There are not significant data available on the use of troglitazone in combination therapy, but it is highly likely to have role in such regimens in combination with sulfonylureas, metformin, insulin , and acarbose . Glucose and insulin levels feel with troglitazone treatment , and insulin -resistance, as assessed by euglycemic, hyperinsulinemic clamp, was reduced. There have been a handful of reports thus far of severe liver failure in patients taking troglitazone , one resulting in death and another necessitating liver transplantation. It is currently recommended that patients be counseled to monitor for and to report any symptoms of liver disease, and that they have liver function tests before starting troglitazone , every 2 weeks for the first 3 months of therapy, and every two months for the remainder of the first year of therapy. The purpose of insulin regimens, especially intensive insulin regimens, is to emulate as closely as possible the normal diurnal and meal-associated pattern if insulin release by the pancreas in order to approximate euglycemia throughout the day and night, while avoiding hypoglycemia .
Human insulin forms dimers in concentrated solutions, and hexamers in the presence of zinc.
These hexamers dissociate after subcutaneous injection, but the dissociation of the hexamers delays the absorption of insulin from the subcutaneous depot. Hence, Regular insulin should be given between 30 and 60 minutes prior to ingestion of the meal, with the interval being determined by the degree of preprandial hyperglycemia . Moreover, the relatively slow absorption of Regular insulin can lead to hypoglycemia prior to the next meal, or, in the case of pre-supper Regular, during the night. Insulin lispro forms hexamers in solution in the presence of zinc, but the stability of these hexamers is greatly reduced, resulting in substantially more rapid insulin absorption. The onset of insulin action is therefore earlier, and insulin lispro should be given 10 to 15 minutes before the meal.