the administration of bolus insulin before each meal is important to maintain postprandial blood glucose levels as close to normal as possible .
rapidacting insulin analogs have a more rapid onset of action than regular insulin , providing improved postprandial glycemic control in multiple daily insulin injection ( mdi ) regimens1 .
premeal insulin dosage was titrated to control target blood glucose levels before each meal and at bedtime . even when premeal and bedtime blood glucose levels are within target range , postprandial hypoglycemia is often observed in patients with premeal rapidacting insulin .
the purpose of the present study was to evaluate suitable premeal bolus insulin for type  2 diabetes .
a total of 56 inpatients who met the inclusion and exclusion criteria were consecutively selected in osaka university medical hospital , in osaka , japan , from may 2005 to may 2007 .
the diabetic meals consisting of 2530  kcal / ideal bodyweight kg , 5060% carbohydrate , 1520% protein and 2025% fat were prepared by dietitians .
all meals were consumed within 20  min without any additional food unless required to treat hypoglycemia .
all patients were switched to premeal mdi using rapidacting insulin , either insulin lispro or aspart .
selfmonitoring of blood glucose was carried out before , and 2  h after meals and bedtime throughout the study .
premeal insulin dosage was titrated to adjust premeal and bedtime blood glucose levels to 81120  mg / dl ( table  1 ) .
after each premeal and bedtime , blood glucose levels were equally adjusted ; when postmeal blood glucose level was more than 30  mg / dl lower than just before the premeal level for at least three occasions , premeal rapidacting insulin was changed to regular insulin just before a meal at the same dosage .
body mass index ( bmi ) , glycated hemoglobin ( hba1c ) , urinary cpeptide excretion and diabetic microvascular complications were examined at the beginning of the study .
sevenpoint blood glucose testing and the incidence of hypoglycemia were collected for 3  days at the end of the hospitalization .
hba1c was expressed as a national glycohemoglobin standardization program ( ngsp ) equivalent value ; that is , hba1c ( ngsp equivalent value ) ( % )  =  hba1c ( japan diabetes society value ) ( % )  +  0.4%2 .
microalbuminuria was defined as a urinary albumin / creatinine excretion ratio more than 30  mg / gcr .
when blood glucose level before lunch , supper or at bedtime was elevated , bolus insulin dosage before breakfast , lunch or supper was titrated , respectively ; and when fasting blood glucose level was elevated , basal insulin dosage at bedtime was titrated .
the present study was carried out in accordance with the declaration of helsinki and with approval from the ethical committee for human studies at osaka university graduate school of medicine .
multivariate logistic regression analysis was used with statview 5.0 software ( sas institute , cary , nc , usa ) .
the characteristics of the study participants were as follows : sex ( male / female ) 41/15 , age 60.5    12.8  years , bmi 25.2    5.2 kg / m , duration of diabetes 14.4    7.3  years , hba1c 9.3    2.0% , urinary cpeptide excretion 48.7    38.0  g / day . among 56 patients ,
premeal rapidacting insulin was used throughout the period in 41 patients ( rapid group ) , and it was changed to regular insulin in 15 patients ( regular group ) .
the prevalence of basal insulin ( table  2 ) and the averages of blood glucose levels ( figure  1 ) were comparable between the rapid group and the regular group .
the prevalence rate of premeal hypoglycemia was comparable in these groups ( regular 3.0    6.6 vs 0.8    2.9% , not significant ) .
the prevalence rate of postmeal hypoglycemia was significantly higher in the regular group than in the rapid group ( 5.5    8.4 vs 0.5    2.4% , p 
the numbers of patients in the regular group were two out of two for bmi 18 , four out of seven for bmi > 18 and 20 , three out of eight for bmi > 20 and 22 , four out of nine for bmi > 22 and 24 , and one out of 30 for bmi > 24 . in the regular group
, age tended to be higher ( p  =  0.07 ) and urinary cpeptide immunoreactivity tended to be lower ( p  =  0.08 ) than the rapid group .
there were no significant differences in the prevalence of microalbuminuria , autonomic neuropathy and retinopathy between these two groups .
sevenpoint blood glucose profiles in the rapidacting insulin group ( rapid group ) and regular insulin group ( regular group ) .
