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Insulin Replacement Therapy Type 2 Diabetes

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Other Options For The Initiation Of Insulin Therapy

Insulin Replacement Therapy for Type 2 Diabetes | Dr. YT

The recent Treating to Target in type 2 Diabetes study compared the introduction of basal insulin at bedtime to insulin initiation with either biphasic insulin twice daily or prandial insulin before meals . The biphasic and prandial insulin regimens provided better glycemic control than once-daily basal insulin but at the expense of increased risks of hypoglycemia and weight gain. Although biphasic insulin reduced A1C levels to the same extent as prandial insulin, the latter regimen was associated with the most hypoglycemic episodes and the highest weight gain . Therefore, and considering that to date there is no clinical trial evidence supporting the specific lowering of postprandial glucose levels when aiming to lower cardiovascular risk in type 2 diabetes, initiation with prandial insulin is generally not a first-choice approach when starting insulin in type 2 diabetic patients. This was confirmed by a recently reported direct comparison of once-daily insulin glargine versus thrice-daily insulin lispro in insulin-naive patients . Finally, also regarding feasibility in clinical practice and patients’ acceptance, three injections per day is the least attractive option for initiation of insulin therapy.

Producing Less Insulin Naturally Over Time

Research has shown that type 2 diabetes progresses as the ability of the bodys pancreatic beta cells to produce insulin dwindles over time. Your beta cells the cells in the pancreas that produce insulin slowly lose function. Experts believe that by the time youre diagnosed with type 2 diabetes, youve already lost 50-80 percent of your beta cell function and perhaps the number of beta cells you had. And the loss continues over the years.

About six years after being diagnosed, most people have about a quarter of their beta cell function left, says Anthony McCall, M.D., Ph.D., endocrinologist and James M. Moss Professor in Diabetes at the University of Virginia School of Medicine. With this minimal function, the need for injected insulin increases.

Some experts say initiating insulin or other blood glucose-lowering medications early in the course of type 2 diabetes can lower blood glucose and even preserve some beta cell function.

Can I Mix Rapid

You can mix a rapid-acting insulin with an intermediate-acting insulin, according to your doctors instructions. Rapid-acting insulin should always be drawn into the syringe first. This will keep the intermediate-acting insulin from getting into the rapid-acting insulin bottle. After mixing rapid-acting insulin in the same syringe with an intermediate-acting insulin, you must inject the mixture under your skin within 15 minutes. Remember to eat within 15 minutes after the injection.

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Impaired Diurnal Pattern Of Meal Tolerance And Insulin Sensitivity In Type 2 Diabetes: Implications For Therapy

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    Throwing Away Your Needles And Lancets

    Herbal Diabetic Patch Blood Sugar Plaster Type 2 Diabetes Treatment ...

    Sharps bins and needle clippers are the safest way of disposing of your insulin needles and your lancets. A needle clipper removes the needle from your insulin pen, and is useful when youre out and about. How you get rid of your sharps bin depends on where you live. Your healthcare team should have information to help you get rid of your bin.

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    What Are The Different Types Of Insulin

    There are four types of insulin, classified according to the following:

    Onset

    20 to 26 hours

    Some people with diabetes may have to take a combination of two different types of insulin to control their blood sugar levels. Some insulin can be purchased already mixed together, such as Regular and NPH insulin, to allow for injection of both types of insulin at the same time. Other types of insulin cannot be mixed together and may require two separate injections.

    Insulin is manufactured at different strengths U-100 insulin is the most common strength. The syringes for administering insulin are different for each different strength. Therefore, a U-100 syringe can be used only with U-100 insulin.

    The type of insulin chosen may reflect the person’s preferences and ability to adhere to any given treatment regimen. Other factors include an individual’s:

    • Type of diabetes

    • Predictability of day-to-day schedule

    • Willingness to monitor blood sugar levels regularly

    • Daily activity levels

    • Understanding of diabetes

    • Stability of blood sugar levels

    Store And Dispose Of Your Insulin And Needles Safely

    Insulin you are not using should be stored in the door of your fridge. You can keep the insulin you are using out of the fridge for a month, as injecting insulin at room temperature is less painful.

    Never put your used needles in the rubbish bin. Your GP or diabetes nurse can give you a container to put used needles in and can organise a place where you can dispose of the container once its full.

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    Managing Diabetes With Insulin

    Injections of insulin can help manage both types of diabetes. The injected insulin acts as a replacement for, or a supplement to, your bodys natural insulin.

    People living with type 1 diabetes cant make insulin, so they must inject insulin to control their blood glucose levels.

    Many people living with type 2 diabetes can manage their blood glucose levels with lifestyle changes and oral medication. However, if these treatments dont help control glucose levels, people living with type 2 diabetes may also need supplemental insulin.

    Initiating Insulin Therapy In Type 2 Diabetes Mellitus

    U-M Type 1 Diabetes 101 | Module 5 | Insulin Delivery Methods

    American Diabetes Association, ADA The following two images are from the above ADA consensus article below.

