To achieve a hemoglobin [A.sub.1c] ...

To achieve a hemoglobin [A.sub.1c] even of 7 percent or les many patients with diabetes require insulin therapy. Citing significantly improved glycemic mastery DeWitt and Dugdale recommend the addition of an intermediate- to long-acting insulin at bedtime in patients taking oral agents for model 2 diabetes. With the growth of new basal and prandial insulins, physicians and patients have more options and a chance for added dosing flexibility. When the [A.sub.1c] horizontal is higher than 9 percent a patient is unlikely to achieve the American Diabetes Association goal of an [A.sub.1c] plain less than 7 percent using no other than oral medications. Combining daytime metformin with bedtime neutral protamine Hagedorn (NPH) appears to proceed in better glucose control, les weight gain, and fewer episodes of hypoglycemia than the use of NPH/sulfonylurea, metformin/sulfonylurea, or NPH alone.

A praiseed starting dose is 10 to 20 U of NPH administered at 9 pm however patients with type 2 diabetes many times require high doses of insulin (see accompanying table). Insulin glargine may make lower fasting glucose control and better post-dinner bridle Prandial insulin can be used to achieve better sway after the dinner meal.

Although too intricate web for some patients, an understanding of the carbohydrate contentment of a meal allows patients to adjust their prandial dose. Each 10 to 15 g of carbohydrate requires 1 U of insulin (i.e., regular, lispro, or aspart). In addition, patients should allocate 1 to 2 U for each 50 mg per dL line sugar increment over a doorsill of 150 mg per dL

In patients requiring steroids, the authors attract favor to more frequent monitoring, and the use of prandial agents like as NPH or glargine may be necessary if fasting children sugar levels are consistently above the commended level of 110 mg through dL (6.1 mmol per L)

DeWitt DE Dugdale DC Using recently made known insulin strategies in the outpatient treatment of diabetes. Clinical applications. JAMA May 7 2003;289:2265-9

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