet or oral an tidiabetic drugs or who require temporary control with insulin. Target glucose level: Blood glucose should be as close as possible to normal levels, i.e. 0.8 g/l in the fasting state and 1.40 g/l after meals. H owever the target must be calculated according to the patients age and diabetic risks. Insulin requirements: Baseline insulin secretion lies in the 0.4 to 0.5 IU/kg/d range which is about two-thirds of the over all daily insulin secretion. Acute secretion reaches 0.3 IU/kg/d. Mean insulin requirements in adults are approximately 0.7 to 0.9 IU/kg/d, i.e. 50 to 60 U/d for a 70-kg adult. Insulin sources: Bovine and porci ne insulins can lead to the development of anti-insulin antibodies. Se mi-synthetic or recombinant human insulins have been obtained by genet ic engineering. The kinetics of one insulin analog, Humalog, has been modified compared with ordinary insulin by transposition of 2 amino ac ids. Available insulins: Ordinary rapid-acting insulins should be inje cted 20 minutes before meals and never just before eating. Intermediat e-acting isophane insulins (14-18 hr) have the same bioavailability ch aracteristics and can be used in combination with ordinary insulin. Lo ng-acting insulins cannot be used with pens; they are active for 24 ho urs. Very-long-acting insulins (Ultralente) are active for 36 hours. I nsulin analogs administered just before food intake can reduce the ris k of postprandial hyperglycemia and late post-prandial hypoglycemia co mpared with rapid-acting insulins. (C) 1998, Masson, Paris.