Patients And Physicians Concerns About Insulin Use In Type 2 Diabetes

There has been considerable controversy about the potential for exogenous insulin to promote macrovascular complications of diabetes. Much of this concern stems from evidence that insulin resistance is associated with increased rates of cardiovascular disease (9). Several studies have demonstrated a correlation between insulin levels and cardiovascular events. However, in these studies of a broad spectrum of individuals, it is likely that elevated endogenous insulin levels are simply a marker...

Step 3 Establish the 24Hour Insulin Dosage

Next is calculation of the approximate 24-hour insulin need. It is done on a unit-per-kilogram basis by multiplying the body weight in kilograms by a factor that takes into account the patient's tissue insulin sensitivity. Suggested conversion factors are shown in Table 4. Thus, a 28-year-old 70-kg man who bikes or plays tennis on a daily basis would be started on 21 units of insulin per day (0.3 units kg), while a man of the same age and height with a sedentary lifestyle would receive 35 units...

Recommended SBGM Test Frequency

Experience has shown that frequent monitoring augments patients' ability to meet their treatment goals and provides the needed feedback to pursue self-management. Still, the times and frequency of testing vary widely among individual patients, depending on their treatment goals, treatment regimen and its complexity, motivation, variability of dietary and exercise habits, physical and cognitive abilities, financial constraints, and concerns for hypoglycemia, ft is generally recommended that...

Who Is Eligible

Every person with type I diabetes should be a candidate for intensive insulin therapy unless there is a contraindication. Exclusions can be medical (history of severe hypoglycemia, too old or too young, illnesses in which hypoglycemia could be life-threatening such as severe coronary, cerebrovascular, or hepatic disease) or nonmedical (unwillingness or inability to follow the program, drug or alcohol abuse, etc.). However, it must be emphasized these factors do not de facto exclude a candidate....

Intermediateacting Insulins

The initial purpose for the development of long-acting insulin preparations was to minimize the number of daily injections needed for glycemic control. Ideally, the action of such an insulin preparation should reflect naturally occurring changes in insulin requirements throughout the day. This would be particularly important during the overnight period, when longer-acting insulins are required to suppress endogenous glucose production. Additionally, the kinetics and dynamics should be highly...

Glucose Uptake by Insulin Independent Tissues

Some glucose transporter isoforms do not require insulin in order to be translocated to the cell membrane. For example, the glucose-2-transporter protein the predominant form in the liver and the endocrine pancreas remains in the cell membrane independent of insulin action. As a result, glucose is taken up passively down its concentration gradient into cells by these constantly available glucose transporter proteins. This allows the liver to take up glucose when the blood glucose concentration...

Replacement of Basal Insulin

Basal insulin is provided by either a continuous subcutaneous infusion from an insulin pump or intermittent injection (daily or twice daily) of insulin formulated to be released slowly from this site (19). Replacement insulin therapy in the basal state (between meals and overnight) has the object of constraining hepatic glucose release to match glucose uptake by non-insulin-independent tissues (Figure 2). The amount of insulin required lo this end varies from person to person (depending on...

Insulin Therapy in Pregnancy

Sansum Medical Research Institute, Santa Barbara, California Before the advent of insulin, few diabetic women lived to childbearing age. Before 1922, fewer than 100 pregnancies in diabetic women were reported most likely these women had type 2 and not type 1 diabetes. Even with this assumption, these cases of diabetes and pregnancy were associated with a greater than 90 infant mortality rate and a 30 maternal mortality rate. As late as 1980, physicians were still counseling diabetic women to...

Insulin Therapy in Children

Tamborlane and JoAnn Ahern Yale School of Medicine, New Haven, Connecticut Type 1 diabetes meliitus in childhood and adolescence presents special challenges to pediatric health-care providers. The combination of severe insulin deficiency and the physical and psychoemotional changes that accompany normal growth and development make day-to-day management of pediatric patients especially difficult. Moreover, the results of the Diabetes Control and Complications Trial (DCCT) have raised...

Insulin Storage

Improperly stored insulin is a common cause of erratic or high blood sugars, and should be considered if there is a change in the patient's glycemic control, or if a patient does not seem to be responding to his insulin as usual, especially when traveling. Patients should be given the following instructions Do not leave insulin in luggage or a car that might be exposed to extreme temperatures. Unopened vials, pens, and pen cartridges should be stored in the refrigerator at 36 F-46 F (2 C-8 C)...

