Farmacologia Molecular
Farmacologia Molecular
Farmacologia Molecular
Andrew Smith, MD, and Chelsea Harris, MD, Lawrence Family Medicine Residency Program, Lawrence, Massachusetts
There is considerable benefit of tight glucose control in patients with type 1 diabetes mellitus. Tight blood glucose
control dramatically decreases the incidence of microvascular and macrovascular complications. Although glycemic
goals should be individualized, most nonpregnant adults should strive for an A1C level less than 7%. Greater
frequency of glucose monitoring and continuous glucose monitoring are both associated with lower A1C levels.
The choice to monitor glucose levels via multiple daily capillary blood samples or
continuous glucose monitoring is based on cost and patient preference. Inten-
sive insulin treatment is recommended with a combination of multiple mealtime
bolus and basal injections or with continuous insulin infusion through an insulin
pump. The option to administer insulin with multiple daily injections vs. a pump
should be individualized. Adjunctive medical therapy is under investigation but is
not currently recommended. All patients with type 1 diabetes should partici-pate
in diabetes self-management education and develop individualized premeal
The benefit of tight glucose control in patients with glycemic control reduces the risk of cardiovascular disease
type 1 diabetes mellitus is well established.1-4 Microvascular by 42% and severe cardiovascular events (nonfatal myo-
complications (e.g., neuropathy, nephropathy, retinopathy) and cardial infarction, stroke, or death from cardiovascular
macrovascular complications (e.g., myocardial infarc-tion, disease) by 57% over 11 years among patients with type 1
cerebrovascular accident, cardiovascular disease– related diabetes.3 Long-term follow-up of the Diabetes Control and
deaths) are dramatically decreased when glucose levels are
maintained as close to the nondiabetic range as possible. 4 The
numbers needed to treat with intensive ther-apy (A1C of WHAT IS NEW ON THIS
approximately 7% vs. 9%) for a 10-year period to prevent TOPIC: TYPE 1 DIABETES
progression of retinopathy and clinical neurop-athy are 3 and
1.5, respectively.2 Additionally, intensive Long-term follow-up of the Diabetes Control and Complica-tions
Trial shows that the benefit of early, aggressive insulin therapy
and intensive glycemic control persists for several decades
after treatment and is associated with a decrease in all-cause
Additional content at https://www.aafp.org/afp/2018/0815/
mortality.
p154.html.
CME This clinical content conforms to AAFP criteria for A well-designed double-blind randomized controlled trial of adults
continuing medical education (CME). See CME Quiz on with type 1 diabetes who were taking metformin did not show
page 149. significant improvement in glycemic control. The poten-tial
cardiovascular disease benefit remains under investigation.
Author disclosure: No relevant financial affiliations.
Patient information: A handout on this topic, written by the In September 2016, the U.S. Food and Drug Administration
authors of this article, is available at https://www.aafp.org/ approved the first combination glucose monitoring and auto-
afp/2018/0801/p154-s1.html. mated insulin delivery device, a hybrid closed-loop system.
154
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TYPE 1 DIABETES
SORT:KEY RECOMMENDATIONS FOR PRACTICE
Evidence
Clinical recommendation rating References
In persons with type 1 diabetes mellitus, self-monitoring C 8 The newer practice of continuous
blood glucose levels more frequently is recommended glucose monitoring, used by approxi-
because it leads to improved A1C levels.
mately 17% of persons with type 1 dia-
Basal-bolus insulin regimens are recommended for most C 14 betes, can also achieve tight glycemic
persons with type 1 diabetes. control.9 With this method, a sensor
The decision to administer insulin via multiple daily C 16 inserted into the subcutaneous tissue
injections or insulin pump can be individualized in per- measures interstitial glucose levels
sons with type 1 diabetes;neither method appears to be in real time and transmits them to a
universally more effective.
receiving device and monitor (Figure 1).
