Audit of multiple insulin injection regimens in a large outpatient diabetic population

Insulin-associated weight gain in diabetes--causes, effects and coping strategies

Insulin therapy or intensification of insulin therapy commonly results in weight gain in both type 1 and type 2 diabetes. This weight gain can be excessive, adversely affecting cardiovascular risk profile. The spectre of weight gain can increase diabetic morbidity and mortality when it acts as a psychological barrier to the initiation or intensification of insulin, or affects adherence with prescribed regimens. Insulin-associated weight gain may result from a reduction of blood glucose to levels below the renal threshold without a compensatory reduction in calorie intake, a defensive or unconscious increase in calorie intake caused by the fear or experience of hypoglycaemia, or the 'unphysiological' pharmacokinetic and metabolic profiles that follow subcutaneous administration. There is, however, scope for limiting insulin-associated weight gain. Strategies include limiting dose by increasing insulin sensitivity through diet and exercise or by using adjunctive anorectic or insulin-sparing pharmacotherapies such as pramlintide or metformin. Insulin replacement regimens that attempt to mimic physiological norms should also enable insulin to be dosed with maximum efficiency. The novel acylated analogue, insulin detemir, appears to lack the usual propensity for causing weight gain. Elucidation of the pharmacological mechanisms underlying this property might help clarify the mechanisms linking insulin with weight regulation.

The reality of glycaemic control in insulin treated diabetes: defining the clinical challenges

The benefits of good glycaemic control in both type I and type II diabetes mellitus are undoubtedly proven. Most national bodies have recommended glycaemic targets, with an HbA(1c) to achieve between 6.5 and 7.5%. However, it is well known that even in clinical trials, and routinely in clinical practice, the majority of patients fail to achieve optimal glycaemic control. The reasons for this failure are complex and multifactorial. Healthcare providers often delay the initiation and intensification of insulin unnecessarily. This stems from a fear of causing hypoglycaemia or weight gain in patients, from doubts about patients' self-care abilities and/or from inadequate resources to provide the necessary structured education to support patient self-management. Patients may be poorly adherent to treatment advice-particularly behavioural aspects such as self-monitoring, diet and exercise-although this may itself derive from inadequate access to effective diabetes education. There is, however, a limit to what can be achieved with existing exogenous insulin therapies due to their imperfect pharmacokinetic and pharmacodynamic profiles. Prominent among these imperfections is the problem of variability of effect from injection to injection with basal insulin formulations. Improvements in this area should benefit control and tolerability.

Type 1 diabetes mellitus in a routine diabetes clinic: the association of psycho-social factors, diabetes knowledge and glycaemic control to insulin regime

In controlled trials intensified diabetes therapy including multiple insulin injection regimes has been shown to improve glycaemic and microvascular disease outcomes in insulin dependent diabetes but this is not clear in routine outpatient practice. We undertook a pragmatic cross sectional study of 200 patients with Type 1 diabetes aged 18-50 years. There were 108 on two insulin injections/day (conventional) and 92 on four injections/day (multiple) with no significant difference for age, sex, social class, body mass index, diabetes duration, hypoglycaemia rate or complications prevalence. The relationship of insulin injection regime used with diabetes knowledge, psychological factors and glycaemic control outcomes was evaluated. Percent glycated HbA1c concentrations (normal range < 5.5%) were worse in the multiple injection group (7.5 +/- 1.7 vs. 6.8 +/- 1.4%, P < 0.001) (mean +/- SD). Their scores for diabetes knowledge (72.5 +/- 8.2 vs. 69.0 +/- 9.8, P < 0.01) were better but treatment satisfaction (29.9 +/- 5.1 vs. 28.5 +/- 6.1, ns) and well-being (49.1 +/- 10.7 vs. 46.5 +/- 12.7, ns) scores were not. Parameters of perceived locus of control were (multiple v conventional): personal (self), 24.5 +/- 5.0 vs. 22.3 +/- 5.9, P < 0.05; medical (doctor), 11.8 +/- 5.1 vs. 10.8 +/- 5.8, ns; situational (chance), 7.9 +/- 5.1 vs. 8.9 +/- 5.9, ns. In multiple regression of HbA1c versus multiple variables only insulin regime (P < 0.001) was significant. We conclude that in routine clinical practice the use of intensive insulin regimes are associated with worse glycaemic control despite patients being marginally more knowledgeable and self directed.

Metabolic control, quality of life, and negative life events: a longitudinal study of well-controlled and poorly regulated patients with type 1 diabetes after changeover to insulin pen treatment

In a previous study of a group of 74 patients with Type I diabetes, quality of life was found to be consistently enhanced a year after transition to multiple injection therapy with the insulin pen, whereas metabolic control (HbA1C) only improved moderately. The aim of the present investigation was to examine quality of life, recent life events, and metabolic control longitudinally in this original study group over a 5-year period beginning 1 year after transition to the insulin pen. Multiple analysis of variance with a repeated-measures design was used to analyze the data longitudinally and compare metabolic control in subgroups of well-controlled and poorly regulated patients during the study period. For the group as a whole, quality of life was found to change only moderately, whereas metabolic control deteriorated significantly across time following transition to the insulin pen. The two subgroups exhibited distinct differences, however, in quality of life, recent life events, and metabolic control patterns. These findings are discussed in terms of the clinical suitability of a multiple injection regimen.

Factors influencing preference of insulin regimen in people with type 1 (insulin-dependent) diabetes

The two commonest insulin regimens in current use in the UK are twice daily administration of short- and intermediate-acting insulins in combination, and soluble insulin before meals with intermediate-acting insulin at bed-time (basal-bolus regimen). A cross-sectional sample of patients with type 1 diabetes was studied using either a twice daily insulin regimen (n = 30) or a basal-bolus regimen (n = 30), to assess their satisfaction with choice of insulin regimen and to examine the relationships between type of insulin regimen, personality, demographic variables and glycaemic control. Patients treated with a basal-bolus insulin regimen tended to be younger (P = 0.07), had an earlier onset of type 1 diabetes (P = 0.04), adjusted their dose of insulin more frequently (P = 0.01), had received more secondary and further education (P = 0.03), belonged to a higher socio-economic class, tended to be unmarried (P = 0.07) and were less likely to be smokers (P = 0.03), than the group treated with twice daily administration of insulin. Current and previous glycaemic control assessed by glycated haemoglobin concentration, showed no correlation with type of insulin regimen, demographic data or personality variables.

Influence of intensified insulin regimen on quality of life and metabolic control in insulin-dependent diabetes mellitus

Seventy-eight non-randomized patients with IDDM, aged 33.8 +/- 9.6 years (mean +/- S.D.), with a duration of diabetes of 16.6 +/- 9.5 years and a HbA1c level of 8.0% +/- 1.5 at baseline were included in the study. The effects of a change from a 3-dose insulin regimen using conventional syringes to a treatment mode using 4 injections per day with a pen injector on metabolic control, perceived distress from diabetes on everyday life and correspondence between expectations and experiences of treatment during a 1-year trial were assessed. The experience measures were registered at baseline and after 3 and 12 months, respectively. HbA1c levels were measured every 3 months. Neither the metabolic control nor the body mass index or rate of hypoglycemic episodes changed during the study period. However, the patients experienced a decreased distress from diabetes, which appeared during the first 3 months and remained unchanged thereafter. The expectations of advantages from the intensified insulin therapy were generally high and were mostly either fulfilled or exceeded by experiences. We conclude that multiple insulin injection therapy, under routine treatment conditions, is subjectively preferable to patients and has favourable effects on their quality of life although something more is required in order to also achieve an improvement of metabolic control.