Insulin Management of Hospitalized Diabetic Patients

University of Vermont College of Medicine, Burlington, Vermont AduJts with diabetes mellitus are admitted to the hospital more frequently than nondiabetics, often for prolonged periods. Particularly common are admissions for hyperglycemic emergencies, local or systemic infections, unstable angina or myocardial infarction, stroke, and orthopedic injuries. One would hope that hospitalization would be a time to reinforce the principles of optimal diabetes care. Instead, glycemic control in the...

Indications For Insulin Therapy In Type 2 Diabetes

Insulin therapy has multiple forms and applications in type 2 diabetes (Table 1). Some of these indications are temporary, such as during an acute illness, in pregnancy, and when those taking metformin are at risk for renal insufficiency or other factors predisposing to lactic acidosis. Insulin is also indicated as initial therapy when individuals present with severe hyperglycemia (fasting glucose over 300 mg dl or random glucose values over 400 mg dl) with significant symptoms such as severe...

Normal Insulin Secretion

A key principle for physiological insulin delivery is to mimic the normal pattern of (3 cell function as closely as possible. Figure 1 shows insulin secretion in a healthy individual, measured every 10 minutes over a normal 24-hour period that included three standard meals the top panel shows the actual data the bottom panel is a stylized version used in this chapter as insulin programs are discussed. The multiple arrows in Figure 1A are large spikes of insulin secretion that occur every 1-3...

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HAAF syndrome see Hypoglycemia-associated autonomic failure and Hypoglycemia unawareness Hemoglobin A,r HbAlc lo assess glycemic control, 5-6, 1516, 114 in children. 133 in pregnancy, 148 contribution of fasting and postprandial glucose level to, 7-10 guideline for optimal glycemic control, 5-6, 15-16. 114 lack of use for the diagnosis of diabetes, 15 methods to measure, 7 Honeymoon effect on insulin requirements, 129-130 Honolulu heart study, 9 Hospi tali zed patients with diabetes, 153-171...

Injection Difficulties

Injection Sites For Insulin

Bruising at injection sites may be related to nicking superficial vessels, and is usually not due to poor injection technique. However, the problem may be worsened in patients taking anticoagulants, corticosteroids, or nonsteroidal antiinflammatory drugs, and in the elderly. Painful injections may be related to the use of alcohol at the site if the site is dirty, patients should wash it with soap and water prior to injection but otherwise no skin preparation is recommended. Injection of cold...

Nutrition Strategies For Type 1 Diabetes

The goals of nutrition therapy for the type 1 diabetic patient are listed in Table i. The usual food intake and exercise habits should be determined prior to the initiation of either conventional or intensive insulin therapy, because it is important to integrate insulin therapy into the patient's accustomed routine. It is recommended that all patients starting insulin therapy meet with a registered dietitian to develop an individualized meal plan that incorporates their food preferences, usual...

Blood Glucose Regulation And Diabetes Eug Ackerman

Effect of excessive weight gain with intensive therapy of type I diabetes on lipid levels and blood pressure results from the DCCT. JAMA 280 2 140-146, 1998. 8. The Diabetes Control and Complications Trial Research Group. Hypoglycemia in the Diabetes Control and Complications Trial. Diabetes 46 2 271-286, 1997. 9. Reichard P, Nilsson BY, Rosenqvisc J. The effect oT long-term intensified insulin treatment on the development of microvascular complications of diabetes mellitus. N Engl J Med 329...

Endocrinol Metab 1999 13 279-294.

Uated intravenous, subcutaneous both Regular and fast-acting , and inhaled insulin. Heinemann et al. demonstrated in 1997 that the relative effectiveness of inhaled insulin was approximately 10 with regard to intravenous insulin administration and 8 with regard to subcutaneous insulin administration. In addition, Heise et al. reported that the onset of action of inhaled insulin appears to be more rapid than that of subcutaneous insulin. Inhaled insulin demonstrated a faster onset of action than...

Mixing Insulins

If possible, avoid teaching patients to mix when first initiating insulin therapy, as the extra steps can overwhelm and confuse them. Emphasize use of a consistent technique. Commercial premixed insulin 70 30, 75 25, 50 50 is useful as interim therapy, or for individuals who cannot master accurate mixing. It was identified a decade ago that mixing long-acting insulin with Regular insulin slows the effect of the Regular insulin through microcrystaJlization most problematic are Ultralente and...