In persons with type 1 diabetes, adjunctive treatment with C 25 The effectiveness of continuous glucose
metformin for improved glycemic control is not advised. monitoring devices depends on adher-
Regular education regarding sick day management and C 35, 37
ence and does not completely eliminate
hypoglycemia should be provided to all persons with the need for capillary testing, which is
type 1 diabetes. still required for device calibration and
to confirm abnormal levels.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-qual-
ity patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, Compared with conventional
expert opinion, or case series. For information about the SORT evidence rating system, go self-monitoring, continuous glucose
to https://www.aafp.org/afpsort.
monitoring has been associated with
improved glycemic control.10 One
randomized controlled trial demon-
Complications Trial shows that the benefit of early, aggres- strated a reduction in A1C levels from approximately 7.6%
sive insulin therapy and intensive glycemic control persists to 7.1% over six months in persons 25 years or older with
for several decades after initiation of treatment. Although type 1 diabetes who used continuous glucose monitoring,
the exact pathophysiologic explanation for prolonged compared with traditional self-monitoring of blood glu-
improved outcomes remains unclear, there is a decrease in cose at least four times daily.11 Data do not show a defin-
all-cause mortality.5 itive reduction in overall severe hypoglycemic events, but
continuous glucose monitoring alarm features and trend
Glycemic Goals alerts can notify patients and caregivers to expeditiously
Tight glycemic control remains the standard of care for most administer treatment.12 The significant increase in cost
patients with type 1 diabetes. The American Diabetes Asso- associated with continuous glucose monitoring needs to
ciation recommends an A1C goal of less than 7% for non- be considered when an individual is choosing between glu-
pregnant adults (Table 1).6 Despite the benefits of lower A1C cose monitoring approaches.13
levels, goals should be personalized to account
for individual preference, history of severe hypo-
glycemia, older age, and frailty. Higher glycemic TABLE 1
targets for older adults or those with functional
impairments, multiple comorbidities, or limited Suggested Glycemic Goals from the American
life expectancy are advisable.7 Diabetes Association
A1C < 7%*
Self-Monitoring
Preprandial glucose level:80 to 130 mg per dL (4.4 to 7.2 mmol per L)
There is a strong association between more fre-
Peak postprandial glucose level†:< 180 mg per dL (10.0 mmol per L)
quent self-monitoring of blood glucose and
lower A1C levels.8 The conventional approach, *—More stringent A1C levels (i.e., < 6.5%) may be considered if preconception/
pregnant or at low risk of hypoglycemia. Less stringent A1C levels (i.e., < 8%) may
practiced by approximately 83% of patients with be considered if history of severe hypoglycemia, limited life expectancy, advanced
type 1 diabetes, is to monitor glucose levels via microvascular or macrovascular complications, extensive comor-bidities, or long-
capillary blood testing.9 Testing is advised before standing diabetes that is difficult to control despite diabetes self-management
education, appropriate glucose monitoring, and medications.
meals, before exercise, before bedtime, occasion- †—Measured one to two hours after the beginning of the meal.
ally postprandially, and anytime hypoglycemia is
Adapted with permission from American Diabetes Association. 6. Glycemic targets:
perceived.6 Although the optimal number of Standards of Medical Care in Diabetes–2018. Diabetes Care. 2018; 41(suppl
daily tests should be individualized, using these 1):S60.
indications corresponds to six to 10 tests per day.
August 1, 2018 ◆ Volume 98, Number 3 www.aafp.org/afp American Family Physician 155
TYPE 1 DIABETES
FIGURE 1 FIGURE 2
Glucose sensor
Monitor
and transmitter
Infusion set
Insulin pump
Insulin Therapy
Consensus guidelines recommend intensive treatment with
a combination of multiple mealtime bolus and basal injec-
tions or continuous insulin infusion through an insulin
pump.14 Conventional insulin pump, which consists of a small
computer containing an insulin reservoir connected via
Approximately 64% of persons with type 1 diabetes in the
tubing to a subcutaneous insertion site; also known as
United States use an insulin pump.9 The conventional porta-ble an infusion set.