    Medical Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of TherapyA consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes

    **The following uptodate.com article uses a version of the ADA algorithms above.

    References

    1. Diabetes Care 2009 Jan 32: 193-203.Online links: http://care.diabetesjournals.org/content/32/1/193.full

    2. Am Fam Physician. 2011 Jul 15 84:183-190.

    3. http://www.uptodate.com/contents/insulin-therapy-in-type-2-diabetes-mellitus

    4. http://www.medscape.org/viewarticle/567952

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    Potential Physiological Effects Of Insulin Replacement Therapy

    What could account for some of the differences in -cell function seen in studies with early aggressive insulin therapy? A study evaluating the anti-inflammatory effects of an insulin infusion on obese subjects without diabetes demonstrated suppression of nuclear factor B. Nuclear factor B is the key transcription factor responsible for the transcription of proinflammatory cytokines, adhesion molecules and enzymes responsible for producing reactive oxygen species . As a consequence, insulin infusion significantly suppressed generation of reactive oxygen species and decreased concentrations of plasma soluble intercellular adhesion molecule-1 , monocyte chemo-attractant protein-1 , and plasminogen activator inhibitor-1 , among other observed anti-inflammatory actions .

    Insulin Detemir Versus Gla

    The results of a clamp-based PK/PD study indicated that detemir and Gla-100 have similar PD effects based on glucose infusion rates during the first 12 h following administration but that rates with detemir are lower between 12 and 24 h, suggesting that a once-daily basal regimen for glargine and a twice-daily basal regimen for detemir might be the most appropriate approach . The authors of a different clamp study reported that, under euglycemic clamp conditions, detemir was associated with a lower within-individual variability for glucose infusion rate and maximal concentration than Gla-100 . However, glargine was noninferior compared with detemir in terms of fasting blood glucose and other indices of glycemic variability in clinical practice settings, with a trend toward higher doses and number of injections with detemir than with glargine .

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    Prandial Insulin Analogues Versus Regular Human Insulin

    Head-to-head trials have generally shown better or similar outcomes with rapid-acting insulin analogues compared with regular human insulin. A meta-analysis found small differences among lispro, aspart, and regular human insulin for HbA1c and a lower risk of severe or nocturnal hypoglycemia with the insulin analogues . Glycemic control was similar or better in patients treated with lispro compared to regular human insulin . Some trials found similar rates of overall , nocturnal, and/or severe nocturnal hypoglycemic events with lispro or regular human insulin, but others found significantly decreased nocturnal episodes with lispro versus regular human insulin . Trials comparing aspart and regular human insulin found small but significant decreases in HbA1c and significantly lower postprandial blood glucose levels with aspart at 6 , 12 , and 30 months . Lower risks of nocturnal severe or severe and nocturnal severe hypoglycemic episodes were seen with aspart versus regular human insulin , but severe hypoglycemic episodes were comparable in others . Another trial, also with basal NPH, found no significant differences in HbA1c or severe hypoglycemic episodes between aspart and regular human insulin at 12 or 64 weeks . In combination with basal insulin glargine, glulisine injected 015 min before meals showed significantly greater reductions in HbA1c than did the regular human insulin injected 3045 min before meals, and severe hypoglycemic episodes were comparable .

    Work Out When To Inject Insulin

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    The time of your insulin injection depends on when your blood glucose level is highest. Most people need to have insulin at bedtime, because your body makes glucose during the night, causing your blood glucose levels to be higher in the morning when you wake. Therefore, an evening dose of insulin helps to maintain lower blood glucose levels overnight. A few people find that their blood glucose levels are highest later in the day. In these people, its best to start insulin in the morning. Some people may need to use insulin 2 or more times a day to get better glucose control. Your doctor or nurse will help you decide on the right schedule for you. It usually takes a few weeks to get your dose and timing right.

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    Insulin Degludec Versus Gla

    Degludec is a second-generation basal insulin analogue which forms multihexamer chains upon injection that slow the absorption of its monomers at the site of injection. In addition, its fatty acid side chain enables dihexamer formation and albumin binding . In a number of studies, similar reductions in HbA1c and weight gain were seen in patients on degludec versus those on Gla-100. However, similar or fewer overall hypoglycemic episodes and fewer nocturnal hypoglycemic episodes were reported with degludec compared with Gla-100.

    Titration Monitoring And Goals Of Therapy

    The ADA recommends that an insulin regimen be adjusted once or twice weekly until self-monitoring of blood glucose targets are reached.9,25 AACE/ACE guidelines differ slightly, recommending adjustment every two or three days.10Table 430 and Figure 125 show different approaches to insulin titration depending on the type of insulin used and the resulting SMBG readings. It should be noted that these recommendations were developed before the U.S. Food and Drug Administration approved new, highly concentrated insulins.