b0 , before breakfast ; b2 , 2  h after breakfast ; bs , before sleep ; l0 , before lunch ; l2 , 2  h after lunch ; s0 , before supper ; s2 , 2  h after supper .
data shown as mean    sd ( range ) . unpaired ttest for parametric data test for betweengroup differences in numbers .
bmi , body mass index ; cpr , cpeptide immunoreactivity ; ns , not significant . multivariate logistic regression analysis was carried out with regular insulin use as a dependent variable , and age , bmi , the prevalence of autonomic neuropathy and urinary cpeptide excretion as independent variables ( table  3 ) .
bmi was only an independent predictor of regular insulin use ( standardized odds ratio 0.649 , p  <  0.005 ) , showing that regular insulin is suitable in lean type  2 diabetic patients .
diabetes is increasing dramatically in asia , and asian people develop diabetes with a lesser degree of obesity4 .
timeaction profiles of currently available subcutaneous insulin products are attenuated and delayed in obese patients5 .
although timeaction profiles of rapidacting insulin in lean type  2 diabetes has not been determined , skinfold thickness was reported to cause insulin malabsorption7 .
in addition , thinner subcutaneous fat tissue at the injection site was associated with enhanced subcutaneous insulin absorption8 .
rapidacting insulin enables us to achieve tighter postprandial glycemic control in the mdi regimen9 ; however , we showed that 15 out of 56 japanese type  2 diabetic patients changed from premeal rapidacting to regular insulin to avoid postprandial hypoglycemia .
regular insulin is usually injected 30  min before a meal ; however , it was injected just before meals in the regular group in the present study , and the sevenpoint blood glucose profile was comparable with that of the rapid group . if regular insulin was injected 30  min before a meal , the peak of insulin effect might be close to rapidacting insulin .
a slower glucose lowering effect was preferable to achieve a good glycemic profile for patients with postprandial hypoglycemia .
the multivariate logistic regression analysis showed that low bmi was an independent factor accounting for the use of regular insulin .
therefore , we assume that rapid absorption of insulin in lean patients explains , at least in part , the reason why regular insulin is suitable for lean diabetic patients . aging and autonomic neuropathy have been reported to be inversely related with gastric emptying10 .
age tended to be higher in the regular group than in the rapid group ( p  =  0.07 ) , but was not an independent factor accounting for the use of regular insulin .
therefore , slow gastric emptying was not a determinant for the usefulness of regular insulin in the present study .
postmeal hypoglycemia was not frequent in both groups , but was significantly higher in the regular group than in the rapid group .
urinary cpeptide secretion tended to be higher in the rapid group than in the regular group ; however , it did not account for postmeal hypoglycemia according to the multivariate analysis ( data not shown ) . in the regular group , 2h postmeal blood glucose declined by an average of 65.9    37.8  mg / dl from the premeal blood glucose in 3  days before switching the insulin from rapid to regular insulin , whereas it increased by 1.2    64.0  mg / dl in the final 3  days with regular insulin . therefore ,
if we continued rapidacting insulin in the regular group , the incidence of hypoglycemia could become more frequent to achieve the target level of premeal glucose . in conclusion , it is likely that regular insulin , rather than rapidacting insulin , is a suitable choice for mealtime bolus insulin in lean type  2 diabetic patients .
 abstractthe aim of the present study was to compare the usefulness of premeal rapidacting and regular insulin in type  2 diabetes patients . 
 a total of 56 type  2 diabetic patients were investigated during hospitalization . 
 premeal rapidacting insulin was applied instead of other medications . 
 premeal insulin was titrated to adjust premeal and bedtime blood glucose levels to 81120  mg / dl . 
 premeal rapidacting insulin was changed to regular insulin just before a meal at the same dosage if the postmeal blood glucose level was lower than the premeal blood glucose level . 
 a total of 15 patients changed to regular insulin , and 41 patients continued rapidacting insulin . 
 the blood glucose level was comparable between these two groups . 
 body mass index was significantly lower in the patients using regular insulin . according to the multivariate logistic regression analysis , 
 low body mass index was an independent variable accounting for the usefulness of regular insulin . 
 regular insulin , rather than rapidacting insulin , is a suitable choice for premeal insulin in lean type  2 diabetic patients . 
Introduction
Materials And Methods
Results
Discussion