Prevention of Hypoglycemia While Achieving Good Glycemic Control in Type 1 Diabetes
The role of insulin analogs
- Paolo Rossetti, MD,
- Francesca Porcellati, MD, PHD,
- Geremia B. Bolli, MD and
- Carmine G. Fanelli, MD, PHD
- From the Department of Internal Medicine, Section of Internal Medicine, Endocrinology and Metabolism, University of Perugia, Perugia, Italy
- Address correspondence and reprint requests to Prof. Geremia B. Bolli, University of Perugia, Department of Internal Medicine, Section of Internal Medicine, Endocrinology and Metabolism, Via E. Dal Pozzo, 6126 Perugia, Italy. E-mail: gbolli{at}unipg.it
Insulin therapy in diabetes, both at onset and after several years’ duration, is primarily directed to maintain near-normoglycemia to prevent the onset and/or delay progression of long-term complications (1,2). However, it is important that regimens of insulin therapy are designed not only to aim at near-normalizing blood glucose, but also to minimize the risk of hypoglycemia. Subjects with type 1 diabetes continuously drift between hyperglycemia and hypoglycemia. If the former prevails, long-term complications are frequently expected (1). On the other hand, hypoglycemia is not only dangerous and unpleasant, but may over time lead to the syndrome of hypoglycemia unawareness (3).
This is relevant in type 1 diabetes but also in type 2 diabetes, since over time, many type 2 diabetic subjects develop progressive pancreatic β-cell dysfunction requiring insulin therapy. Because in subjects with advanced type 2 diabetes the neuroendocrine responses to hypoglycemia are as abnormal as in type 1 diabetic patients (4), insulin therapy may become responsible for frequent and/or severe hypoglycemia in type 2 diabetic patients as well.
The goal of minimizing the risk of hypoglycemia while achieving good glycemic control is feasible as long as 1) a rational plan of insulin therapy is adopted, 2) blood glucose is properly monitored, 3) blood glucose targets are individualized, and 4) education programs are widely implemented.
In the present article, the importance of the use of insulin analogs as a key tool to achieve good glycemic control and prevent hypoglycemia is emphasized.
PHYSIOLOGY OF PLASMA GLUCOSE HOMEOSTASIS
Normal nondiabetic subjects maintain plasma glucose <100 mg/dl in the fasting and <135 mg/dl in the postprandial period. In the fasting state, this is due to the continuous release of insulin from the pancreas, which results in steady plasma insulin, thus restraining hepatic glucose production and thereby preventing fasting hyperglycemia. At mealtime, the normal pancreas releases …