insulin pump consists of an insulin reservoir, a computer chip
Illustration by Dave Klemm
to manage dosage delivery, and an infusion set with flexible
tubing (Figure 2). The unit can be clipped onto a belt or
waistband. A soft plastic cannula at the end of the tubing
inserts under the skin to deliver the insulin. Alternatively, a Most patients who use the pump use rapid-acting insu-lin
patch pump attaches an entire unit directly to the skin, does (e.g., aspart [Novolog], glulisine [Apidra], lispro [Hum-alog]),
not require a line of plastic tubing to deliver the insulin to the whereas a small minority still use regular insulin. Rapid-acting
cannula, and receives insulin delivery programming via a insulin boluses can be administered immedi-ately before meals
wireless handheld unit. Regardless of the type of pump used, to allow more flexibility.17 Small amounts of rapid-acting
the cannula insertion site is rotated every two to three days. insulin are continuously infused to provide basal insulin.
Despite the risks of lipodystrophy, cannula site dis-comfort, Depending on pump type, basal rates can be titrated as low as
and increased cost, many patients still prefer the pump to 0.01 units per hour.18 Patients who do not use the pump tend to
performing multiple daily injections. use long-acting insulin (e.g., detemir [Levemir], glargine
Basal-bolus regimens, whether through a pump or injec- [Lantus]) to meet basal demands.
tions, are considered more physiologic because they Intensive glucose control requires knowing the various
attempt to mimic normal β-cell secretion. This is in contrast factors affecting a patient’s insulin sensitivity and dos-ing
to the conventional insulin therapy used before the Diabetes requirements (Table 2).19,20 Insulin sensitivity varies
Con-trol and Complications Trial in which patients used throughout the day and throughout a person’s lifetime.
mixed short- and intermediate-acting insulins in twice-daily Puberty, pregnancy, and illness are physiologic states that
dos-ing.15 Some studies have shown improved A1C levels often require extra insulin titration. Before dosing of pre-
in adults with type 1 diabetes who use continuous infusion meal insulin, consideration needs to be made regarding
pumps. However, studies have not shown better effective- planned carbohydrate intake, planned exercise or activity
ness universally for either approach. Therefore, the levels, and current blood glucose levels (eTable A). Choice
decision between multiple daily injections or continuous of insulin type needs to account for duration of action, cost,
pump ther-apy should be individualized.16 and route of administration15,21 (eTable B).
156 American Family Physician www.aafp.org/afp Volume 98, Number 3 ◆ August 1, 2018
TYPE 1 DIABETES
Adjunctive Therapies adults with type 1 diabetes taking metformin did not show
Adjunctive therapies for patients with type 1 diabetes are significant improvement in glycemic control.25 The poten-
under investigation but are not currently recommended. 22 tial cardiovascular disease benefit from adjunctive therapies
Sodium glucose cotransporter-2 inhibitors, which pro-mote the remains under investigation.
renal excretion of glucose, are approved for use in patients
with type 2 diabetes but have not been approved for use in Lifestyle Management and Disease Prevention
patients with type 1 diabetes. Pramlintide (Sym-lin)—a DIABETES SELF-MANAGEMENT EDUCATION
synthetic analogue of human amylin that reduces postprandial All patients with type 1 diabetes should participate in
glucose via slowed gastric emptying, inhibition of glucagon continuous diabetes self-management education, which
secretion, and satiety promotion—is approved by the U.S. works to empower patients to understand how diet, phys-
Food and Drug Administration for use in type 1 diabetes and ical activity, and insulin affect their glucose levels and how
may have an association with improved glyce-mic control; glycemic levels relate to acute and chronic complications
however, long-term benefits remain unclear.23 Despite studies (Table 3).6,26-29 Diabetes self-management education has
suggesting that the addition of metformin might reduce insulin been shown to improve A1C levels and quality of life, and
doses in patients with type 1 diabe-tes,24 this has not been reduce health care costs.30,31 National standards for diabe-
substantiated. Additionally, a recent well-designed double- tes self-management education have been published by the
blind randomized controlled trial of American Diabetes Association in conjunction with the
American Association of Diabetes Educators.32
Online diabetes education resources are avail-
TABLE 2 able at http://professional.diabetes.org/content/
diabetes-educator-resources. To find a diabe-tes
Concepts in Insulin Therapy educator or a preexisting diabetes education
Term Definitions and examples program, visit http://www.diabeteseducator.org/
living-with-diabetes.
