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New Insulin Classification System Announced
posted 04/22/04
'Clear' and 'Cloudy' vs Time Course of Action!! Insulins have
hitherto been distinguished as clear (short-acting) and cloudy (long-acting).
However the introduction of glargine, which is a clear long-acting insulin, has
prompted the need for reclassification.
In view of the increasing emphasis on intensive insulin therapy using basal-bolus regimens, a new, simple, pragmatic classification is suggested in which insulins are categorized according to the timing and purpose of administration: basal (maintenance), bolus (meal) and biphasic (mixed).
Why Basal-bolus?
Over the last decade, greater emphasis on tighter glycemic control has favored
the use of basal-bolus insulin regimens. This requires both prescriber and
patient to think in terms of background (basal) longer-acting insulin supply
separately from prandial (bolus) shorter-acting insulin supplements.[1]
Should the era of the basal-bolus regimen change the manner in which we
categorize insulins?
For most patients, the purpose of insulin treatment is to
return blood glucose concentrations as close to the physiological norm as
reasonably possible. Subcutaneous injections cannot recreate the portal delivery
or the subtle momentary adjustments of insulin secretion by the pancreatic
beta-cells. Once-daily subcutaneous injection of a long-acting insulin is
occasionally sufficient in type 2 diabetic patients, usually in conjunction with
oral agents, but twice-daily mixtures of isophane (protamine)
intermediate-acting with regular (neutral) short-acting insulin are generally
preferred. However, complex basal-bolus regimens more often produce a closer
approximation to the normal daily profile of circulating insulin, producing a
daily blood glucose profile that shows a greater resemblance to normal (figure
1). Nevertheless, it is accepted that such regimens do not necessarily produce
lower HbA1C values in all patients, although they should in principle manage the
demands of glucose homeostasis in a more physiological manner.
Insulin prescribing and management are no longer the preserve of the specialist.
Insulin therapy is often initiated in primary care, and patients are empowered
to make crucial decisions about day-to-day adjustments of dosage. To improve
communication it would be advantageous for a simpler classification of insulins;
'basal', 'bolus' and 'biphasic' would clearly signify the manner in which they
are used This approach would avoid any potential misnomer from the trade names
which may only allude to an inappropriate characteristic of an insulin (e.g.
Actrapid is not actually 'rapid-acting', it is short-acting).
A pragmatic approach should help to demystify some of the complexities of
insulin administration and nomenclature for both the prescriber and patient.
Source: Diabetes In Control.com: The British Journal of Diabetes
and Vascular Disease.
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