What is the clinical implication of a type 1 diabetes mellitus patient, 163 cm tall, weighing 55 kg, on 20 units of insulin per day?

From the Guidelines

The patient's current insulin dose of 20 units per day is likely inadequate for their weight, as the typical starting dose for a patient with type 1 diabetes is around 0.5 units/kg/day 1.

Calculating the Daily Insulin Requirement

• The patient's weight is 55 kg, so their daily insulin requirement would be approximately 0.5 units/kg/day x 55 kg = 27.5 units/day.
• This dose can be split into basal insulin (around 50% of the total daily dose) and prandial insulin (around 50% of the total daily dose) 1.

Clinical Implications

• The patient's current dose of 20 units per day may not be enough to control their blood glucose levels, putting them at risk for hyperglycemia and diabetic ketoacidosis.
• The patient should be monitored closely for signs of hyperglycemia and diabetic ketoacidosis, and their insulin dose should be adjusted accordingly.
• Education on carbohydrate counting and adjusting prandial insulin doses based on carbohydrate intake, premeal glucose levels, and anticipated physical activity should be considered for the patient 1.

Insulin Regimen

• A multidose regimen that combines premeal use of shorter-acting insulins with a longer-acting formulation, usually at night, may be beneficial for the patient 1.
• The long-acting basal dose should be titrated to regulate overnight, fasting glucose, and postprandial glucose excursions should be controlled by a well-timed injection of prandial insulin 1.

From the FDA Drug Label

The dosage of LEVEMIR should be individualized based on the physician’s advice, in accordance with the needs of the patient. For patients with type 1 or type 2 diabetes on basal-bolus treatment, changing the basal insulin to LEVEMIR can be done on a unit-to-unit basis. The dose of LEVEMIR should then be adjusted to achieve glycemic targets Daily Basal Insulin Dose (U/kg) Prestudy mean 0.360.39 End of study mean0.490.45 Daily Basal Insulin Dose (U/kg) Prestudy mean 0.480.49 End of study mean0.670.64

The patient is taking 20 units of insulin per day, and weighs 55 kg.

• The daily basal insulin dose for this patient would be approximately 0.36 U/kg (20 units / 55 kg).
• This dose is within the range of prestudy mean doses reported in the clinical studies for type 1 diabetes mellitus patients 2.
• However, the optimal dose for this patient should be individualized and adjusted to achieve glycemic targets 2.
• The patient's height and weight are not directly relevant to the clinical implication of the insulin dose, but the dose should be monitored and adjusted as needed to achieve optimal glycemic control.

From the Research

Clinical Implication of Insulin Dosage

The patient in question is 163 cm tall, weighing 55 kg, and is on 20 units of insulin per day. According to the study 3, patients with type 1 diabetes typically require an insulin dosage of 0.5 to 1.0 unit per kg per day. Based on this, the patient's insulin dosage is within the recommended range, as 20 units per day is approximately 0.36 units per kg per day.

Insulin Regimen

The study 4 states that the mainstay of management for type 1 diabetes is a regimen of multiple daily injections of insulin or continuous subcutaneous insulin delivered via an insulin pump. For most patients, a regimen consisting of 50% of the total daily dose prescribed as basal insulin and 50% prescribed as bolus insulin is used. However, the study 5 found that the basal insulin requirement in patients with type 1 diabetes depends on the age and body mass index, and the average percent of total daily basal insulin dose to total daily insulin dose (%TBD/TDD) was approximately 24% under inpatient conditions.

Factors Affecting Insulin Requirement

The study 3 mentions that factors such as onset, peak, and duration of action can influence the ability of a particular insulin regimen to help control glucose levels. Patient factors, including individual variations in insulin absorption, levels of exercise, and types of meals consumed, also influence the effectiveness of an insulin regimen. The study 6 notes that the pathogenesis of type 1 diabetes can be divided into three stages depending on the absence or presence of hyperglycaemia and hyperglycaemia-associated symptoms.

Alternative Therapies

The study 7 discusses the use of alternative agents in addition to insulin therapy for patients with type 1 diabetes, including metformin, alpha-glucosidase inhibitors, pioglitazone, GLP-1 agonists, DPP-IV inhibitors, and SGLT-2 inhibitors. These medications offer varying mechanisms of action that can help to reduce insulin resistance and prevent or deter weight gain. However, the use of these alternative agents is not directly relevant to the patient's current insulin dosage.

Key points to consider:

• The patient's insulin dosage is within the recommended range
• The basal insulin requirement depends on the age and body mass index
• Factors such as insulin absorption, exercise, and meal types can influence the effectiveness of the insulin regimen
• Alternative therapies may be considered to reduce insulin resistance and prevent weight gain, as discussed in 7