A Review of Insulin-Dosing Formulas for Continuous Subcutaneous Insulin Infusion (CSII) for Adults with Type 1 Diabetes.

Dosing guidelines for patients with type 1 diabetes using continuous subcutaneous insulin infusion (CSII), which are historically based on clinical experience and retrospective studies of patients consuming an American diet, recommend that basal insulin should represent approximately 50 % of the total daily dose (TDD). Recent prospective studies in the USA and Japan conclude that the more appropriate proportion is closer to 30-40 % of TDD. In addition, currently used formulas for calculating the carbohydrate-to-insulin ratio (CIR) and correction factor (CF) may lead to underdosing of bolus insulin by as much as 12.

Misled by the Morning "Fasting" Plasma Glucose.

Because of its ease and simplicity of its measurement, the morning fasting plasma glucose (FPG), has been as used a surrogate marker for the entire basal day when titrating once-nightly basal insulin. Common in obese insulin-treated patients with type 2 diabetes, late and large evening meals elevate the FPG. This has led to dosing of basal insulin well beyond the basal requirements and contributes to hypoglycemia and weight gain seen with this therapy.

Liraglutide achieves A1C targets more often than sitagliptin or exenatide when added to metformin in patients with type 2 diabetes and a baseline A1C <8.0%.

Objective: Compare the safety and efficacy of liraglutide to that of sitagliptin or exenatide as add-on to metformin in patients with type 2 diabetes (T2D) and glycated hemoglobin (A1C) <8.0%.

Methods: Post hoc analysis of 26-week data from liraglutide 1.

The number of basal rates required to achieve near-normal basal glucose control in pump-treated type 2 diabetes.

Background: It has been reported that most pump-treated patients with type 2 diabetes require only two or fewer basal rates. Using daily continuous glucose monitoring (CGM)-directed titration, this premise was re-evaluated at near-normal glycemic control.

Patients And Methods: Thirty subjects who were insulin-naive (n = 10), on basal insulin (n = 10), or on basal-bolus insulin therapy (n=10) ate a fixed diet.

Contribution of the dawn phenomenon to the fasting and postbreakfast hyperglycemia in type 1 diabetes treated with once-nightly insulin glargine.

Objective: To observe the effect of the dawn phenomenon on basal glucose and postbreakfast hyperglycemia in patients with type 1 diabetes treated with once-nightly insulin glargine and premeal insulin lispro.

Methods: In 49 study subjects consuming a fixed isocaloric (50% carbohydrate) diet of usual food, the insulin glargine dose was titrated from daily continuous glucose monitoring downloads to achieve a basal glucose goal of <130 mg/dL 4 hours after meals and during serial meal omissions but with fewer than 10% of readings at <70 mg/dL during 24 hours. Patients also performed self-monitoring of plasma glucose 7 times a day (before and 2 hours after each meal or omitted meal and at bedtime).

How much do I give? Dose estimation formulas for once-nightly insulin glargine and premeal insulin lispro in type 1 diabetes mellitus.

Objective: To evaluate the mathematical relationships between dosing factors in type 1 diabetic patients using multiple daily injections.

Methods: In this single-center, prospective study in type 1 diabetic patients, the basal continuous glucose monitoring glucose target was less than 130 mg/dL with fewer than 10% of 24-hour readings at less than 70 mg/dL. Basal glucose for the 4-hour meal periods was obtained from once-daily serial meal omissions.

Continuous glucose monitoring-guided insulin dosing in pump-treated patients with type 1 diabetes: a clinical guide.

This article describes our methods for structured continuous glucose monitoring (CGM)-guided insulin dosing in pump-treated type 1 diabetes. Some of the methods have been reported and some are based on clinical experience. It is expected that this guide will help those involved in the care of such patients and who have experience with CGM to achieve better glucose control in their patients.

No higher dose requirements with insulin detemir than glargine in type 2 diabetes: a crossover, double-blind, and randomized study using continuous glucose monitoring.

Background: In a previous publication we reported no difference in the 24-hour glucose response between two basal analog insulins, detemir and glargine, when taken once a day in type 2 diabetes mellitus (T2DM). We now report the dose comparison observed within this randomized, double-blind, crossover study.

Method: Of 36 patients on basal insulin and other noninsulin treatments, 29 completed the study.

