![]() The arrival of continuous glucose monitors to clinical practice has proven beneficial in specific circumstances. However, there is no consensus to guide the choice of injection or pump therapy in a given patient, and research to guide this decision-making is needed ( 12). However, a recent systematic review and meta-analysis concluded that pump therapy has modest advantages for lowering A1C (–0.30% ) and for reducing severe hypoglycemia rates in children and adults ( 11). Most studies comparing multiple daily injections with CSII have been relatively small and of short duration. There are multiple approaches to insulin treatment, and the central precept in the management of type 1 diabetes is that some form of insulin be given in a planned regimen tailored to the individual patient to keep them safe, out of diabetic ketoacidosis, and avoid significant hypoglycemia, with every effort made to reach the patient’s glycemic targets. Despite the advantages of insulin analogs in patients with type 1 diabetes, for some patients the expense and/or intensity of treatment required for their use is prohibitive. ![]() In addition, new longer-acting basal analogs (U-300 glargine or degludec) may confer a lower hypoglycemia risk compared with U-100 glargine in patients with type 1 diabetes ( 9, 10). Inhaled human insulin has a rapid peak and shortened duration of action compared with RAA and may cause less hypoglycemia and weight gain ( 7), and faster-acting insulin aspart may reduce prandial excursions better than RAA ( 8) further investigation is needed to establish a clear place for these agents in diabetes management. More recently, two new insulin formulations with enhanced rapid action profiles have been introduced. In people with type 1 diabetes, treatment with analog insulins is associated with less hypoglycemia and weight gain as well as lower A1C compared with human insulins ( 4– 6). Over the last 25 years, rapid-acting and long-acting insulin analogs have been developed that have distinct pharmacokinetics compared with recombinant human insulins: basal insulin analogs have longer duration of action with flatter, more constant plasma concentrations and activity profiles than NPH insulin rapid-acting analogs (RAA) have a quicker onset and peak and shorter duration of action than regular human insulin. Follow-up of subjects from the DCCT more than 10 years after the active treatment component of the study demonstrated less macrovascular as well as less microvascular complications in the group that received intensive treatment. However, intensive therapy was associated with a higher rate of severe hypoglycemia than conventional treatment (62 compared with 19 episodes per 100 patient-years of therapy). In this landmark trial, lower A1C with intensive control (7%) led to ∼50% reductions in microvascular complications over 6 years of treatment. The study was carried out with short-acting (regular) and intermediate-acting (NPH) human insulins. The Diabetes Control and Complications Trial (DCCT) demonstrated that intensive therapy with multiple daily injections or continuous subcutaneous insulin infusion (CSII) reduced A1C and was associated with improved long-term outcomes ( 1– 3). However, over the past three decades, evidence has accumulated supporting more intensive insulin replacement, using multiple daily injections of insulin or continuous subcutaneous administration through an insulin pump, as providing the best combination of effectiveness and safety for people with type 1 diabetes. Severe metabolic decompensation can be, and was, mostly prevented with once or twice daily injections for the six or seven decades after the discovery of insulin. In addition to hyperglycemia, insulinopenia can contribute to other metabolic disturbances like hypertriglyceridemia and ketoacidosis as well as tissue catabolism that can be life threatening. Because the hallmark of type 1 diabetes is absent or near-absent β-cell function, insulin treatment is essential for individuals with type 1 diabetes.
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