Comparison of two intensified conventional insulin regimens with three and four daily injections

E. Faglia, F. Favales, M. Brivio, P. Calia, A. Quarantiello

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When choosing an intensified conventional insulin therapy, no specific differentiation is made between the three-injection regimen (regular insulin at breakfast and lunch, and regular + intermediate-acting insulin at diner) and the four-injection regimen (regular insulin at breakfast, lunch and diner, and intermediate-acting insulin at bedtime). No published studies have evaluated to our knowledge the differences between these two regimens. In 1991, we proposed to 30 stable type 1 diabetic patients without residual insulin secretion a change from three to four daily injections: 7 refused, 4 were later excluded for intercurrent events; 19 followed the four daily injection regimen for 2 years. In these non randomized 19 patients, the Student's test for paired data was used to compare with a self-controlled study the 1989-90 three-daily injection period with the 1991-92 four-daily-injection period in order to evaluate any differences in daytime blood glucose values (bi-monthly out-patient measurements taken at 8 am, 10 am, 3 pm and 5 pm), nocturnal blood glucose levels at 3 am (bi-monthly patient self-monitoring by means of a blood glucose meter, for a total of 188 vs 188 measurements), HbA1c (a total of 203 vs 207 bi-monthly out-patient measurements), the number of nocturnal hypoglycaemic attacks, body weight and mean insulin requirement. The results show a clear reduction in the number of hypoglycaemic attacks (20 vs 85: p <0.001), a reduction in morning blood glucose level (9.18 ± 0.34 vs 12.09 ± 0.66 Mm/l p <0.001), an increase in nocturnal glycaemic levels (7.56 ± 0.35 vs 6.60 ± 0.35 Mm/l p <0.001), no difference in blood glucose levels at other times, and no statistically significant variations in HbA1c, insulin requirements or body weight under the four daily injection regimen. Analogous comparisons were made in 16 other Type 1 diabetic patients with similar characteristics, who remained on three daily injections therapy throughout the four years of the study: no difference was found between the periods 1989-90 and 1991-92 in any of the parameters under consideration. We conclude that, in comparison with the three-daily-injection regimen the four daily injections regimen reduces the risk of nocturnal hypoglycaemia and improves morning blood glucose levels, but does not affect overall metabolic control. The absence of any change in insulin requirement shows that our results are not due to greater, but rather to better insulinisation.

Original languageEnglish
Pages (from-to)575-581
Number of pages7
JournalDiabete et Metabolisme
Issue number6
Publication statusPublished - 1993


  • dawn phenomenon
  • metabolic control
  • multiple injections insulin regimen
  • nocturnal hypoglycaemia

ASJC Scopus subject areas

  • Endocrinology
  • Endocrinology, Diabetes and Metabolism
  • Internal Medicine


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