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Objective: To describe our clinical experience with U500 insulin in insulin-resistant patients, including change in glucose control, body weight, insulin dose, and hypoglycemic episodes., Methods: In September 2010, we undertook a retrospective chart review of patients who had U500 insulin in their medication list in the preceding 2 years who were treated in the endocrinology section at Dartmouth Hitchcock Medical Center. Glycosylated hemoglobin (A1C), body weight, and insulin dosage were documented before U500 insulin introduction, after 6 months of U500 insulin use, and at the last clinic visit when the patient was still taking U500 insulin. Hypoglycemic episodes and number of daily injections were recorded., Results: Records of 53 patients were analyzed, one of the largest reports of U500 insulin use published to date. The mean A1C level decreased from 10.1% before U500 insulin was initiated to 9.1% after 6 months of U500 use to 8.6% at the last follow-up visit (mean follow-up was 36.6 ± 24 months). At the last charted visit, body weight increased by a mean of 6.8 kg and insulin dosage increased by a mean of 0.44 units/kg. We observed a significant increase in the number of nonsevere hypoglycemic episodes and a decrease in the number of daily injections., Conclusion: Patients with uncontrolled, severely insulin-resistant diabetes can be satisfactorily treated with U500 insulin with the potential to improve glycemic control. An increase in body weight, insulin dosage, and the number of nonsevere hypoglycemic episodes was observed.

Objective: To investigate, in a clinical setting, the effect of implementation of continuous subcutaneous insulin infusion (CSII) on control of plasma glucose and to identify factors associated with improved glycemic control in patients with type 1 diabetes mellitus., Methods: Nineteen patients (16 women and 3 men) with type 1 diabetes were studied retrospectively. Their mean age was 42.6 years (range, 30 to 58), and the mean duration of diabetes was 21 years. The subjects underwent follow-up for a mean of 14 months after conversion to CSII therapy. With use of paired t tests, pre-CSII and follow-up data were evaluated relative to changes in weight, insulin dosing, and glycosylated hemoglobin (HbA(1c))., Results: At follow-up, the total daily dose of insulin had decreased by 18%, from a baseline mean value of 45.2 IU to 37.1 IU (P = 0.02). HbA(1c) was reduced from 8.4% to 7.7% (P<0.01). The total daily insulin-to-weight ratio also significantly decreased from 0.66 IU/kg to 0.53 IU/kg (P<0.05). Before insulin pump use, the regular/NPH insulin ratio was 0.5 IU; at follow-up, the pump bolus/basal insulin ratio was 1.0 IU (P = 0.02). No weight gain was observed; the mean weight of the study patients decreased 0.2 kg, from 69.4 kg at baseline to 69.2 kg at follow-up (not significantly different)., Conclusion: In a clinical setting, CSII therapy in patients with type 1 diabetes improves glycemic control and lowers the total daily basal insulin dose without affecting weight. Improved glycemic control was associated with a shift in insulin therapy from a high percentage of intermediate-acting insulin to a greater percentage of insulin administered in a meal-associated bolus form. This study emphasizes the importance of mealtime insulin adjustment for tight glycemic control in patients using CSII therapy. Future studies evaluating the benefits of decreased total insulin and an increased bolus/basal insulin ratio may be important in helping to understand how to avoid long-term complications of diabetes.