Selecting an Insulin Program for Type 1 Diabetes

In some insulin programs, intermediate-acting insulin can be used to cover meals that will be consumed 4–6 hours after injection. For example, NPH taken at breakfast can be used to cover the carbohydrate eaten at lunch, since their peak activity occurs around 4–8 hours later. However, because of its broad and sometimes unpredictable peaks, NPH taken in the morning can often cause blood glucose level to drop before lunch, especially if the meal is delayed.

Each insulin has its share of pluses and minuses, and choosing the right combination of basal and bolus insulins is not a simple decision. Here, then, is a user’s guide to some of the most commonly used insulin programs.

Option 1: The Beater
BREAKFAST: NPH plus aspart, lispro, or glulisine
DINNER: NPH plus aspart, lispro, or glulisine

The standard program used throughout the 1980’s and 1990’s (using Regular insulin, not one of the analogs), this plan’s main benefit — its simplicity — is also its main drawback. Although only two injections are needed a day, with intermediate-acting insulin peaking around lunchtime and tapering off in the afternoon, the Beater plan severely limits flexibility in terms of meal times and carbohydrate amounts at each meal. The large dose of intermediate-acting insulin in the morning predisposes the user to low blood glucose if lunch is even slightly delayed or if you’re more active than usual. Because you’re not taking an insulin bolus at lunchtime, you may experience high blood glucose levels right after eating. Also, if your basal insulin dissipates before your dinnertime injection, a late afternoon high can occur. With the Beater program, a bedtime snack may be needed to prevent low blood glucose at night, when the evening dose of NPH is peaking.

The Beater is a great program if you don’t like injecting yourself or if your meals and activity patterns don’t vary much from day to day. But it’s not so good if you want to manage your blood sugar intensively or if you prefer a more flexible schedule and meal plan. Many people with Type 1 diabetes start out on the Beater plan but progress to three or more daily injections for better diabetes control.

Note: Premixed insulins, such as combined NPH and lispro, can make this therapy even more convenient for some, because they eliminate the need to mix the insulins yourself. However, premixed insulins make it impossible to increase or decrease the dose of one insulin type without also changing the other.

Option 2: The Economy Compact
BREAKFAST: NPH plus aspart, lispro, or glulisine
DINNER: aspart, lispro, or glulisine
BEDTIME: NPH

This plan was designed to correct one of the common problems with the Beater program, frequent low blood glucose at night. By moving the second intermediate-acting insulin injection from dinnertime to bedtime, the insulin’s peak activity is shifted to early morning (when hormonal activity tends to cause high blood glucose), which reduces the risk of lows in the early part of the night, when insulin needs are typically lowest. However, the morning injection of the intermediate-acting insulin still tends to result in a blood sugar level drop before lunch (a midmorning snack may be necessary to prevent this), and afternoon high blood glucose can also be a problem, since the morning intermediate-acting insulin provides minimal coverage by late afternoon. An additional shot of rapid-acting insulin may be needed if you choose to have an afternoon snack.

As with the Beater program, this plan can produce frequent lows, and it can be difficult to adjust for daytime exercise due to the inconsistent absorption of the intermediate-acting insulin. The lunch meal must be consistent in carbohydrate from day to day, since it is covered by the morning injection.