Splitting the Evening Insulin Dose To Avoid Low Blood Sugar Levels and To Improve Sugar Control in Patients with Type 1 Diabetes. Ann Intern Med. 2002;136:I29. doi: 10.7326/0003-4819-136-7-200204020-00002
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Published: Ann Intern Med. 2002;136(7):I29.
Type 1 diabetes mellitus (also called juvenile diabetes) occurs when the pancreas stops making insulin. Insulin helps the body use the energy in foods. Without insulin, blood levels of sugar become high. Over time, high blood sugar levels can lead to blindness, kidney failure, damage to nerves, and heart disease. To keep blood sugar levels in the normal range, people with type 1 diabetes must inject insulin several times each day and follow a special diet. There are several types of insulin. Short-acting (regular or lispro) insulins begin to act soon after injection. Long-acting (neutral protamine Hagedorn [NPH], lente, ultralente, or glargine) insulins do not begin to act until several hours after injection, but then they continue to act for many hours. For example, a dinnertime injection of long-acting insulin controls sugar levels throughout the night. A very low blood sugar level (hypoglycemia) is a dangerous complication of insulin treatment. To avoid hypoglycemia during the night, doctors often tell patients to “split” their evening insulin dose by taking short-acting insulin at dinner and long-acting insulin at bedtime instead of taking both forms of insulin at dinnertime (“mixing”). However, nobody has done a careful study to see whether “splitting” is truly better than “mixing” the evening insulin.
To see whether splitting the evening insulin dose decreases hypoglycemia and improves blood sugar control compared with mixing evening insulin at dinner.
22 patients with type 1 diabetes, all of whom were injecting insulin four times daily at the beginning of the study.
The researchers assigned patients at random to a 4-month period of either mixed (regular [short-acting] and NPH [long-acting] insulin at dinnertime) or split treatment (regular insulin at dinner and NPH insulin at bedtime). After 4 months, the patients switched to the other treatment. Patients measured their blood sugar levels before meals and at bedtime daily, at 3:00 a.m. every other day, and whenever they thought their sugar level was low. The researchers measured the number of hypoglycemic episodes and the general sugar control.
Split treatment led to fewer episodes of nighttime hypoglycemia than mixed treatment. General sugar control was also better with split treatment.
This study did not include the types of patients who are at greatest risk for hypoglycemia, such as young children or older adults. In addition, it is not known whether the study's results apply to patients who use types of short-acting and long-acting insulin other than regular and NPH insulin.
This study supports the common recommendation that patients split evening insulin doses into short-acting insulin with dinner and long-acting insulin at bedtime.
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Cardiology, Endocrine and Metabolism, Diabetes, Coronary Risk Factors.
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