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From New York, USA:

I am interested in learning how other Type 1 diabetics regulate their daily injections, meals, and monitoring, to attain a target range of glucose levels during the course of each day. I primarily find problems with overnight levels that are fine at bedtime, but rise in the morning (at fasting testing), even though I have not eaten any snack upon going to bed.


We diabetologists are striving every day with our patients to obtain as "normal" as possible metabolic control, with the goal of preventing of complications while maintaining as "normal" as possible the quality of life. To attain this goal, we encourage continuing education of patients and their parents on how to handle insulin dosages, food and exercise on a very flexible basis: this means being aware of what insulin timing and absorption mean in terms of avoiding extremes of blood sugars, and to allow a normal consumption of food and a good amount of daily exercise.

A major problem in replacing insulin is that currently no depot insulin (Lente, NPH) exists that is capable of mimicking exactly the basal insulin secretion of the healthy pancreas. Because all the available long-acting insulins have a peaks as part of their profile, excess action at midnight and insulin waning at dawn may occur whenever such an insulin preparation is given at supper time, often resulting in hypoglycemia in the early evening and hyperglycemia in the morning.

The very important problem of overnight blood sugar levels in IDDM is further complicated by two more phenomena: the Somogyi effect and the dawn phenomenon.

To sum up, insulin deficiency during the night time is the most important cause of fasting hyperglycemia, and also contributes to the next day's metabolic control. You can ask your doctor how to correct this abnormality either by splitting the evening mixed insulin administration (for example, by changing to Regular before supper and NPH at bedtime).


[Editor's comment: Many endocrinologists feel that synthetic human Ultralente comes close to not having any peak effect, especially when given in two doses per day. The older animal-source Ultralente (which is no longer available in the USA) came even closer. WWQ]

Original posting 29 Jun 97


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