[Practical aspects of intensified insulin therapy using the basal bolus principle]

In type 1 (insulin-dependent) diabetic patients, a good metabolic control can often be achieved only by means of an intensified insulin-giving regimen. This requires multiple insulin injections, whereby 60 to 70% of the total daily insulin amount are administered as preprandial boli of short or intermediate acting insulin. The remaining 30 to 40% of the daily insulin dosage are usually given as bedtime injection. With this form of therapy, sufficient metabolic control can be achieved in the majority of patients; however, due to the kinetics of subcutaneously injected insulin, there are some limitations to this therapeutic regimen. Physiological overnight insulin requirements, i.e. relatively small insulin requirement during the first part and increased insulin requirement during the second part of the night, are difficult to meet with currently available insulin preparations. It is, therefore, nearly impossible to achieve euglycemic fasting blood glucose levels without taking the risk of nocturnal hypoglycemia. Moreover, intensified insulin therapy requires regular selfmonitoring of blood glucose, and the patients have to stick to a quantitative diet and to a relatively fixed time schedule for meal ingestion. Several practical aspects as to the time and site of injection, postponing or "skipping" meals, etc., are discussed.