http://exhibits.library.stonybrook.edu/mfp/files/original/718a29ec15d25cbb6a477d3556be0fdd.pdf da7a7236e5d976ec8ac1cfd95b801264 PDF Text Text EFFICACY OF DIVIDED AND SINGLE DOSE SCHEDULES IN INSULIN COMA THERAPY ARNOLD G. BLUMBERG, M.D., PETER LADERMAN, M.D., AND MAX FINK, M.D.1 [Reprinted from THE AMERICAN JOURNAL or Vol. 116, No. 9, March, 1960] PSYCHIATRY, �1960 ] CLINICAL NOTES 839 EFFICACY OF DIVIDED AND SINGLE DOSE SCHEDULES IN INSULIN COMA THERAPY ARNOLD G. BLUMBERG, M.D., PETER LADEBMAN, M.D., AND MAX FINK, M.D.1 While many technics for the administration of insulin in insulin coma therapy have been advocated(3), recent reports(4) have assessed multiple divided doses as more effective and safer than other methods. Previous studies indicated that the production of coma was directly related to the level of hypoglycemia and its duration (1) and that deep coma for sustained periods was essential to the treatment result in insulin therapy(2, 3). It seemed reasonable to test the suggestion of increase-d efficacy for a modified insulin administration by comparing the length and depth of coma and the blood sugar levels in patients treated both by single and divided insulin dose methods. If the divided dose schedule were more effective, it would be expected that the induced coma would be equal or greater in depth and duration; that the time for onset would be equal or shorter; and the blood sugar levels lower for divided dosage than single administration. the dose was increased in 10 unit incre— ments. At the time when coma was produced, a single dose equivalent to the 3 doses was given on the succeeding day. For each treatment, coma depth and the time of onset was determined. Coma was defined as the loss of consciousness (failure to respond meaningfully to verbal signals), associated with the appearance of the Babinski reflex, and the loss of the lid reflex. An adequate coma treatment was defined as the persistence of this depth of coma, or deeper (loss of pupillary or corneal reflexes) for at least one hour. At half-hour intervals true blood sugar levels were serially determined by the Somogyi method. The resulting blood sugar curves and their level at the time of onset of coma, were compared for each subject with the blood sugar curve and coma data obtained on a single administration of an equivalent dose. METHOD The blood sugar levels at various intervals after the administration of divided doses of insulin compared with a single dose of insulin in one patient is presented in Figure 1. This pattern has been reproduced in each of the patients studied. For each, the blood sugar curve drops rapidly in the first hour without respect to the initial dose, and flattens at progressively lower levels as the total dosage of insulin increases. Coma characteristically is reported in subjects in whom the blood sugar curve is below 21 mg.% for an extended period of time(1). The time of onset of coma and the blood sugar level at coma in each of the patients is presented in Table 1. In five of the 6 Consecutive patients referred for insulin coma therapy were given daily increasing amounts of insulin in 3 divided doses until a coma level was achieved. The same total dosage was then given in one injection. Six patients were studied in this manner. Each patient was started on the following insulin dose schedule : first day—10 units; second day—10 units and 2 doses of 5 units each at intervals of one half hour; third day—3 doses of 10 units at half hour intervals ; and fourth day—20 units followed by 2 doses of 10 units. On each successive day From the Departments of Internal Medicine and Experimental Psychiatry, Hillside Hospital, Glen Oaks, L. 1., N. Y. 1 [Reprinted from THE OBSERVATIONS AMERICAN JOURNAL OF PSYCHIATRY, Vol. 116, No. 9, March, 1960] �' 'n' 9 Ir" : 840 CLINICAL NOTES [ March I % TRUE BLOOD SUGAR LEVELS FOLLOWING ADMINISTRATION OF INSULIN IN DIVIDED AND SINGLE DOSE SCHEDULES 9 9° ~7‘ 9; 8° 3 O \\ .- _ \\ I \ 7o \.\ as INSULIN DOSAGE IN UNITS 20.20.20... —---— 10.70.70... .......... 90.90.90“. ———-— ...q’ \ \\ '\ ———- AT auo MINJNYEuRVALS “ " “ I20,I20.I20u." —'-— 360u. IN " " " SINGLE DOSE E K <1 0D U) D oo _J with divided doses in 4 of the 6 cases. It was identical in one and lower with the divided dose in one. As there was no evidence in these studies that the divided dose method was more effective in the production of insulin coma than the single dose method, the divided dose technic was discontinued. m CONCLUSIONS MI 3 a: [— O 60 90 IZO I50 TIME IN MINUTES AFTER ADMINISTRATION 30 IBO ZIO OF INITIAL DOSE 240 cases, there was no difference in the time required to induce coma by either the single or the divided dose methods. In one subject (Sc) coma was observed in 132’) hours with a single dose as compared with 3 hours with divided doses. TABLE 1 ONSET OF COMA AND BLOOD SUGAR WITH DIVIDED AND SINGLE DOSAGE SCHEDULES PT D G H c So V Time for Coma Blood Sugar Value (minutes) (mg. %) Insulin Divided Single Divided Single U nit: Dore Dore Dose Dose 330 360 270 390 360 210 210 210 210 180 210 135 190 210 210 90 210 150 4 14 15 12 12 8 0 4 15 7 8 20 The average blood sugar at the time of coma was lower with the single doses than The coma produced with the divided insulin doses did not occur earlier and was not deeper than that produced by the single dose. The increased effort in divided dose schedules is justified neither by increased safety nor by increased depth or duration of the induced hypoglycemia. There was no, evidence that the initial dose of insulin sensitized the subject so that subsequent doses produced a greater hypoglycemic effect. The total hypoglycemic effect of divided doses appears to be less, if anything, than the effect of a single dose. BIBLIOGRAPHY 1. Blumberg, A. G., Cohen, L., Croghan, J., and Kelsey, D.: J. Hillside Hospital, 5: 41, 1956. 2. Fink, M.: J. Hillside Hospital, 6: 197, 1957. 3. Kalinowsky, L., and Hoch, P.: Shock Treatments, Psychosurgery and Other Treatments in Psychiatry. New York: Crune & Stratton, 1952. 4. Laqueur, H. P., and LaBurt, H. A.: Proc. Annual Meeting, American Psychiatric Association, Phila., 1959. �� Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Efficacy of divided and single dose schedules in insulin coma therapy. Am J Psychiatry. 1960 Mar; 116:839-40. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-43-009 Date A point or period of time associated with an event in the lifecycle of the resource 1960 Creator An entity primarily responsible for making the resource Blumberg, Arnold G.; Laderman, Peter; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint from THE AMERICAN JOURNAL of PSYCHIATRY, Vol. 116, No. 9, March, 1960 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. 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