ABSTRACT
There are few bigger challenges for medical practitioners than taking care of patients with type 1 diabetes mellitus. The difficulties are numerous. Glucose homeostasis is normally controlled by a complex physiology of precise variations in insulin secretion that exactly counter the wide swings in nutrient intake, physical activity, and stress of modern society. Attempts over the years to approximate this system using subcutaneous insulin have suffered from insulin preparations that lack the pharmacokinetics of the normal system. In addition, the average physician received little training in insulin usage during his or her internship and residency, and there have been few CME programs in this area. Also, there is a clear understanding by most physicians that if they aggressively push insulin doses to tolerance, the result too often is hypoglycemia that can vary anywhere from annoying to life-threatening. Finally, patients are not always advocates for their care; sometimes the attitude is ‘‘The fewer shots, the better’’ or ‘‘I feel great, so why must I do so many finger sticks?’’ The net consequence is that premixed insulins are the most prescribed insulin preparations in the United States, and national surveys continue to show distressingly high HbA1c values.
88 Leahy
