*3.1.3 Twice dosing regimen*

This uses pre-mixed insulin, which is a combination of short-acting and NPH insulin insulin in a fixed proportion or a free mixture of regular insulin and intermediate-acting insulin. It is given two times a day. Two-thirds (2/3) of the total dose is given in the morning and 1/3 is given in the evening.

Patients should be educated on insulin use, storage dosage, and Side effects in simple terms and in a dialect they understand; this includes knowledge about insulin injections, injection sites and how to rotate, doses and dose adjustment, how to take care of injection sites, signs of hypoglycemia and its management, and short-term and long-term complications. And in both the regimen, the gadget for delivering insulin is mostly syringes; a few times there are pens, and rarely do they use pumps.

In Africa, a very sensible regimen of insulin use is the premixed Twice-daily dose. It is Cost-effective and available, and patients and their families love it because of the infrequent injections. With the progress of diabetes services in the continent, healthcare professionals (HCPs) started to modify this regimen by adding a fixed pre-lunch dose of short-acting insulin (since it is the biggest meal in most countries). In addition to that, the concept of the basal bolus regimen started to emerge especially among patients coming from the developed side of the world. Endocrinologists in the recent years have seen the benefits of the basal bolus regimen of delivering insulin in the form of a better glycemic control and fewer hypoglycemic bouts. What is currently observed from the developed world is the impact of continuous glucose monitoring on the time one spends in target blood glucose when using pumps and flash glucose monitoring [23–25].

As sweet as it sounds, continuous glucose monitoring goes hand in hand with carb counting, which has many challenges in Africa. Carb counting is a bit difficult in Africa since families eat in one plate, and it is difficult to know the exact amount of food the child is going to eat. To overcome that, a scale system is used based on the blood glucose readings (pre/post meals over a week or so). The daily pattern of the patient is figured out, and a fixed short- or rapid-acting insulin is given before each meal. The second challenge of using a basal bolus regimen is the resistance to regularly and frequently check blood glucose at home even if strips are given for free.

Regarding the insulin pumps, the number of patients who use them started to escalate, specifically among prosperous and highly educated people. The decision to shift a patient to use an insulin pump is not easy. It is highly recommended in