Basal insulin Sometimes referred to as background insulin
Administered to help control blood glucose levels MOTIVATIONAL INTERVIEWING
between meals and while sleeping
Motivational interviewing techniques can be an
Suggested empiric TBD formulas: effective strategy for improving glycemic con-trol.
TBD = 0.2 × weight (kg) One randomized controlled trial demon-strated that
TBD = 0.4 × total daily insulin dose adolescents with newly diagnosed type 1 diabetes
Bolus insulin Rapid- or short-acting insulin administered with meals were able to decrease their A1C level by an average
to cover carbohydrate intake or administered one of 0.6% over 12 months (com-pared with an
time to correct for hyperglycemia increase of 0.2% in the control group) by
Insulin-to- Calculated for a particular patient and particular meal participating in motivational inter-viewing sessions
carbohydrate The amount of carbohydrates (g) that, when eaten, will every six to eight weeks.33 For resources on
ratio (ICR) require 1 unit of insulin (e.g., a ratio of 1:6 at breakfast motivational interviewing specif-ically for diabetes,
equals 1 unit of insulin for every 6 g of carbohydrate visit https://www.niddk.nih. gov/health-
eaten at breakfast)
information/communication-pro-
Suggested empiric ICR formula:
grams/ndep/health-professionals/practice-trans-
ICR = 100 / TBD
formation-physicians-health-care-teams/ diabetes-
Correction The drop in blood glucose level expected to be achieved practice-changes/engaging-patients/ motivational-
factor (CF) by administering 1 unit of insulin (e.g., a correction factor of interviewing.
1:25 means that administering 1 unit of insulin decreases
blood glucose level by 25 mg per dL)
NUTRITION
The correction factor may be written as a ratio or as a
Nutritional therapy should be individualized and
whole number (i.e., CF = 1:25 or 25)
supervised under the care of a dietitian.
Suggested empiric CF formula:
Matching carbohydrate intake with insulin ther-
CF = ICR x 4.5
apy and activity level is a complex practice. One
TBD = total basal dose.
approach to managing mealtime insulin is to eat
Information from references 19 and 20. a set amount of carbohydrates with each meal
and use a fixed insulin dose. A second approach
August 1, 2018 ◆ Volume 98, Number 3 www.aafp.org/afp American Family Physician 157
TYPE 1 DIABETES
is to match insulin doses according to variable amounts of suggest that as glucose monitoring techniques and insu-lin
carbohydrates that one plans to consume. Alcohol intake types become more sophisticated, this pattern may be
should be restricted to no more than one drink per day for changing, and the rate of severe hypoglycemia may not be
women and two drinks per day for men. greater in those with tight glucose control.9
PHYSICAL ACTIVITY
The American Diabetes Association TABLE 3
suggests that adults with type 1 dia-betes
should engage in 150 minutes of Type 1 Diabetes Mellitus Chronic Care Maintenance
moderate- to vigorous-intensity physi- Assessment Frequency Comments
cal activity per week with no more than History and physical examination
two consecutive days without activity.26 Blood pressure Every visit General adult goal < 140/90 mm Hg
Prolonged sitting should be interrupted May be lower (e.g., 130/80 mm Hg) in
every 30 minutes with light activity.34 patients at high cardiovascular disease
risk and higher (e.g., 120 to 160/80 to
CARDIOVASCULAR 105 mm Hg) in pregnancy
DISEASE PREVENTION Body mass index Every visit Increased weight or body mass index
may correlate with increased insulin
Atherosclerotic cardiovascular disease resistance
is the leading cause of morbidity and Review glucose levels and Every visit Assess for compliance, risk of diabetic
