Building Competency in Diabetes Education THE ESSENTIALS

BASAL-BOLUS INSULIN THERAPY | 12-12

Risks of basal-bolus insulin therapies Personal t ime and financial investment

The time required to test BG, maintain records, engage in dialogue with health-care professionals and learn about and evaluate personal approaches/responses to therapies under different conditions is considerable. The cost of supplies (e.g. pump-therapy supplies, strips for frequent BG monitoring, sensors) is also a consideration, especially for those who have limited health-care benefits or provincial/territorial financial coverage.

Risk of hypoglycemia Hypoglycemia remains the main barrier to achieving glycemic targets and the most common side effect for people on intensive insulin therapy (15).

Basal-bolus insulin vs. conventional insulin therapy In the DCCT, the intensive therapy study participants had three times the rate of severe hypoglycemia. Achieving near-normal glycemic control may also be associated with increased hypoglycemic unawareness, so the risk of severe hypoglycemia may be increased (8). However, in the decades since the DCCT, strategies to lower the risk of hypoglycemia have evolved (see Chapter 8: Acute Complications, and below). Studies since the DCCT have identified adequate SME and SMS, appropriate glycemic targets, self monitoring of bood glucose,, insulin analogues, professional support and intensive therapy as factors that can result in less hypoglycemia (16,24). If hypoglycemic unawareness occurs, patients will need to adjust their target BG goals upward to provide a more acceptable margin of safety and reverse the unawareness. All persons on insulin should be equipped to address hypoglycemia by carrying a glucose source at all times. If patients are at risk of severe hypoglycemia, it is important to prepare significant others/colleagues to assist with a severe hypoglycemic episode, including the use of glucagon, if necessary. Rapid- or long-acting insulin analogues to improve BG control and reduce risk of hypoglycemia Improved A1C, postprandial glycemic control and less hypoglycemia are noted when using rapid-acting insulin analogues and appropriate basal insulin vs. short-acting insulin (1). For people with optimal glycemic control, the use of long-acting insulin analogues with short- or rapid-acting insulin resulted in a lower fasting plasma glucose and fewer nocturnal hypoglycemic events compared with once- or twice-daily NPH/N insulin (1). Several studies