Key Points

• Thresholds for beginning supplemental insulin in type 2 diabetic patients vary depending on whether microangiopathic complications are likely to develop if glucose is not controlled over the patient's lifetime; the better the prognosis, the lower the threshold.

• For elderly patients, keeping fasting serum glucose (FSG) less than 150 mg/dL or HbA1c less than 8% will attenuate the risk of dehydration and metabolic decompensation in the face of stress.

• Appropriate and frequent insulin is the essential therapy of type 1 diabetes and should be used more often in type 2 diabetes if the patient fails to achieve the glycemic goal.

The discovery of insulin by the Toronto group in 1921 has saved the lives of millions of type 1 diabetic patients who would have succumbed to diabetic ketoacidosis. The remarkable efficacy of insulin despite its nonphysiologic route of administration has stimulated the development of insulins with pharmacokinetic effects mimicking the beta-cell secretion pattern, from short-acting and long-acting beef, pork, and fish extracts, to genetically synthesized human insulins introduced in the 1980s, to biochemically designed insulins with more predictable onset and duration of action (Table 34-4).

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