mortality among persons with diabe- symptoms of extremes in ketoacidosis, and risk or presence of
tes.27 Particular attention should be glucose levels hypoglycemia
given to maximizing blood pressure Tobacco cessation Every visit For smokers only
counseling
and lipid control (Table 4).27
Contraception or precon- Every visit For women of childbearing age
Angioten-sin-converting enzyme ception planning If not using contraception:prescribe
inhibitors and angiotensin receptor prenatal vitamin, discontinue poten-
blockers should be used preferentially tially teratogenic medications, and
in patients with diabetes who have maximize glycemic control
hypertension and microalbuminuria Depression screening Annually and Increase frequency if result is positive
as needed
(urinary albumin-to-creatinine ratio
Foot examination Annually Inspection, pulses, reflexes, sensation/
greater than 30 mg per g).27
monofilament
158 American Family Physician www.aafp.org/afp Volume 98, Number 3 ◆ August 1, 2018
TYPE 1 DIABETES
TABLE 3 (continued)
August 1, 2018 ◆ Volume 98, Number 3 www.aafp.org/afp American Family Physician 159
TYPE 1 DIABETES
TABLE 4
TABLE 5 FIGURE 3
160 American Family Physician www.aafp.org/afp Volume 98, Number 3 ◆ August 1, 2018
TYPE 1 DIABETES
August 1, 2018 ◆ Volume 98, Number 3 www.aafp.org/afp American Family Physician 161
TYPE 1 DIABETES
4. Nathan DM; DCCT/EDIC Research Group. The diabetes control and 22. George P, McCrimmon RJ. Potential role of non-insulin adjunct therapy in
complications trial/epidemiology of diabetes interventions and compli- Type 1 diabetes. Diabet Med. 2013;30(2):179-188.
cations study at 30 years: overview. Diabetes Care. 2014;37(1):9-16. 23. Lee NJ, Norris SL, Thakurta S. Efficacy and harms of the hypoglycemic
5. Orchard TJ, Nathan DM, Zinman B, et al.;Writing Group for the DCCT/ agent pramlintide in diabetes mellitus. Ann Fam Med. 2010;8(6):542-549.
EDIC Research Group. Association between 7 years of intensive treat- 24. Vella S, Buetow L, Royle P, Livingstone S, Colhoun HM, Petrie JR. The
ment of type 1 diabetes and long-term mortality. JAMA. 2015;313(1): 45- use of metformin in type 1 diabetes: a systematic review of efficacy.
53. Diabetologia. 2010;53(5):809-820.
6. American Diabetes Association. 6. Glycemic targets:Standards of Med- 25. Petrie JR, Chaturvedi N, Ford I, et al.;REMOVAL Study Group. Cardio-
ical Care in Diabetes–2018. Diabetes Care. 2018;41(suppl 1):S55-S64. vascular and metabolic effects of metformin in patients with type 1
7. Lipska KJ, Ross JS, Miao Y, Shah ND, Lee SJ, Steinman MA. Potential diabetes (REMOVAL):a double-blind, randomised, placebo-controlled
overtreatment of diabetes mellitus in older adults with tight glycemic trial. Lancet Diabetes Endocrinol. 2017;5(8):597-609.
control. JAMA Intern Med. 2015;175(3):356-362. 26. American Diabetes Association. 4. Lifestyle management:Standards of Medical
Care in Diabetes–2018. Diabetes Care. 2018;41(suppl 1):S38-S50.
8. Miller KM, Beck RW, Bergenstal RM, et al.; T1D Exchange Clinic Net-
work. Evidence of a strong association between frequency of self-mon- 27. American Diabetes Association. 9. Cardiovascular disease and risk man-
itoring of blood glucose and hemoglobin A1c levels in T1D exchange agement:Standards of Medical Care in Diabetes–2018. Diabetes Care.
clinic registry participants. Diabetes Care. 2013;36(7):2009-2014. 2018;41(suppl 1):S86-S104.
9. T1D Exchange. Better, faster research:the value of the T1D Exchange 28. American Diabetes Association. 3. Comprehensive medical evaluation
Clinic Registry. 2016. https://t1dexchange.org/pages/slideshows/value-of- and assessment of comorbities: Standards of Medical Care in Diabe-tes–
the-t1d-exchange-clinic-registry/. Accessed August 30, 2017. 2018. Diabetes Care. 2018;41(suppl 1):S28-S37.
