• Basal-bolus regimen with the same advantages as the Ultralente program
• Less middle-of-the-night hypoglycemic risk than Ultralente—24-hour near-constant effect of glargine makes for an ideal basal insulin
• Avoids mixing, because single insulins are given at each injecion—can thus use an insulin pen for all injections for maximal convenience and accuracy in dosing
Disadvantages • Difficult to compensate for variances in physical activity
This is a variation on the Ultralente program that substitutes glargine as the basal insulin. This insulin has only recently come to market, and experience with it is Limited. However, what has been observed to date has raised considerable hope that it will be an ideal basal insulin because of its near-constant ("peakless") effect over 24 hours (16,21), which should help lower or eliminate the nocturnal hypoglycemia that is sometimes seen with Ultralente (22-25).
Figure 2B shows the program: lispro or aspart insulin at each meal, and glargine at bedtime. It is a four-shot program because glargine cannot be mixed with other insulins', the manufacturer recommends that it be given at bedtime when other insulins generally are not given, to avoid inadvertent mixing. The restriction against mixing reflects its insolubility at a physiological pH, which accounts for the prolonged duration of action when injected into the subcutaneous space. The pH of the glargine bottle/cartridge is 4, which keeps it soluble for injection and explains why it cannot be mixed with other insulins. For most patients, four shots instead of three shots per day is only a minor annoyance because of the relative painlessness of modern injection systems. Moreover, many patients find insulin pens preferable to syringes (at the writing of this chapter, glargine is available only in vials but the manufacturer expects to have a pen system shortly).
This program has all the advantages of the previously described Ultralente regimen, and eliminates many of the disadvantages. It is excellent for patients who want maximal flexibility for dietary habits. Further, the studies to date have shown a high consistency of day-to-day insulin effect for glargine, and a nearly flat insulin profile over 24 hours (16,21), which makes for a near-perfect basal insulin. These characteristics avoid the main disadvantages of Ultralente—its day-to-day variability in insulin action, and the substantial peak that causes mid-dle-of-the-night hypoglycemia in some patients. However, it should again be stated that glargine is very new to the market, and the reported benefits need to be confirmed in real-world clinical settings. On the other hand, the difficulty of using a long-lasting basal insulin in patients whose physical activity varies widely is as true with glargine as it is for Ultralente.
How do you do it?
1. Calculate the 24-hour insulin need as described in Table 4.
2. Give 50% of the 24-hour dosage as glargine at bedtime.
3. Give the remaining 50% of the 24-hour dosage at meals with, on aver
<u a age, 30-40% at breakfast, 30% at lunch, and 30-40% at dinner depending on the patient's eating habits.
4. Adjust these starting dosages if the patient has unusual eating, exercise, or work habits.
5. Perform daily fasting, pre-meai or 2-hour postmeal, and bedtime SBGM along with weekly middle-of-the-night SBGM.
6. Example: 70-kg male who is moderately physically active. Total daily insulin dose is 70 kg X 0.4 units/kg = 28 units. Total glargine: 28 X 50% = 14 units. Total lispro or aspart: 28 X 50% = 14 units. Pre-breakfast lispro or aspart: 14 X 40% = 6 units. Pre-lunch and pre-supper lispro or aspart: 14 X 30% = 4-5 units. Final: 6 units lispro or aspart pre-breakfast, 4 units lispro or aspart pre-lunch, 4-5 units lispro or aspart pre-dinner, and 14 units glargine at bedtime. Adjust insulin doses as needed based on the SBGM values to attain the glyce-mia goals in Table 2.
Was this article helpful?
Diabetes is a disease that affects the way your body uses food. Normally, your body converts sugars, starches and other foods into a form of sugar called glucose. Your body uses glucose for fuel. The cells receive the glucose through the bloodstream. They then use insulin a hormone made by the pancreas to absorb the glucose, convert it into energy, and either use it or store it for later use. Learn more...