Updated July 25, 2006

Selecting an Insulin Program for Type 1 Diabetes

by Gary Scheiner, M.S., C.D.E.

The Station Wagon is one of those work-intensive, low-glitz regimens known as multiple daily injection therapy. Intermediate- or long-acting insulin taken once a day at bedtime provides an early-morning peak to cover typically higher morning insulin needs, as well as a prolonged “tail” of action that usually ensures the presence of background insulin throughout the day. Because intermediate-acting insulin is not peaking during the day, you have more flexibility with meal times. However, the intermediate- or long-acting insulin may not last a full 24 hours, putting some users at risk for high blood sugar in the afternoon or evening.

The Station Wagon plan is a fairly reliable program that offers good diabetes control, although it also requires frequent “pit stops” to fuel up with insulin at every meal and carbohydrate-containing snack. Taking insulin with each meal and snack allows you to closely match insulin doses to anticipated carbohydrate consumption and planned activity, as well as to make timely corrections for high readings before meals. Many people find that using insulin pens instead of syringes can make frequent injections less of a chore.

Option 4: The Muscle Car
BREAKFAST: aspart, lispro, or glulisine
LUNCH: aspart, lispro, or glulisine
DINNER: aspart, lispro, or glulisine
SNACK: aspart, lispro, or glulisine
ONCE A DAY, AT A CONSISTENT TIME: glargine or detemir

Glargine and detemir are those hot, new insulins that everyone wants to take for a test drive. They are the first formulations that serve as truly basal insulins—that is, they provide relatively steady and peakless coverage for approximately 24 hours. As with the Station Wagon program, the Muscle Car plan requires injections at every meal and snack. Although glargine or detemir can be injected at any time of day, it must always be given in a separate syringe, since mixing it with another insulin can alter its activity.

People on this program must be willing to take lots of shots, but the lack of a basal insulin peak translates into consistent absorption and activity from day to day, allowing flexible meal, snack, and exercise times and enabling you to match mealtime boluses to carbohydrate consumption and planned activity. Occasionally, people may have high readings in the morning due to the liver’s increased glucose production at night. Lows can also occur in the middle of the day, when basal insulin needs tend to be lower.

Using basal glargine or detemir together with mealtime rapid-acting insulin more closely mimics the activity of a healthy pancreas than other injection regimens. Overall, long-acting insulin users seem to experience far fewer lows and have much better overall diabetes control than those who use intermediate-acting insulin.

Option 5: The Engineered Import
Insulin pump therapy

Insulin pumps are beeper-size, computerized devices that contain only rapid-acting insulin. Pumps are programmed by the user to deliver tiny pulses of insulin every few minutes, providing basal insulin coverage throughout the day and night. Larger boluses are programmed and delivered with the touch of a button at mealtimes. The insulin is delivered by way of a small, soft plastic tube called an infusion set, which is inserted just below the skin. The infusion set must be changed every couple of days to prevent infection and ensure consistent insulin absorption.

What makes pump therapy unique is the ability to adjust basal insulin levels in a fairly precise manner. By programming the basal insulin output to match the body’s normal production of glucose, pump users can attain the utmost freedom and flexibility in terms of food, activity, and sleep patterns. Special basal insulin patterns or temporary basal rates can also be set for certain days or for occurrences such as the premenstrual period, pregnancy, stress, illness, or extended exercise, when basal needs may be higher or lower than usual.

Gary Scheiner is a Certified Diabetes Educator with his own private practice in Wynnewood, Pennsylvania, specializing in intensive diabetes management. He has had Type 1 diabetes for 20 years and currently follows the Engineered Import Plan (pump therapy) but drives a Dodge Grand Caravan. Gary and his staff of Certified Diabetes Educators offer diabetes education and management consultations via phone, fax, and Internet to people throughout the world. Please direct inquiries to Gary at his Web site, www.integrateddiabetes.com, via e-mail at gary@integrateddiabetes.com, or by phone at (877) 735-3648.

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