407modalities available for the management of T1DM are summarized in the table
given below.Modality Remarks
Basal–bolus insulin
therapyNear physiological
Able to achieve target HbA1c in 10–15 %
Cumbersome
High glycemic variability
Insulin pumps Near physiological
Expensive
Only 20–30 % achieve target HbA1c
Mechanical failure poses risk of DKA
No difference in hypoglycemic events and weight gain as
compared to basal–bolus
Metformin Limited data
Only in obese T1DM as an adjunct to insulin therapy
Pioglitazone Not effective
α-glucosidase inhibitor As an adjunct to insulin therapy
Limited benefits
DPP4 inhibitor Experimental as an adjunct to insulin therapy
Reduces glycemic variability
GLP1 agonist Experimental as an adjunct to insulin therapy
Trend toward improvement in HbA1c in those with preserved
C-peptide
SGLT 2 inhibitor Limited and short-term data as an adjunct to insulin therapy
Higher incidence of euglycemic DKA- Why basal–bolus insulin regimen is preferred over fixed-dose premixed insulin
in patients with T1DM?
Premixed insulin consists of short-acting and intermediate-acting insulin in a
fixed proportion, in order to deliver prandial and basal insulin together to mini-
mize the number of injections, thereby providing convenience to the patients.
Patients with T1DM are characterized by severe insulin deficiency, and admin-
istration of premixed insulin twice a day fails to mimic physiological insulin
secretion as it does not adequately cover post-lunch and early morning hyper-
glycemia. In addition, the premixed insulin regimen is associated with higher
glycemic excursions, lower patient’s satisfaction, and poor quality of life score
as compared to basal-bolus regimen even at the same level of HbA1c. Further,
fixed-dose formulation does not allow the flexibility to adjust the dose of regu-
lar and NPH insulin independently. Therefore, in patients with T1DM, pre-
mixed insulin twice a day result in higher glycemic variability, frequent episodes12 Diabetes in the Young