Now that we have the pathogenesis and the
complications of diabetes mellitus behind
us, we’ll take a look at an important topic
of management of diabetes mellitus.
Ultimate objective… glycemic control, if
you were able to properly monitor it, it would
decrease the complications, big time, of…
especially of your blood vessels.
Once again, we talked about microvascular
complications of type I and type II diabetes
You’re referring to your issues of diabetic
retinopathy, diabetic nephropathy, diabetic
If it’s macrovascular diseases, that-that
is referring to your atherosclerosis and you’re
referring to coronary arterial disease, referring
to your renal arterial stenosis, referring
to cerebrovascular accidents, peripheral vascular
disease… things that we have talked about
The Diabetic Association offers the following
Prior to eating preprandial, you want your
glucose level to be between 80 to 120…
80 to 120 milligrams per decilitre.
At bedtime before going to sleep, you would
want your glucose levels to be between 100
After eating, obviously your glucose levels
However, you still want it to be less than
180 because a big time pathologic effect of
your diabetes mellitus is after you eat and
you have the spikes and that’s the problem,
The spikes over a long period of time, say
years and years and years… the spikes are
what really, truly causes the ultimate damage
to let’s say the blood vessels in vascular
For you to be able to control the spikes,
you should be able to control your complications.
You would like the HbA1C to be less than seven
percent and what this means, once again, is
that you have your glucose that is then being
bound to haemoglobin and over let’s say
the lifespan of an RBC will give you an average.
Less than seven percent is equivalent to…
BG is blood glucose of approximately 150 milligrams
Therefore, if it starts rising above seven
percent, you’re highly suspicious of your
patient having diabetes mellitus.
Now, a type I diabetic requires insulin pump
immediately whereas with type II diabetes,
we will be talking about a whole host of medications
that hopefully will be able to give you what
ADA recommends with glycemic control.
Begin our topic with insulin therapy and we
have total daily dosage, TDD.
For type I typically 0.5 units.
I would know this in great detail and diabetes
is such a huge issue in our society and so,
therefore, the more that you know about this,
the better off you’ll be on your wards and
on your boards.
With type II, typically one to two units per
kilogram per day; if on insulin therapy alone
roughly half of your total daily dosage is
given as basal and by that we mean, continuous
insulin in the form of what’s known as glargine
subcutaneous daily… daily.
Glargine, we’ll talk more about the drugs
We have determir subcutaneous two times a
day; your NPH subcutaneous and I will talk
to you about NPH coming up, or continuous
subcutaneous insulin diffusion CSII.
To continue our discussion of insulin… the
remaining half of TDD, so we have half and
half, is given as parandial coverage.
Remember I told you once again, it’s quite
important for you to make sure that you cover
the spikes that take place with glucose after
eating so this then covers the meal and the
Generally, this is given as a rapid acting
insulin just prior to breakfast so that you
are then preventing the spikes that I was
I’ll give you a few management or regimens
and which we will walk through the different
times of the day and different regimens that
are quite commonly asked on your boards.
Insulin is the only current approved therapy
for treatment of diabetes during pregnancy.
The types of insulin… it’s important that
you pay attention to the types, big time.
If it’s rapid acting, the drugs include…
one of the names include lispro, aspart and
what’s known as glulisine.
Rapid acting, onset… minutes five to fifteen.
This is typically given so that you can then
prevent the spikes from occurring.
The peak will be approximately an hour.
Keep it simple for right now, give yourself
Generally speaking, as you go through the
table, and then at some point come back in,
highlight or commit to memory the details.
Duration about two to four hours, so rapid
acting… lispro is a big one.
Regular… this is once again minutes, but
double that of rapid with onset.
The peak here regular a little bit later,
so approximately two to four hours; duration
is a little bit longer five to eight hours.
To make your life a little bit easier, if
you wish to double each one of this, for example,
rapid onset 15 minutes, regular onset 30 minutes.
Peak in rapid one hour; the peak in regular
The duration in rapid four hours; regular
we have eight hours.
At first, keep it simple, give yourself a
pattern; if you’re not familiar with the
details then you go back.
Then we have something called intermediate
and we’ll refer to this as being NPH.
Onset here a lot longer two hours; peak a
lot longer at 10 hours or 6 to 10; duration
almost an entire day… intermediate.
Then we have long-acting…we have glargine
Two hours for onset pretty much the same as
intermediate; there is absolutely no peak
or non-effective peak.
The duration here will be a day at least or
perhaps even more especially with glargine.
We’ll take the table here and I’ll give
you a few graphs upcoming in which a couple
of regimens become very important to you so
that you have an idea as to what kind of graph
and how to utilize it when you’re dealing
Let’s take a look, examples of insulin regimens.
Remember that NPH means intermediate and we
have the rapid acting regular and with regular,
you probably want to double that of what you
find with rapid-acting referring to lispro.
At first, I’d like for us to start at the
top and the middle.
The X-axis refers to the times in a day so
we have morning, we have afternoon, evening
And you’ll notice that we have given in
the morning regular and with regular, remember
it takes about double that of onset.
So, you’re looking at approximately 30 minutes
of onset and you’re looking at approximately
two hours of it peaking.
In the meantime, the one in the morning gives…
well, we have given your NPH intermediate.
This then covers what’s occurring throughout
the entire day.
Next, in the evening, you’ll be given regular
once again and you’ll also give your intermediate
or lente so that you can cover what’s occurring
at night with your spikes.
Let’s take a look at what happens in the
bottom left, another regimen.
Lispro refers to your rapid acting and by
rapid acting, we’re referring to 15 minutes
with it, onset approximately an hour for it
What’s occurring here is that with every
meal… morning breakfast, afternoon lunch,
evening dinner… you’re trying to maintain
or trying to control that spike by giving
the rapid acting.
In the meantime, to make sure that you cover
yourself throughout the entire day, you then
have your lente or your NPH.
Now, what we’re seeing here on the X-axis
would be various meals obviously… breakfast,
lunch and supper, okay, supper S, dinner.
And then on the bottom and to the right, we
have another regimen.
We have three doses of the regular that we’re
In addition to that, we have, during supper
in the evening, we’re giving an ultralente
so that we have proper coverage at night.
Three different coverages just to give you
an idea as to how insulin regimens work.
You divide these with the times of the day,
you divide these with the meals of the day
and depending as to what you want to use or
combination of intermediate-regular, intermediate-rapid-acting
and so on and so forth.