Case 2: Treatment Options |
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Treatment Option C: Initiate Multiple Daily Injections (MDI)
Patients with severe ß-cell dysfunction require both basal and prandial insulin. Multiple daily injections (MDI) (ie, more than 2 injections a day) can achieve the goal of physiologic insulin replacement.7
Action: A number of options are available when MDI becomes necessary (Table 8). Regular insulin, insulin lispro, and insulin aspart all provide prandial insulin; NPH and insulin glargine are used to provide basal insulin. Timing is important, as each has a lag time to onset of action, and each individual has unique BG before meals on any given day. Regular insulin should be injected approximately 30 minutes prior to eating, while insulin lispro and insulin aspart can be injected from 0 to 15 minutes prior to eating and may indeed even be safely taken at the end of the meal if forgotten earlier. Rapid-acting insulin allows patients to adjust their injections to match their lifestyle instead of having to adapt their lives around the timing of meals.
Table 8. Insulins Currently Available in the US| Time to Peak Insulin (min) | Onset of Action (min) | Time to Peak Action (hr) | Duration of Action (hr) | |
| Aspart | 40–50 | 10–20 | 1–3 | 3–5 |
| Lispro | 30–90 | 10–15 | .8–4.3 | 3–5 |
| Regular | 80–120 | 30 | 2.5–5 | 8 |
| NPH | — | 1.5 | 4–12 | 24 |
| Glargine | — | 1–1.5 | Peakless | 24 |
Comment: Several obstacles may exist in the minds of some patients when faced with the necessity to initiate MDI therapy. A multidisciplinary team that includes a diabetes educator, a dietitian, and an endocrinologist will be key to educating patients about the importance of SMBG, diet, exercise, and awareness of hyper- and hypoglycemic symptoms. Diabetes educators will assist patients in a number of areas, including10:
- The importance of healthy eating and exercise
- How to adjust their regimen according to their changing lifestyle or daily meal schedules
- How to monitor their BG levels, keep daily BG records, and use the information for personal decision-making regarding titration
- What the basal/prandial theory of treatment involves
- How to draw up and inject a correct insulin dose, and use insulin pens or other delivery systems
- How to recognize, treat, and prevent hypoglycemia
- The importance of wearing and carrying identification such as a “MedicAlert” bracelet, necklace, and card
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