29. Chiang JL, Kirkman MS, Laffel LM, Peters AL;Type 1 Diabetes Sourcebook
10. Pickup JC, Freeman SC, Sutton AJ. Glycaemic control in type 1 diabe-tes
Authors. Type 1 diabetes through the life span:a position statement of the
during real time continuous glucose monitoring compared with self
monitoring of blood glucose: meta-analysis of randomised controlled American Diabetes Association. Diabetes Care. 2014;37(7):2034-2054.
trials using individual patient data. BMJ. 2011;343:d3805. 30. Cooke D, Bond R, Lawton J, et al.; U.K. NIHR DAFNE Study Group.
Structured type 1 diabetes education delivered within routine care: impact
11. Tamborlane WV, Beck RW, Bode BW, et al.; Juvenile Diabetes Research
on glycemic control and diabetes-specific quality of life. Diabe-tes Care.
Foundation Continuous Glucose Monitoring Study Group. Continuous
2013;36(2):270-272.
glucose monitoring and intensive treatment of type 1 diabetes. N Engl J
Med. 2008;359(14):1464-1476. 31. Robbins JM, Thatcher GE, Webb DA, Valdmanis VG. Nutritionist visits,
diabetes classes, and hospitalization rates and charges: the Urban Dia-
12. Hommel E, Olsen B, Battelino T, et al.;SWITCH Study Group. Impact of
betes Study. Diabetes Care. 2008;31(4):655-660.
continuous glucose monitoring on quality of life, treatment satis-faction,
and use of medical care resources:analyses from the SWITCH study. 32. Beck J, Greenwood DA, Blanton L, et al. 2017 national standards for dia-
Acta Diabetol. 2014;51(5):845-851. betes self-management education and support. Diabetes Educ. 2017;
43(5):449-464.
13. Huang ES, O’Grady M, Basu A, et al.;Juvenile Diabetes Research Foun-
33. Channon SJ, Huws-Thomas MV, Rollnick S, et al. A multicenter random-
dation Continuous Glucose Monitoring Study Group. The cost-effec-
ized controlled trial of motivational interviewing in teenagers with dia-
tiveness of continuous glucose monitoring in type 1 diabetes [published
betes. Diabetes Care. 2007;30(6):1390-1395.
correction appears in Diabetes Care. 2010;33(9):2129]. Diabetes Care.
2010;33(6):1269-1274. 34. Katzmarzyk PT, Church TS, Craig CL, Bouchard C. Sitting time and
mortality from all causes, cardiovascular disease, and cancer. Med Sci
14. American Diabetes Association. 8. Pharmacologic approaches to gly-
Sports Exerc. 2009;41(5):998-1005.
cemic treatment:Standards of Medical Care in Diabetes–2018. Diabe-tes
Care. 2018;41(suppl 1):S73-S85. 35. Seaquist ER, Anderson J, Childs B, et al. Hypoglycemia and diabetes: a
report of a workgroup of the American Diabetes Association and the
15. DeWitt DE, Hirsch IB. Outpatient insulin therapy in type 1 and type 2 Endocrine Society. Diabetes Care. 2013;36(5):1384-1395.
diabetes mellitus:scientific review. JAMA. 2003;289(17):2254-2264.
36. Cryer PE. Diverse causes of hypoglycemia-associated autonomic fail-ure
16. Yeh HC, Brown TT, Maruthur N, et al. Comparative effectiveness and in diabetes. N Engl J Med. 2004;350(22):2272-2279.
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37. Brink S, Joel D, Laffel L, et al.; International Society for Pediatric and
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17. Radermecker RP, Scheen AJ. Continuous subcutaneous insulin infusion Pediatr Diabetes. 2014;15(suppl 20):193-202.
with short-acting insulin analogues or human regular insulin:efficacy,
38. U.S. Food and Drug Administration. FDA news release:FDA approves
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2016. https://www.fda.gov/newsevents/newsroom/pressannouncements/
18. McAdams BH, Rizvi AA. An overview of insulin pumps and glucose sen- ucm522974.htm. Accessed August 30, 2017.
sors for the generalist. J Clin Med. 2016;5(1):E5. 39. Russell SJ, El-Khatib FH, Sinha M, et al. Outpatient glycemic control with a
19. Petznick A. Insulin management of type 2 diabetes mellitus. Am Fam bionic pancreas in type 1 diabetes. N Engl J Med. 2014;371(4):313-325.
