Pre Meal Regular and Bedtime NPH

Advantages

• Provides more flexibility for varying exercise habits than Ultralente or glargine

• Less risk of nocturnal hypoglycemia than Ultralente

• An insulin pen can be used for all injections, for maximal convenience and accuracy in dosing

Disadvantages

• Minimal flexibility for dietary variations

• Must wait 30 minutes between the Regular insulin injection and the meal

• Longer effect of Regular insulin versus lispro and aspart means greater risk of between-meal "hypos"

Program

This is a common intensive insulin program outside the United States (as already discussed, the United States uses Ultralente and rapid-acting insulin at meals; die difference reflects the insulin manufacturers that serve various geographical areas and the products they sell as opposed to any great advantage of one regimen over another). Figure 2C shows how it is done: Regular insulin 30 minutes before each meal and NPH at bedtime (by 11 p.m. even if staying up past that time). The 30-minute waiting period between taking the Regular insulin and eating is important in order to match the peak insulin effect and the postprandial rise in glycemia.

Overview

This program is based on a different principle than the previously discussed glar-gine and Ultralente regimens, as a single insulin is used for basal and bolus coverage during the day. This allows less dietary flexibility than with Ultralente or glargine, especially for variations in mealtimes. For example, eating lunch at 12: 00 noon and dinner at 9:00 p.m. versus the usual 6:00 p.m. will be accompanied by substantia] pre-dinner hyperglycemia because of waning of the Regular insulin effect. Some patients prevent this by taking an extra, small dose of Regular in the middle of the afternoon. The ability to compensate for variation in meal size is also limited with this regimen, as changing the Regular insulin dosage for a smaller or larger than normal meal affects basal insulin delivery at the same time. Thus, this is not the best regimen for patients who want substantial flexibility in their diet.

In contrast, it provides more flexibility for exercise and sports than either Ultralente or glargine, as the Regular insulin coverage is 5-6 hours compared with the much longer duration of glargine and Ultralente.

How do you do it?

1. Calculate the 24-hour insulin need as described in Table 4.

2. Give 30% of the 24-hour dosage for the breakfast injection, 25% at lunch, 25% at dinner, and 20% at bedtime. (The latter percentage is for insulin-sensitive patients, the usual case in type 1 diabetes. For a patient with type 2 diabetes, nighttime coverage usually requires a much higher perceniage of the daily insulin because of the typical presence of insulin resistance.)

3. Adjust these starting dosages if the patient has unusual eating, exercise, or work habits.

4. Perform daily fasting, pre-meal or 2-hour postmeal, and bedtime SBGM along with weekly middle-of-the-night SBGM.

5. Example: 70-kg male who is moderately physically active. Total daily insulin dose is 70 kg X 0.4 units/kg = 28 units. First injection: 28 X 30% = 8 units. Second and third injections: 28 X 25% = 7 units. Fourth injection: 28 X 20% = 6 units. Final: 8 units Regular pre-breakfast, 7 units Regular pre-lunch, 7 units Regular pre-dinner, 6 units NPH at bedtime. Adjust insulin doses as needed based on the SBGM values to attain the glycemia goals in Table 2.

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Diabetes 2

Diabetes 2

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...

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