66% of patients suffer from hypoglycemia. Many patients do not notice they are running low blood glucose levels.

Hypoglycemia without warning leads to brain disfunction. At 2.5-3.0 mm/L if not corrected it is then too late and hypoglycemia occurs. After 15 years on insulin 25% of patients have occasional instances of acute hypoglycemia requiring support from a third party, family, friend, colleague.

Fast acting insulin peaks at 1-2 hours. Moderate insulin peaks at 6-8 hours. Peaks are usually at mid-day before lunch, and at night. Snacks are important to avoid hypoglycemic peaks. Women are reluctant to snack whereas men are usually comfortable at snacking.

Exercise causes low glucose for 18 hours after the exercise is taken. This can be compensated fro by reducing insulin intake at night.

Human insulin is one molecule different from animal insulin. A substantial number of patients do not feel comfortable when treated by human insulin and prefer animal insulin.

After 15 years problems sometime arise with patients who have switched insulins from animal to human insulin. Human insulin is a reasonable insulin but is not suitable for some patients.

The absorption of insulin, and in fact of any endocrinology replacement therapy seeks to mimic that normally produced by the human body. The administration of insulin requires further development in this area. Some patients find that 2-3 injections per day are better however in the USA until 20 years ago many patients were only having a single insulin injection per day. Location of the insulin injection can also play an important role. For example if injected in the leg of a cyclist this can lead to fast insulin reactions.

Case 1 was a 48 year old factory supervisor. 27 years an insulin dependent diabetic. Experienced in managing his diabetes. Manipulates insulin injection dosage and times according to glucose readings. His wife was concerned about frequent hypos, some with loss of consciousness. Job was on the line. Erratic glucose readings from 1.8-24 mm/L. Active walking between work sites. Driving could be a problem. He needs to know about how much glucose to take to correct hypoglycemia. His family should be included in discussions. He needs to avoid complex carbohydrate foods. He may need quick acting insulin if blood glucose levels are high. Two injections per day.

Case 2 was a 26 year old ballet dancer on insulin for 9 years. Rehearses from 2.00-6.00pm and perform from 9.00pm - 3.00am. Wakes at mid-day. Encountered regular hypos during performances and high glucose levels of 20 mm/L in the morning. Exercise compensated for some insulin requirement. Acarbose may be of assistance but side effects may be a problem. Insulin dosage should be reduced during exercise.

Case 3 was an obese lady requiring large doses of insulin 56 units 30/70 am and 38 units 30/70 pm. High HbA1c 12%. When hospitalised the patient turned out not to require insulin.

Regular blood glucose monitoring was seen as being of advantage to these patients with at least 4 glucose tests per day.