Multiple Insulin Injection Therapy

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Multiple Insulin Injection Therapy
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• Introduction
• Goals of multiple insulin injection.
• High light of treatment method.
• Glycemic control effect.
• Diet treatment.
• Type of insulin
• Insulin preparation.
• What to mix and what not to mix.
• Type of regimen
• Western regimen.
• Our regimen.
• Future regimen.
• Important phenomena
• Somogyi phenomena.
• Dawn and predawn phenomena.

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• Clinical Goals
• Elimination of ketosis.
• Elimination of hyperglycemia and its symptoms.
• Prevention of chronic complications.
• Additional Goals
• Maintaining desirable weight.
• Maintaining normal growth and sexual maturation.
• Maintaining psychosocial well-being.
• Achieving normal fertility and pregnancy.
• Sustaining normal family and sexual life.
• Control Goals
• HbA1c lt7.
• Pre-meal SMBG 80-120 mg/dl (4.4-6.7 mmol/l).
• Bed time SMBG 100-140 mg/dl (5.6-7.8 mmol/l).

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• Insulin
• Type 1 diabetes is dependent on insulin for
  survival.
• Insulin is classified by source or duration of
  action.
• Human insulin has less allergy or lipoatrophy.
• More than one injection is needed and different
  types.
• Proper action During honeymoon phase.
• The commonest side effect is hypoglycemia.
• Nutrition
• Enable near normal blood glucose level.
• Maintain a reasonable body weight.
• Protein 10-20, Fat 15-25, Carbohydrate 65.
• Fibers, vitamins, and minerals.
• Food exchanges or carbohydrate counting.
• Total daily calorie intake adjustment.
• Exercise
• Should be integrated.
• Weight control and improve well being.

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• The total calories intake depends on patients age
  and activity but have to related to the desirable
  body weight.
• Total daily calories IBW X
  Estimated daily energy
• Add 300 kcal/day during pregnancy.
• Add 500 kcal/day during lactation.
• Fibers, sweeteners, vitamins, and minerals.

25 years male IBW 60 kgm
Carbohydrate (65) 390 Protein (10) 60 Fat
(25) 150
Carbohydrate 100
gm Protein (10) 15
gm Fat (25) 17 gm
Diet Carbohy.
Protein Fat _ Arabian bread 30
gm --- --- Cheese
5 gm 10 gm 10 gm Honey
50 gm 2 gm 3
gm Glass of milk 10 gm 5
gm 5 gm_ Total 95
gm 17 gm 18 gm
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The plan of insulin type and dose will depend
on - The shape of glucose curve. - The diet
and exercise.
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Action Name Onset Duration Very
rapid Lispro / Novo rapid 10-15 min 2-3
hrs Rapid Crystalline zinc (CZI) 30-45 min 4-6
hrs Intermediate Neutral Protamine Hagedorn
(NPH) 1-2 hrs 6-12 hrs Lente zinc
Long acting Ultralente zinc 6-8
hrs 18 hrs Lantus (glargine) 4-8 hrs 24
hrs Premixed 80 NPH20CZI 30-45 min 6-12
hrs 70 NPH30CZI 30-45 min 6-12 hrs 50
NPH50CZI 30-45 min 6-12 hrs
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Action Name Mix(1) Very rapid Lispro / Novo
rapid Yes(2) Rapid Crystalline zinc
(CZI) Yes(2) Intermediate Neutral
Protamine Yes(2) Hagedorn (NPH) Yes(2)
Lente zinc Yes(2) Long
acting Ultralente zinc No Lantus
(glargine) No_ Premixed 80
NPH20CZI No 70 NPH30CZI No 50
NPH50CZI No_ (1) Mixing different type of
insulin has to be fron the same source (ie same
company) (2) Mixing different type of insulin
has to be fron the same source (ie same company)
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Post- prandial hyperglycemia
Pre-prandial hyperglycemia
10/90 20/80 30/70 40/60 50/50
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Glucose variations in our culture
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• Regular and NPH use twice daily the commonest
  regimen used.
• Premixed with different concentration (30/70,
  40/60, 50/50).
• Lunch is the biggest meal usually but no
  insulin dosing.

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• Hyperglycemia
• Window
• Cause
• Lack of insulin
• Lunch effect
• afternoon snacks
• Effect
• Pre-meal hyperglycemia
• ? HbA1c by 1.7

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Treat by adding regular dose pre-lunch
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Treat by adding regular dose pre-meals and small
one before sleep
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Week end Problem

• Hypoglycemia
• Window
• Cause
• NPH evening dose
• ? Late sleep
• Effect
• Somogyi effect

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Treat by moving am dose late and regular dose
pre-supper and NPH at night
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Treat by moving am dose late and regular dose
pre-supper and another dose pre bed
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• Cause
• Counter regulatory hormones response to
  hypoglycemia at med-night.
• Increase in hepatic glucose production.
• Insulin resistance because of the Counter
  regulatory hormones.

• Treatment
• Decrease pre-supper intermediate insulin.
• Defer the dose to 9 PM.
• Change or start pre-bed snack.

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• Cause
• Less insulin at bed time.
• More food at bed time.
• Not using NPH at night.

• Treatment
• Use enough dose.
• Reduce bed time snack.
• Add NPH pre-supper.