When Too Much Insulin Has Little Effect On Glycemic Target
Current use of basal insulin has been shaped by treat-to-target trials that have emphasized systematically titrating the insulin dose without limit until an FPG of 100130 mg/dL is reached . Overbasalization is said to occur when FPG is uncontrolled despite uptitration of basal insulin and the A1C target remains unmet . Since basal insulin is not designed for postprandial coverage, patients may experience hypoglycemia in the fasting state without seeing any additional reduction in their A1C. Furthermore, patients are prone to experience postprandial hyperglycemia due to a lack of mealtime insulin as a result of -cell failure. Overbasalization may cause hypoglycemia during the day and evening hours if insulin dose adjustments are based on fasting blood glucose values. Increased activity levels during the day can lead to hypoglycemia if too much basal insulin is given daily.
A basal insulin dose > 0.5 units/kg , a > 50 mg/dL difference between bedtime and the next mornings SMBG value , or an absolute morning glucose level < 70 mg/dL should be recognized as potential overbasalization. Increasing basal insulin to > 0.5 units/kg has been shown to not improve A1C or mean FPG and is associated with weight gain . Patients whose FPG is near or within the target range but whose A1C remains elevated after treatment intensification with basal insulin should be considered for therapy that effectively reduces postprandial glycemia .
What Is Insulin Made Of
Insulin is made in different ways. The insulin molecule is like two joined strings of beads.
You and your healthcare team will discuss which insulin you can take.
Human insulin This is synthetic and made in a laboratory to be like insulin made in the body. Analogue insulin This is also synthetic and made in the laboratory but scientists have managed to alter the position of some of the beads to create genetically engineered insulin known as analogues. Animal insulin This isnt used much anymore, but some people find that purified insulin from animals works best for them. It comes from cows or pigs.
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One Type Of Insulin Can Be Inhaled
In the United States, theres one brand of insulin that can be inhaled. Its a rapid-acting form of insulin. Its not suitable for everyone with type 2 diabetes.
If your doctor thinks you might benefit from rapid-acting insulin, consider asking them about the potential benefits and downsides of using an inhalable medication. With this type of insulin, lung function needs to be monitored.
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Why Is This Medication Prescribed
Human insulin is used to control blood sugar in people who have type 1 diabetes or in people who have type 2 diabetes that cannot be controlled with oral medications alone. Human insulin is in a class of medications called hormones. Human insulin is used to take the place of insulin that is normally produced by the body. It works by helping move sugar from the blood into other body tissues where it is used for energy. It also stops the liver from producing more sugar. All of the types of insulin that are available work in this way. The types of insulin differ only in how quickly they begin to work and how long they continue to control blood sugar.
Over time, people who have diabetes and high blood sugar can develop serious or life-threatening complications, including heart disease, stroke, kidney problems, nerve damage, and eye problems. Using medication, making lifestyle changes , and regularly checking your blood sugar may help to manage your diabetes and improve your health. This therapy may also decrease your chances of having a heart attack, stroke, or other diabetes-related complications such as kidney failure, nerve damage , eye problems, including changes or loss of vision, or gum disease. Your doctor and other healthcare providers will talk to you about the best way to manage your diabetes.
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Human Insulin And Its Analogs
It was expected that the rapid-acting and long-acting analogs, which more closely approximate physiological insulin secretion, would confer important clinical benefits . With respect to type 2 diabetes, the topic of this review, it is important to note that most patients with type 2 diabetes have residual endogenous insulin secretion in the context of insulin resistance. Therefore, the rationale for imitating the insulin secretion pattern of human physiology is less convincing than in type 1 diabetes. Indeed, in patients with type 2 diabetes, the rapid-acting analogs were not found to be superior to regular insulin in reducing A1C levels or rates of overall hypoglycemia . The clinical benefits of the long-acting insulin analogs compared with NPH insulin are limited to a reduction in hypoglycemia .
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How Should Insulin Therapy Be Intensified
The available options for additional insulin injections include a second injection of basal insulin, prandial insulin before one or more meals, or a switch to biphasic insulin. The choice between intensification of basal insulin versus the introduction of prandial or biphasic insulin should be individualized based on patients’ diurnal blood glucose profiles. When considering the profiles obtained with NPH insulin or long-acting insulin analog once daily, the effect appears to wane during the day, even in patients starting insulin therapy, i.e., with remaining endogenous insulin secretion . These patients could benefit from adding a second injection of basal insulin . However, in the context of declining endogenous insulin secretion, daytime hyperglycemia is usually related to elevated postprandial glucose levels, favoring the initiation of prandial or biphasic insulin.
You Can Use Different Delivery Devices
To inject insulin, you can use any of the following delivery devices:
- Syringe. This empty tube attached to a needle can be used to draw a dose of insulin from a bottle and inject it into your body.
- Insulin pen. This injectable device contains a premeasured amount of insulin or cartridge filled with insulin. The individual dose can be dialed up.