Comparison of the post-meal glucose response to different insulin bolus waveforms in insulin pump- and pre-meal pramlintide-treated type 1 diabetes patients.

Background: Both pramlintide and insulin pump waveforms separately provide improved post-meal glucose control. However, when used together there may be a mismatch in actions leading to hypoglycemia. We studied the three currently available waveforms and a "modified combination wave" (MC) in pramlintide-treated patients.

How much do I give? Reevaluation of insulin dosing estimation formulas using continuous glucose monitoring.

Objective: To reevaluate current formulas for determining the total basal insulin dosage (TBD), insulin to carbohydrate ratio (ICR), and correction factor (CF) from weight or total daily dosage (TDD) in pump-treated patients with type 1 diabetes mellitus.

Methods: From a post hoc analysis of data from 4 previously published studies, subjects who met the inclusion criteria were selected. No subject was duplicated.

Minimal reduction in insulin dosage with pramlintide therapy when pretreatment near-normal glycemia is established and square-wave meal bolus is used.

Objective: To evaluate the effect of near-normal glucose control before initiation of pramlintide therapy and square-wave meal bolus on self-reported hypoglycemia and the percentage change in dosing parameters after attaining the maximum pramlintide dosage.

Methods: In this prospective study, insulin pump-treated patients with type 1 diabetes had insulin dosages optimally titrated on the basis of daily continuous glucose monitoring (CGM). Pramlintide therapy was initiated, and the dosage was increased 15 mcg/meal per week.

Once-daily insulin detemir is comparable to once-daily insulin glargine in providing glycaemic control over 24 h in patients with type 2 diabetes: a double-blind, randomized, crossover study.

Once-daily dosing with insulin detemir and insulin glargine were compared in a double-blind, randomised, crossover study in type 2 diabetes subjects previously treated with other antihyperglycaemic medications. Blood glucose was measured through continuous glucose monitoring (CGM). Insulin dose was adjusted daily during the titration phase to achieve target blood glucose values of (70-120 mg/dL) during the basal period, defined as 2400-0600 hours.

Agreement between glucose trends derived from three simultaneously worn continuous glucose sensors.

Background: Sensors detect the rate and direction of glucose trend. They need to be accurate and reproducible as could be evidenced by strong agreement between multiple sensors. We evaluated this relationship through simultaneously worn glucose sensors using several methods of slope analysis.

Basal bolus dosing: a clinical experience.

Basal bolus insulin dosing (BBD) may be defined as the physiological replacement of basal and bolus insulin to achieve near normal glycemia without hypoglycemia and loss of life quality. Normally, continuous and variable basal insulin release provides partial suppression of hepatic glucose production to maintain euglycemia during the fasting period. With meals, additional insulin is released in a biphasic pattern to further suppress hepatic glucose production and to increase glucose transport into muscle, fat and liver.

Evaluation of a patient education booklet (SimpleStart) effect on postprandial glucose control in type 2 diabetes.

Background: Post-meal hyperglycemia is emerging as a cardiovascular risk factor and may be elevated despite a hemoglobin A1C (A1C) of <7%. The Simple Start DVD (LifeScan, Milpitas, CA) was developed to educate patients about glycemic targets and dietary changes that could lessen glycemic excursions. We evaluated SimpleStart in a controlled, randomized, prospective trial using continuous glucose monitoring (CGM).

A prospective evaluation of insulin dosing recommendations in patients with type 1 diabetes at near normal glucose control: bolus dosing.

Background: Current bolus insulin dosing recommendations are based on retrospective studies of patients with Type 1 diabetes in whom the glucose control was not intensely established. Using continuous glucose monitoring (CGM), we prospectively studied these recommendations in patients treated with continuous subcutaneous insulin infusion.

Methods: Thirty subjects were studied over a mean of two weeks of continuous glucose monitoring with near daily insulin adjustments.

A prospective evaluation of insulin dosing recommendations in patients with type 1 diabetes at near normal glucose control: Basal dosing.

Background: Current basal insulin dosing recommendations are based on retrospective studies of Type 1 patients with diabetes in whom the glucose control was not intensely established. Using continuous glucose monitoring (CGM) we prospectively studied these recommendations in patients treated with continuous subcutaneous insulin infusion.

Methods: With CGM 30 subjects were titrated with daily insulin adjustments to achieve a basal glucose targets of <5% of values <70 mg/dl and <20%, >170 mg/dl.