Algorithms or Sliding Scales

A common element of intensive insulin programs is insulin algorithms short-term adjustments in doses for variable activity, diet, etc. Unlike pattern management, the dose changes are made only once, to cover the event. Each patient's algorithms are unique, and are based on the patient's and caregiver's identification of diet, exercise, and other habits that cause the blood glucose values to deviate from the usual range, then designing and validating diet and or insulin fixes. Algorithms are...

References

The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 329 977-986, 1993. 2. UK Prospective Diabetes Study UKPDS Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional Ueatment and risk of complications in patients with type 2 diabetes. Lancet 352 837-853, 1998. 3. UK Prospective...

Neutral Protamine Hagedorn Insulin

The most commonly used intermediate-acting insulin is neutral protamine Hagedorn NPH insulin isophane . It was developed in the Novo-Hagedorn laboratories in Denmark in 1946 by Krayenbuhl and Rosenberg 37 , based on the original observation of Hagedorn that insulin's effect was prolonged when combined with proteins such as protamine 38 , and that of Scott and Fisher showing that small amounts of zinc lengthened the action of protamine insulin 39 . NPH contains equal amounts of protamine and...

Pattern of Insulin Secretion

Insulin secretion has a diurnal rhythm, with an increased rate of secretion during the day and decreased secretion at night 12 . Also, insulin is secreted in both an ultradian 13 and a high-frequency pulsatile pattern 14 . The ultradian pulses occur with a frequency of one pulse each 40 minutes, a rate that is decreased in patients with type 2 diabetes. The high-frequency pulses occur at one pulse per 6 minutes. Almost all insulin is secreted in these high-frequency discrete insulin secretory...

Insulin Absorption

Insulin absorption, and thus the liming of its action, is affected by many variables. The insulin formulation. The protamine in NPH and the excess zinc in Lente and Ultralente promote crystallization, which causes the cloudy appearance and slower absorption compared with Regular insulin or the rapid-acting analogs clear insulins . Raising skin temperature, such as by taking a shower or hot tub after an injection, increases absorption. Similarly, massaging the injection site increases local...

Longacting Insulins

The long-acting insulin used in the United States is Ultralente. As indicated above, it is an insulin-zinc crystalline preparation that was developed to be a basal, long-acting insulin because in animal form its duration of action when injected subcutaneously exceeds 24 hours and is relatively peakless. Because human Ultralente is more soluble, its duration of action is significantly shorter Table 2 . In a recent study 9 , human Ultralente was shown to have an onset of action of 1.0 0.2 hour...

Basalbolus Intensive Insulin Therapy What Is Basal Bolus Insulin Treatment

BasaJ-bolus coverage combines the available insulin preparations Table 1 into programs that take into account the unique dietary, exercise and other habits of your patient to mimic as closely as possible physiological insulin delivery i.e., provide insulin in approximately the correct amount when needed, and not provide it when unnecessary in order to attain near-normal daytime and nighttime glycemia. By necessity, multiple shots and frequent self-blood-glucose monitoring SBGM are required....

Bibliography

ACE Consensus Conference on Guidelines for Glycemic Control article online , 2001. Available from paper.php. Accessed Aug 24, 2001. Adler AI, Stratton IM, Neil HA, Yudkin JS, Matthews DR, Cull CA, Wright AD, Turner RC, Holman RR. Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes UKPDS 36 prospective observational study. Br Med J 321 412-419, 2000. Cefalu WT, Wang ZQ, Bell-Farrow AD, McBride D, King T. Clinical validity of a self-test...

Insulin Pens

Insulin pens are multidose devices in which a small disposable needle is twisted on and the dosage dialed in Figure 1 . Pens have been widely used in Europe Table 1 Insulin Pen Manufacturers and Products Novopen 3 Novopen 1.5 Novopen prefilled Uses any 1.5-cc cartridge up to 30 units in 1-unit increments Uses any 1.5-cc cartridge up to 15 units in ' 2-unit increments Adaptor allows filling the reusable 3.15-cc cartridge with any manufacturer's insulin Disposable pens filled with 3 cc delivered...