Insulin Therapy for Treatment of Newly Diagnosed Type 1 Diabetes

Dr. Fran Cogen Health Pro
  • At last count, Ann Bartlett's blog on the FDA and insulin pumps has clocked in at least 32 comments (one of which was mine). A majority of these comments pertain to the choice of basal/bolus insulin regimes employed to treat type 1 diabetes. I have written other blogs that discuss insulin preparations, pros and cons of different regimes, and rationales behind the different choices. I would like to discuss the three basal/bolus regimes currently recommended by diabetes teams throughout the world.

    1. Multiple Daily injections with a basal insulin (glargine <lantus>) or Levemir <detemir>) and bolus insulin (humalog, novolog or apidra) with
      1. Basal insulin plus fixed doses of bolus insulin at meals (modified basal/bolus therapy), or
      2. Basal insulin plus doses of bolus insulin using insulin/carbohydrate ratios and insulin sensitivity factors (correction factors) that are calculated by the person with diabetes (classic basal/bolus therapy).
    2. Insulin pump therapy with programmed basal rates, insulin/carbohydrate ratios and insulin sensitivity factors

    (Of course, we still use conventional insulin therapy with NPH/Regular/rapid acting insulin when it is appropriate.)

    Add This Infographic to Your Website or Blog With This Code:


    Question: "Which is the best insulin regime to employ for the newly diagnosed type 1 patient (child, adolescent, young adult, adult)?"

    Answer: Match the insulin requirements and psychosocial needs to the person with diabetes and his/her family.


    To determine which form of insulin therapy is appropriate for each individual, a needs assessment must be conducted. After gathering information from the family, caregiver, school nurse, and day care situation an informed decision can be made. Keep in mind that the insulin regime may be changed if it is not working! No insulin therapy is ever static; changes are constantly being made during the course of treatment. Indeed, if a person with diabetes begins to experience extensive hypoglycemia on multiple daily injections despite multiple attempts to resolve the problem, I often recommend transition to insulin pump therapy. Another example is the need for different amounts of basal insulin at different times of the day. Basal insulin such as Lantus or Levemir is given in one or two doses and leaves no room for adjustments in between. If a person with diabetes requires extra insulin between 3 am and 7 am (dawn phenomenon), there is little room to manipulate these basal insulins by injection. An insulin pump, however, has the ability to deliver an increased (or decreased) amount of basal rate in a specific time period. MDIs have the advantage of security in the awareness that the insulin has been manually injected and absorbed without the worry of pump malfunction or tubing issues. Both forms of basal/bolus therapy are efficacious (DCCT).


    Many people with diabetes have expressed their feelings in regard to MDI vs. insulin pump therapy. There are those who are convinced that the best option is to start insulin pump therapy immediately; others want to utilize manual injections. However, the literature has demonstrated that overall hb A1c levels are similar with both forms of basal/bolus therapy. The key universal concept is the requirement for insulin. As such, it is my opinion that the means by which insulin is delivered should be determined by the person with diabetes (with assistance of caregivers, if the patient is a child or teen) and the diabetes team. Having stated this point of view, each family is unique and has different needs. Thus, what will work for one family may not be appropriate for another. There are even geographic differences, such as one school district will allow a child to administer insulin by injection or pump bolus independently and another will require the same child to go to the nurse's office.


    One theme that does seem to keep surfacing is that if one does not utilize pump therapy, one is not doing everything possible to control his/her diabetes. Indeed, many parents of children with diabetes experience much guilt after deciding that the pump is not for their family after extensive education. It is hard enough to cope with managing diabetes successfully, let alone feeling guilty after decisions are made with a child/teen or adult's best interests at heart. I was very much saddened by one blogger who felt shamed when conversations with other parents abruptly ceased after the realization that her child was not on a pump.

    Add This Infographic to Your Website or Blog With This Code:


    Most importantly, the child/teen/family must receive adequate education and follow-up to successfully manage diabetes. After appropriate teaching and reinforcement, transition to more intensive insulin regimes would be appropriate. To start someone an insulin pump without adequate training and diabetes educator support would be akin to driving without appropriate instruction. People will not succeed with insulin pump therapy without educational and emergency resources. In my opinion, the biggest problem with insulin pump therapy is user error as opposed to mechanical pump errors and malfunctions. Indeed, pumps, being mechanical devices, do fail. However, with appropriate instructions, a well-trained family will know how to trouble-shoot to avoid acute complications.


    The diabetes team at Children's National Medical Center requires a trial on multiple daily injections with insulin/carbohydrate ratios and insulin sensitivity factors for the patients to learn and understand how to apply the concepts that will eventually be required with insulin pump therapy. (Many of our patients elect to continue MDI and not transition to the pump). Indeed, this is the time in which minor/major adjustments to Insulin/carbohydrate ratios and insulin sensitivity factors may occur with markedly improved blood sugars. Sometimes "tweaking" of these factors, along with attention to portion size and types of carbohydrates, may do the trick! There is a huge amount of material to learn in regard to all forms of basal/bolus therapy with enormous attention to detail. Insulin pump therapy relies on computerized settings that are programmed by the user as opposed to multiple daily injections in which the person with diabetes determines dose by use of I/C ratios and ISFs. Some people want to be in control of their management by directly administering insulin to injection; others are very comfortable letting the pump do its thing. The decision to pump is an individual choice, and not necessarily an exclusive one. Some individuals employ both regimes: insulin pump therapy during the week, multiple daily injections during the weekends for convenience.


    The key point to remember is that insulin is necessary to treat diabetes. Basal/bolus therapies, whether by MDI or insulin pump therapy, are the means by which insulin is delivered. They are not mutually exclusive. At times, one regime may be more beneficial than the other. However, both forms of basal/bolus therapy are highly effective in hb A1c reduction. We are all working together to find which regime is right for you at this particular time knowing that next month (or even next week), it might be time to change and try something new.


    Add This Infographic to Your Website or Blog With This Code:

    If you're in the DC area, be sure to purchase a ticket to the April 25 game between the Washington Nationals and Los Angeles Dodgers and support children with diabetes!

Published On: March 30, 2010