Intensive insulin therapy for treatment of type I diabetes.

Intensive insulin therapy is best defined as a comprehensive system of diabetes management with the patient and management team as partners. The system is directed at improvement of glycemia and patient well-being. Glycemic targets should be individually defined. Frequent self-monitoring of blood glucose, probably at least four times per day, is essential for meticulous control. The benefits include improved psychosocial functioning and the potential of lessening the risks of chronic complications of diabetes. The risks relate to problems associated with hypoglycemia, which are increased if meticulous glycemic control is sought. One of the important elements of intensive therapy is a multiple-component insulin program designed to provide effective insulinemia coinciding with each major meal and continuous basal insulinemia throughout the 24-h day. This may be achieved with continuous subcutaneous insulin infusion (CSII) or multiple injections with various insulin regimens, although CSII may offer real advantages in terms of the pharmacokinetics of insulin delivery. Other pharmacokinetic issues to be considered involve selection of injection sites, timing of premeal insulin, and mixing insulins. Many studies have shown that, albeit with effort, excellent glycemic control can be achieved by various intensive insulin-therapy regimens. The implementation of a program of intensive therapy involves patient self-management in terms of altering insulin dosages, food intake, and/or activity in an attempt to achieve the target level of glycemia selected. In motivated patients willing to embark on such a course of therapy, intensive insulin therapy can be worthwhile. It should be considered for all patients with type I (insulin-dependent) diabetes mellitus.

The effect of ejaculation on albumin excretion rate.

Microalbuminuria predicts the development of diabetic nephropathy. Large daily variations in albumin excretion rates are frequently observed. Because seminal fluid contains protein and albumin, we reasoned that sexual activity, ejaculation, or residual urethral semen could contribute to albumin content in urine and thus effect determination of albumin excretion rate. Our study was designed to determine the effect of ejaculation of albumin excretion rate and to ascertain if patients routinely should be advised to refrain from sexual activity during or before the urine collection period. Ten normotensive, nondiabetic men (age 31.0 +/- 2.3 years) collected 24-h urine specimens on three occasions: after 3 days of abstinence from sexual activity, during a 24-h period which included one ejaculatory episode, and on a day following sexual activity. Results for albumin excretion rate were: abstinence day: 4.8 +/- 0.7 micrograms/min; sex day: 6.3 +/- 1.1 microgram/min; post-sex day: 4.9 +/- 1.0 micrograms/min. There was no significant difference between these values when compared directly or after log transformation. There also were no differences in urinary creatinine excretion or clearance. We conclude that in nondiabetic individuals ejaculation does not influence albumin excretion rate.

AADE guidelines. Infection control guidelines for patient education as a means of preventing blood-borne disease transmission during diabetes self-care procedures.

There exists a potential for blood-borne disease transmission with many diabetes self-care behaviors. It is necessary for the diabetes educator to instruct the patient regarding infection-control practices.

Type I diabetes and insulin therapy.

Intensive insulin therapy is composed of an entire therapeutic program of diabetes management. One component of that program is a multiple-component insulin regimen. There are several important pharmacokinetic issues that must be appreciated when prescribing insulin. These include differences in absorption characteristics between animal and human insulin, variations in intraindividual insulin absorption, the influence of injection sites on insulin absorption, and lag time. Only physiologic insulin regimens should be used in patients with type I diabetes, and there are advantages and disadvantages to the various available options. There are theoretic reasons why CSII may be better for many patients. Finally, the nurse specialist/educator who is initiating the insulin therapy should be familiar with the general guidelines for the various insulin regimens in addition to implementing appropriate diabetes algorithms.

Prevalence and consequences of nocturnal hypoglycemia among conventionally treated children with diabetes mellitus.

To determine the prevalence and predictors of, and the glucose responses after, nocturnal hypoglycemia, we studied 135 pediatric patients with insulin-dependent diabetes mellitus on 388 nights. The frequencies of blood glucose values less than 60, 50, and 40 mg/dl (3.3, 2.8, and 2.2 mmol/L) at 2 AM were 14.4%, 7.0%, and 2.1%, and at 6 AM were 6.7%, 2.6%, and 0.5%, respectively. Longer duration of diabetes, higher daily insulin doses, and lower glycosylated hemoglobin values were all significant but weak predictors of 2 AM hypoglycemia (glucose less than or equal to 60 mg/dl (less than or equal to 3.3 mmol/L). A 10 PM glucose concentration less than or equal to 100 mg/dl (less than or equal to 5.6 mmol/L) was present on 48% of nights with 2 AM glucose values less than or equal to 60 mg/dl (less than or equal to 3.3 mmol/L), but only 24% of nights with 10 PM blood glucose values less than or equal to 100 mg/dl (less than or equal to 5.6 mmol/L) were followed by 2 AM hypoglycemia. After treatment of 70 episodes of 2 AM glucose concentrations less than or equal to 60 mg/dl (less than or equal to 3.3 mmol/L), mean 6 AM glucose concentration was 95 +/- 6 mg/dl (5.7 +/- 0.3 mmol/L) and less than or equal to 100 mg/dl in 68.6%. In only 4.3% of these cases was the 6 AM glucose concentration greater than 200 mg/dl (greater than 11.1 mmol/L). Among patients who experienced 2 AM hypoglycemia, after-breakfast glucose values were not greater on days with 2 AM hypoglycemia than on days without it. These data indicate that 2 AM hypoglycemia is relatively common in patients with insulin-dependent diabetes mellitus, is frequently preceded by a 10 PM glucose value less than or equal to 5.6 mmol/L, and is less well predicted by other factors. Appropriate treatment of 2 AM hypoglycemia seldom results in either before-breakfast or after-breakfast blood glucose values greater than 200 mg/dl (greater than 11.1 mmol/L). Early-morning hypoglycemia is an uncommon cause of otherwise unexplained, prebreakfast hyperglycemia in children with insulin-dependent diabetes mellitus.