Intensive insulin therapy in clinical practice

Achieving optimal blood glucose control, without an unacceptable rate of hypoglycaemia or unacceptable restrictions on lifestyle, is not simple with presently available insulin preparations and monitoring tools. There is considerable evidence that achieved control is relatively independent of the means or frequency of insulin delivery provided at least two injections per day are used, probably due to a combination of the unphysiological nature of insulin absorption profiles, the poor reproducibility of insulin absorption in any individual, and the erratic nature of normal human behaviour. Accordingly the appropriate use of insulin to obtain good metabolic control requires the continued and informed expertise of both patient and advising professional, but also attention from both to self-motivation in order to make the desired lifestyle changes possible. Newer approaches to insulin delivery will continue to demand a high level of understanding and expertise to make them effective, until such time as automatic minute-to-minute control of insulin delivery can be restored. [Diabetologia (1997) 40: S 83–S 87]