- Insulin pump. This automated device delivers small and frequent doses of insulin into your body, through a catheter placed under your skin.
You can talk to your doctor about the pros and cons of different delivery methods for your medication.
Practicing healthy habits can potentially delay or prevent your need for insulin therapy. If youve already started insulin therapy, adjusting your lifestyle might help reduce the amount of insulin you need to take.
For example, it might help to:
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Update On Insulin Management In Type 2 Diabetes
Joshua J. Neumiller, PharmD, CDE, CGP, FASCP, is an assistant professor, and Carol H. Wysham, MD, is an adjunct professor in the Department of Pharmacotherapy, College of Pharmacy at Washington State University in Spokane. Dr. Wysham is also a clinical endocrinologist for Rockwood Clinic in Spokane. Peggy Soule Odegard, BS, PharmD, BCPS, CDE, FASCP, is an associate professor and director of the geriatrics program at the University of Washington School of Pharmacy and a clinical pharmacist and diabetes educator at the University of Washington Department of Medicine in Seattle. She is also an associate editor of Diabetes Spectrum.
Note of disclosure: Dr. Wysham has received honoraria for speaking engagements from Sanofi-Aventis, Novo Nordisk, and Eli Lilly and Co., all of which are manufacturers of insulin products for the treatment of diabetes.
Joshua J. Neumiller, Peggy Soule Odegard, Carol H. Wysham Update on Insulin Management in Type 2 Diabetes. Diabetes Spectr 1 January 2009 22 : 8591.
This article provides a brief overview of the various insulin products currently available on the market and discusses considerations regarding insulin therapy in people with type 2 diabetes. Issues involving the initiation, titration, and optimization of insulin therapy to meet individual patient treatment goals are discussed.
Insulins Commonly Used In Dogs And Cats
Peak Action and Duration of Effect
0.250.5 U/kg q 12 hr .5
Dogs0.250.5 U/kg q 12 hr.
Commonly used in dogs injection pens available for dogs and cats.
Shaking insulin bottle is required.
NOTE: In dogs, the manufacturer recommends a starting dose of 0.5 U/kg q 24 hr.
Recombinant DNA origin human insulin
FDA Approval Status
Peak Action and Duration of Effect
12 U per cat q 12 hr.Dogs0.250.5 U/kg q 12 hr.230.51 U/kg q 24 hr.15
Commonly used in cats not commonly used in dogs.
Some clinicians believe that for dogs, a starting dose of 0.25 U/kg q 12 hr is appropriate and 0.5 U/kg q 12 hr should be reserved for potentially challenging diabetics. Once-daily dosing in dogs is now approved by the FDA.
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People With Type 2 Diabetes
Type 2 diabetes is typically a progressive disease and most do not require insulin when first diagnosed. Blood glucose levels are often manageable with lifestyle changes such as more careful meal planning and exercise. Antidiabetic drugs, such as oral medications like metformin or non-insulin injectables, may be added if blood glucose level goals are not being met. Because Type 2 diabetes is a progressive disease, at some point the production of insulin in the pancreas may not be sufficient and insulin injections may be necessary.
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Concerns About Insulin Therapy
Pain, weight gain, and hypoglycemia may occur with insulin therapy. Pain is associated with injection therapy and glucose monitoring, although thinner and shorter needles are now available to help decrease pain. Weight gain associated with insulin therapy is due to the anabolic effects of insulin, increased appetite, defensive eating from hypoglycemia, and increased caloric retention related to decreased glycosuria. In the U.K. Prospective Diabetes Study, patients with type 2 diabetes who were taking insulin gained an average of 8 lb, 13 oz , which was associated with a 0.9 percent decrease in A1C level compared with patients on conventional therapy.5
Hypoglycemia may occur from a mismatch between insulin and carbohydrate intake, exercise, or alcohol consumption. Hypoglycemia has been associated with an increased risk of dementia and may have implications in cardiac arrhythmia. 6,7 All patients should be instructed on the symptoms and treatment of hypoglycemia. American Diabetes Association guidelines recommend that the blood glucose level be checked if hypoglycemia is suspected , then treated with a fast-acting carbohydrate, such as juice or glucose tablets. The blood glucose level should be rechecked after 15 minutes to make sure it has normalized.8
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Type 2 Diabetes: Which Medication Is Best For Me
- By Samar Hafida, MD, Contributor
If you are living with type 2 diabetes, you certainly are not alone. One in 10 people in the US has diabetes, according to the CDC. However, despite considerable progress in diabetes treatment over the past 20 years, fewer than half of those with diabetes actually reach their target blood sugar goal.
In part, this may be because doctors can be slow to make changes to a patients treatment plan, even when a patients treatment goals are not being met. One reason for this may be the overwhelming number of medications currently available. And yet, waiting too long to adjust treatment for type 2 diabetes can have long-lasting negative effects on the body that may raise the risk of heart and kidney disease and other complications.
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