● Simpler regimens (eg, twice-daily injections of short-acting [regular] and

intermediate-acting [NPH] insulin mixed together in the same syringe and given in fixed
amounts before breakfast and dinner) are not recommended unless the patient cannot
or will not adhere to multiple injections or an insulin pump.
● Ang treatment talaga sa Type 1 dm is bolus basal. Meaning may basal insulin ka which
controls your glucose levels throughout the day and bolus which controls your glucose
after you eat. Ang goal kasi ng insulin regimen is to mimic the physiologic insulin in our
body na wala yung patient na may type 1 dm.
○ So basically ang nagcocompete lang is whether long acting or intermediate
acting

● BASAL PRANDIAL (basal bolus same lang sila) INSULIN

○ Regular insulin and isophane (NPH-intermediate) is cheaper than the analogs of
insulin (aspart, glargine etc) so it depends on the patient

● Meron tayong 2 treatment regimens na pwede pagpilian for type 1 dm

1. Rapid/Short + NPH (intermediate) - merong premixed dito, administered
once or twice daily
a. According sa bullet 1, preferred yung long acting unless issue
yung compliance
2. Rapid/Short + Long acting

> summarize ko yung result ng study NPH vs Long

● Little glycemic advantage: LONG
● Less weight gain: LONG
● Slightly lower risk of severe hypoglycemia and nocturnal hypoglycemia: LONG
● Pero ang catch, once daily NPH lang ginamit na comparator eh diba dapat 2x daily so,
hindi pa din masama kung NPH yung gagamitin ng patient considering mas mura, pero
mas preferred lang long acting based on this study

● So clear na satin na preferred yung LONG ACTING over Intermediate acting, gagamitin lang
intermediate acting pag factor yung pera and patient compliance dahil mas madalas maginject sa
long acting (1 inject of long acting, per meal bolus)

Basal insulin options — The choice of basal insulin depends upon patient preference,
lifestyle, and cost concerns.

COMPARE NATIN LONG ACTING

● Insulin glargine – In patients with type 1 diabetes, glycemic control is similar if
once-daily glargine is given before breakfast, before dinner, or at bedtime, but there is
less nocturnal hypoglycemia with breakfast administration [39].
○ So breakfast yung preferred (sabi din kasi may peak yung glargine kaya siguro
pwede mag hypoglycemia pero according sa book peakless yung glargine so
 kaya pwede siya ibigay kahit kelan dahil basal insulin lang naman yung
icocorrect niya)
● Although many patients can achieve stable basal serum insulin concentrations with a
single daily injection of U-100 insulin glargine given in the morning or evening (regimens
3 and 4) (table 2), this is not always the case. Some patients with type 1 diabetes
achieve better glycemic control with U-100 glargine given twice per day (regimen 5)
(table 2). U-100 insulin glargine has a half-live of 12 hours.
○ Usually once a day siya pero in some patients twice a day. In our case, once a
day insulin glargine siya at night.

● Insulin detemir – The duration of action of insulin detemir is shorter than that of insulin
glargine (detemir is 17hrs glargine is ~24hrs)[40], though still somewhat longer than
NPH (10-20hrs). In one study, a detemir dose of 0.29 units/kg provided the same effect
as 0.3 units/kg NPH but with a longer duration of action (16.9 versus 12.7 hours,
respectively) [41]. Like NPH, twice-daily injections appear to be necessary in most
patients with type 1 diabetes. Duration of action is shorter when lower doses are used.
○ factor : 2x daily injections - PATIENT’S COMPLIANCE

● Insulin degludec – Insulin degludec is a very long-acting (>42 hrs) basal insulin available
in U-100 and U-200 formulations (table 1) [42]. It is administered once daily at any time
of day. In contrast to U-100 glargine and detemir insulins, degludec may be mixed with
rapid-acting insulins without appreciably altering the kinetics of the degludec or the
rapid-acting insulin. The long-term safety profile of insulin degludec is unknown.
○ According sa notes from last sem, glargine is not meant to be mixed with other
insulin (not sure if literally or pointing to 2 insulin regimens) degludec pwede

● So eliminated yung detemir kasi 2x daily injection, next is degludec vs glargine. Based
sa mga nabasa ko favorable yung degludec NG SUPER LIIT LANG meaning lamang
lang siya ng konti so not a big issue if youll choose glargine over degludec. So our
decision will base on pricing, GLARGINE is much cheaper than DEGLUDEC. Source ko

🎉🎉🎉
sa amerika sorry naman rush na (SingleCare cost $350+ (degludec) $70+(glargine)
● SO THE WINNER IS INSULIN GLARGINE (LANTUS)

NEXT, BOLUS AKA PRANDIAL INSULIN

Next na maglalaban dito is SHORT ACTING (regular insulin) VS RAPID ACTING (aspart, lispro,
glulisine)

● PRICE: mas mura REGULAR INSULIN

● CONVENIENCE, reduction of HYPOGLYCEMIA: Rapid acting
○ Why?
○ Rapid acting administered 10-15 minutes BEFORE meals or IMMEDIATELY after
meals, SHORTER duration of action so less hypoglycemic episode (avoided ang
post prandial hypogly)
 ○ Short acting, administered 30-45 minutes BEFORE meals, longer duration of
action prone to hypoglycemia
○ Correlate natin sa table (sorry di same yung minutes sa net ko lang kinuha to
pero gets same point pa din naman)

● SO ANG WINNER IS RAPID ACTING

● Between rapid acting, since same naman sila i guess price na lang labanan dito. Sorry
guys cram na to eto na lang muna
● Price sa mercury:
- Novolog (wala daw sila sa system)
- Apidra - 435
- Humalog - 420

● Based dito we choose glulisine(apidra) kasi mas mura

 ● SUMMARY WE CHOOSE: LONG ACTING AND RAPID ACTING (Glargine and Lispro,
respectively)

🥲
○ Ideally to, not taking into account yung 1 beses na nga lang na long acting ng
patient di pa niya magawa
○ So baka magbagong buhay na lang siya kasi nagka DKA na nga siya eh
○ Ang isang alternative kasi dito yung NPH diba so recall niyo na lang

How to administer: additional info lang just in case tanungin

Injection technique — The following is a description of subcutaneous insulin injection:

●Choose the site to inject (figure 2). It is not necessary to clean the skin with alcohol unless the
skin is dirty.

●Pinch up a fold of skin and quickly insert the needle at a 90° angle (or other angle, as
described above) (figure 4). Keep the skin pinched to avoid injecting insulin into the muscle.
Depending upon your body type, you may not need to pinch up a fold of skin.

●Push the plunger down completely to inject the insulin. Hold the syringe and needle in place for
5 to 10 seconds.

●Release the skin fold.

●Remove the needle from the skin.

If blood or clear fluid (insulin) is seen at the injection site, apply pressure to the area for five to
eight seconds. The area should not be rubbed, because this can cause the insulin to be
absorbed too quickly.

Needles and syringes should only be used once and then thrown away. Needles and syringes
should never be shared. Used needles and syringes should not be included with regular
household trash but should instead be placed in a puncture-proof container.