Iatrogenic brittle diabetes: the hold-the-insulin decision

Modern diabetes management often involves multiple daily insulin injections (MDII) for individuals with insulin-dependent diabetes mellitus (IDDM). Such insulin regimens are increasingly composed of a larger percentage of regular insulin and a smaller percentage of intermediate- and long-acting insulin. Withholding insulin in these individuals may precipitate acute metabolic catastrophe and attendant ketosis or, even worse, frank diabetic ketoacidosis. A comprehensive understanding of normal glucose metabolism and the principles of MDII by all health care professionals both in and out of the hospital setting will foster improved metabolic control in the individual with IDDM, reduce health care costs, and have a positive effect on decreasing diabetic complications.