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Meal-time + basal insulin therapy: Is all not well?

Published:November 09, 2019DOI:https://doi.org/10.1016/j.diabres.2019.107923
      The combination of basal and meal-time insulin therapy has a long history, growing from the introduction of basal insulin in the 1940–1950s, and the realization that this could not cover peri-meal needs. The explanation for this was not really clear until the advent of radioimmunoassay in the 1970–1980s, and indeed it was only when a small amount of C-peptide became available to investigational use that physiological meal-time insulin secretion could be quantified as around 50% of total daily requirement [
      • Kruszynska Y.T.
      • Home P.D.
      • Hanning I.
      • Alberti K.G.
      Basal and 24-h C-peptide and insulin secretion rate in normal man.
      ]. Meanwhile the advent of continuous subcutaneous insulin therapy (CSII) allowed unmodified insulin to be used as basal therapy [
      • Pickup J.C.
      • Keen H.
      • Parsons J.A.
      • Alberti K.G.M.M.
      Continuous subcutaneous insulin infusion: an approach to achieving normoglycaemia.
      ], only to be challenged by Robert Turner and colleagues as being potentially matched by meal-time + basal combination therapy, commonly designated multiple daily injections (MDI) [
      • Turner R.C.
      • Ward E.A.
      • Phillips M.A.
      • Dornan T.L.
      • Ward G.M.
      • Hockaday T.D.R.
      Continuous subcutaneous insulin infusion or subcutaneous insulin injections.
      ]. Since that time meal-time + basal insulin regimens have been the cornerstone of insulin therapy in type 1 diabetes (where pumps are not desired or feasible), and have been the final line of the type 2 diabetes therapeutic algorithm as islet B-cell function reached its terminal decline [

      Clinical Guidelines Task Force. Global guideline for type 2 diabetes. Brussels: International Diabetes Federation; 2005. www.idf.org.

      ,
      • Inzucchi S.E.
      • Bergenstal R.M.
      • Buse J.B.
      • et al.
      Management of hyperglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD).
      ].

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