Building Competency in Diabetes Education THE ESSENTIALS

BASAL-BOLUS INSULIN THERAPY | 12-9

• While the general principle is to start with the most minimally invasive therapy possible, the underlying principle of empowering patient choice is equally important. The health-care professional must make recommendations according to both principles. This will involve ensuring patient awareness of available options and collaboration with the patient in determining goals and selecting therapy. There is growing evidence to suggest short-term intensive insulin therapy used early in the course of type 2 diabetes can improve glycemic control resulting in normal glucose levels without the use of antihyperglycemic agents (23). • In practice, patient choice has increased the number of people with type 2 diabetes who use IT systems, including insulin pumps. Newer combination injectable agents may change this. • The significant reduction in the progression of retinopathy and nephropathy demonstrated in the long-term (eight years) Kumamoto Study also supports the more aggressive use of IT in patients with type 2 diabetes (24). In this study, patients receiving MDI with preprandial regular insulin and intermediate-acting insulin before bed were compared to a control group receiving BID conventional therapy. The risk of retinopathy was reduced by 68 and 57% in the primary and secondary prevention groups receiving IT, respectively (24). The benefits of IT were proven through the DCCT. Reductions in the onset and progression of retinopathy, nephropathy and a reduction in neuropathy were associated with maintaining BG at near-normal levels. The personal benefits associated with these reductions are enormous, including increased duration of life free from disability and personal pain, and decreased long- term health-care costs for the patient and society (21). Fewer complications positively affect quality of life. The goals of the DCCT were fasting and preprandial BG of 3.9 to 6.7 mmol/L, postprandial BG of <10 mmol/L, 3:00 AM glucose levels >3.6 mmol/L and A1C approximately 6.05%. These goals were not achieved during the study in spite of the support and high level of contact with health professionals (25). However, the results of the DCCT showed that patients in the intensive- therapy group had a mean A1C of 7.1%, compared to 8.9% in the conventional-treatment group. Thus, while those on IT regimens did not achieve the goals set out in the study, they did achieve significant reductions in A1C and had significant positive health outcomes with respect to the development and progression of long-term complications (10). The DCCT cohort continues to be followed in the EDIC study. During the EDIC, the Benefits of basal-bolus insulin therapies Fewer complicat ions