Physician. 2011;84(2):183-190. 40. Robertson RP, Davis C, Larsen J, Stratta R, Sutherland DE; American
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Technol. 2012;6(1):191-203. 41. Havas S, Donner T. Tight control of type 1 diabetes:recommendations for
21. Donner T. Insulin – Pharmacology, Therapeutic Regimens and Princi- patients. Am Fam Physician. 2006;74(6):971-978.
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23, 2017. 1985-1992.
162 American Family Physician www.aafp.org/afp Volume 98, Number 3 ◆ August 1, 2018
TYPE 1 DIABETES
eTABLE A
Adjust insulin dose based on the difference between current glucose level and target level using the correction factor
Calculate the difference between current (premeal) glucose level and target glucose level
Adjust (increase or decrease) insulin dose based on the difference between current and target levels (e.g., if premeal glu-
cose is 90 mg per dL [5.0 mmol per L] over target and the correction factor is 30, then use 3 additional units of insulin)
Inject insulin
Caveats:
Additional factors to consider include physical activity and type of insulin
In place of adjusting insulin doses based on variable food intake, some patients eat a set amount of carbohydrates with
each meal and use a fixed insulin dose;although this requires less variability in insulin management, it also requires a
more stringent approach to meals and limits dietary flexibility
Meal: Turkey sandwich with two slices of whole wheat bread, cheese, turkey
Apple
Greek yogurt
Carbohydrate ratio:1:6
Correction factor: 25
*—Carbohydrate values obtained from American Diabetes Association. My food advisor. http://tracker.diabetes.org/. Accessed August
23, 2017.
August 1, 2018 ◆ Volume 98, Number 3 www.aafp.org/afp American Family Physician 162A
TYPE 1 DIABETES
eTABLE B
Insulin Types
Effective
Insulin Onset Peak duration Cost*
Rapid acting
Aspart (Novolog) 5 to 15 minutes 30 to 90 minutes 5 hours $540 for five 3-mL flexpens (100 units per mL)
Glulisine (Apidra) 15 to 30 minutes 30 to 60 minutes 4 hours $425 for five 3-mL solostar pens (100 units per mL)
Lispro (Humalog) 5 to 15 minutes 30 to 90 minutes 5 hours $550 for five 3-mL kwikpens (100 units per mL)
Short acting
Regular 30 to 60 minutes 2 to 3 hours 5 to 8 hours $165 for one 10-mL vial (100 units per mL)
Intermediate acting
Isophane insulin 2 to 4 hours 4 to 10 hours 10 to 16 hours Novolin:$25 for one 10-mL vial (100 units per mL)
(neutral protamine Humulin:$290 for five 3-mL kwikpens (100 units
Hagedorn) per mL)
Long acting
Detemir (Levemir) 3 to 4 hours Small peak 6 to 20 to 24 hours $425 for five 3-mL flexpens (100 units per mL)
8 hours
Glargine (Lantus) 2 to 4 hours No peak 20 to 24 hours $260 for five 3-mL solostar pens (100 units per mL)
*—Estimated retail price of brand-name insulin based on information obtained at https://www.healthcarebluebook.com (accessed April 11, 2018).
Information from:
DeWitt DE, Hirsch IB. Outpatient insulin therapy in type 1 and type 2 diabetes mellitus:scientific review. JAMA. 2003;289(17):2254-2264.
Donner T. Insulin – Pharmacology, Therapeutic Regimens and Principles of Intensive Insulin Therapy. South Dartmouth, Mass.:MDText.com, Inc.;
https://www.ncbi.nlm.nih.gov/books/NBK278938/. Accessed August 23, 2017.
162B American Family Physician www.aafp.org/afp Volume 98, Number 3 ◆ August 1, 2018