This patient has moderate insulin requirements, needing between half and one unit of insulin per kilogram of body weight. He therefore has two daily injections of combined (pre-mixed / biphasic) insulin (Comb 25), 9 units every morning and 6 units every evening. On Monday and Tuesday diabetes control was good: there was hardly any sugar in the urine, blood glucose was between 80 mg/dl (4.4 mmol/l) and 120 mg/dl (6.7 mmol/l), and there were no hypoglycaemic attacks. The HbA_1c reading was 9.2%. On Wednesday and Thursday at midday (1 p.m.) and in the evening (6 p.m.) a large amount of sugar suddenly appeared in the urine. The blood glucose readings were also high - 180 mg/dl (10 mmol/l) to 240 mg/dl (13.3 mmol/l) - although the before-breakfast (7 a.m.) and late evening (10 p.m.) results were still good.

On Friday the patient therefore increased the morning insulin dose, initially by 1 unit to 10 units. As this produced hardly any improvement, from Saturday onwards the insulin dose was raised to 12 units. Now his metabolism returned to normal. The evening dose of 6 units of insulin was left unchanged. On Sunday at 1 p.m. there was a mild episode of hypoglycaemia. But control was generally improved. Treatment should be continued with 12 units and 6 units of insulin. An HbA_1c reading below 7-8% is the aim.

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