Impaired absorption and omission of insulin: a novel method of detection using the diabetes advisory system computer model.

The Diabetes Advisory System (DIAS) is a decision-support program developed to assist insulin dose adjustment in type 1 diabetes. In this paper, we show how it might be used to identify impaired absorption or omission of insulin in patients with poorly controlled blood glucose. An evaluation of glucose results from four outpatients with persistent hyperglycemia is presented (age 19-48 years with type 1 diabetes for 13-18 years of duration, HbA1c 9.4-13.6%). Each had completed a 4-day record of blood glucose (BG, pre-meal and bedtime), dietary (carbohydrate) intake, and insulin doses (with injection sites). From these data, DIAS modeled a glucose profile (simulated glucose, SG) for the same period. Qualitative assessments were made of differences between BG and SG, and selective reduction or complete removal of insulin doses where BG >> SG. Large improvements in modeling were attributed to either impaired absorption or omission of insulin. Confirmation of these problems was sought from the patients by detailed consultation and physical examination. Impaired insulin absorption was suspected in two patients, both having significant injection site abnormalities. Insulin omission was suspected in the other two subjects. Both had normal injection sites, and one admitted to missing doses. Following retraining, data from three patients showed noticeable improvements in overall modeling as well as glucose control. Using DIAS in the evaluation of patients with type 1 diabetes may highlight previously unrecognized injection site abnormalities or insulin dose omission. This could assist rational optimization of insulin therapy in cases of persistently poor glucose control.