    Fasting blood glucose levels for 3 consecutive days Adjustment of basal insulin dose Premeal or bedtime blood glucose levels for 3 consecutive days Adjustment of rapid-acting insulin dose
    Titration schedule for basal insulin* Titration schedule for rapid-acting insulin
    > 180 mg per dL 8
    < 60 mg per dL 4

    The ADA suggests a target A1C of less than 7% for most nonpregnant patients with type 2 diabetes. An A1C goal of less than 6.5% may be appropriate for patients with short duration of type 2 diabetes that is treated with lifestyle changes or metformin only, a long life expectancy, and no significant cardiovascular disease, as long as significant hypoglycemia or other adverse effects do not occur. For patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbidities, or long duration of type 2 diabetes, an A1C goal of less than 8% or more may be appropriate .9

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    Figuring Out Carbs And Insulin

    Both Carbohydrates: Why We Love Carb Counting and Be Confident! Face Carb Counting Positively! provide useful information on figuring out how many carbs are in the food that you eat. After you have determined this, you have to come up with the amount of insulin you need per meal. This is based on your insulin/carbohydrate ratio.

    One way to figure this out is the Weight Approach. This method is based on the observation that insulin sensitivity decreases as weight increases.

    If you weigh around 180 pounds, your Insulin to Carbohydrate ratio is 1:10 . Say you are eating lunch and you have calculated that your lunch has only 20 grams of carbohydrates, you divide the number of grams by the 10 and you get 2 meaning you need to inject 2 units of insulin. If your lunch has 120 grams of carbs, you divide 120 by 10 and you will need to inject 12 units of insulin. This is why one mom said that her life was made up of numbers!

    It is recommended that you use this I:C ratio as a beginning and test it out over the course of 10 to 14 days, keeping a record of your blood sugar before each meal and then take a reading 3 to 4 hours after.

    Why Insulin Can Become Necessary For A Person With Type 2 Diabetes

    Successful Insulin and Amylin Replacement Therapy for Your Type 1 Diabetes Patients

    Starting insulin treatment should not be seen as a setback.

    People with type 2 diabetes may require insulin when their meal plan, weight loss, exercise and antidiabetic drugs do not achieve targeted blood glucose levels.

    Diabetes is a progressive disease and the body may require insulin injections to compensate for declining insulin production by the pancreas. That is why starting insulin treatment should never be seen as a failure.

    Starting insulin treatment should never be seen as a failure.

    Treatment with insulin may be added to an antidiabetic medication or completely replace it. Regardless of the treatment, lifestyle habits are essential to managing diabetes.

    Many people are reluctant to inject insulin for various reasons:

    • Fear of pain or needles
    • Fear of weight gain
    • Memories of loved one who had to take insulin

    If this is the case, do not hesitate to discuss your concerns with a health care professional. Some of your fears may be due to false beliefs. Learning more about todays insulin treatment will probably allay your fears. For many people, insulin is an effective way to achieve good blood-sugar control, which can prevent or delay certain diabetes complications over the long term.

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    How Can Therapeutic Approaches Be Revised

    Even when individuals with conditions or circumstances allowing exemption from specific glycemic targets are removed from discussion, a sizable group of people who have no apparent reason not to attain HbA1c in the 5364 mmol/mol range remains. Insulin therapy is often said to be unlimited in its capacity to lower glucose levels, but in practice, even very high prescribed doses sometimes yield results that fall short of expectations . The underlying causes of failure of usual treatments are undoubtedly numerous, and to understand them calls for further effort to identify the personal characteristics of each person that may prove relevant . In many cases, progressive obesity, as a marker for high calorie intake and insulin resistance, identifies a metabolic challenge that resists success even when ample insulin is delivered to tissues. Other medical conditions may be important. Examples include unrecognized Cushing syndrome or a genetic or acquired disorder of extreme insulin resistance.

    For some people, psychological factors may interfere with adherence to the regimen or lead to very poor decisions on the timing and dosage of insulin. Obtaining accurate information about actual use of insulin and other medications, independent of what has been prescribed, can be very challenging. For others, environmental pressures, including financial constraints, family or work-related conflict, or social isolation, may prove to be central factors.

    How Is Insulin Administered

    Insulin has to enter the body’s bloodstream to be effective. This is accomplished through injections into the fat layer, usually in the arm, thigh, or abdomen. Different sites on the body allow the insulin to enter the blood at different rates. Insulin injected into the abdominal wall works the fastest, whereas injection into the thigh works the slowest. Insulin must be administered to the body via an injection and cannot be taken by mouth because it is destroyed in the stomach during digestion.

    The timing of insulin injections is very important. Rapid or short-acting insulin usually needs to be administered before mealtimes–before sugar from a meal starts to enter the bloodstream. Always consult your doctor concerning your individual insulin treatment, including injection sites, dosage, frequency, and specific times of administration. Long-acting insulin should be taken at the same time every day, but your meal times can be flexible. Intermediate-acting insulin or mixed insulin needs to be taken at the same time every day along with a fixed eating schedule.

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    How To Get Free Prescriptions For Diabetes Medicine

    Youre entitled to free prescriptions for your diabetes medicine.

    To claim your free prescriptions, youll need to apply for an exemption certificate. This is known as a PF57 form. To do this:

    • fill in a form at your GP surgery
    • you should get the certificate in the post about a week later itll last for 5 years
    • take it to your pharmacy with your prescriptions

    Save your receipts if you have to pay for diabetes medicine before you receive your exemption certificate. You can claim the money back if you include the receipts along with your completed PF57 form.

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