Insulin-replacement therapy usually includes both long-acting insulin (basal) and short-acting insulin (to cater to postprandial needs). In a diverse group of type 1 diabetes patients, the average daily insulin dose is typically 0.5-0.7 units/kg body weight. However, obese patients and pubertal adolescents may need more due to insulin resistance.
The basal dose constitutes about 40%-50% of the total daily dose, with the rest as premeal insulin. The mealtime insulin dose should mirror anticipated carbohydrate intake and a supplemental scale of short-acting insulin can be added for blood glucose correction. Achieving euglycemia requires more complex regimens involving multiple injections of long- or short-acting insulin.
Therapeutic endpoints guide the insulin dose used, assisted by self-monitoring of glucose and A1c measurements. Postprandial injection of a short-acting analog, based on actual food consumption, may enable smoother glycemic control in patients with gastroparesis. Hypoglycemia, a significant risk, must be balanced against the benefits of normalizing glucose control. Insulin treatment is linked with modest weight gain and rare allergic reactions. Atrophy of subcutaneous fat at the injection site (lipoatrophy) was a side effect of older insulin preparations. At the same time, hypertrophic subcutaneous fat depot is attributed to the lipogenic action of insulin at repeated injection sites.
Insulin dosage regimens generally include a mixture of analogs given as daily injections. Typically, most patients are prescribed long and short-acting analogs.
Long-acting formulations account for 40-50% of the total daily dose, and pre-meal short-acting insulin covers the remaining.
Examples include a single daily injection of long-acting glargine and three premeal short-acting insulin injections. At times, a less intensive regimen with twice-daily intermediate-acting NPH insulin for basal coverage and regular short-acting insulin before three meals are prescribed.
Glucose self-monitoring and regular A1c tests are essential to avoid undesirable insulin effects.
The most common adverse effect is hypoglycemia or abnormally low blood sugar. Such low glucose levels may cause brain damage or cardiac arrest.
Some rare effects, such as allergic reactions to recombinant human insulin, are seen in some cases.
Repeated injections at the same site significantly enlarge subcutaneous fat depots due to insulin's lipogenic action.
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