Foods And Beverages To Limit
If youve been diagnosed with type 2 diabetes, or even if youre trying to avoid diabetes and manage your weight, there are certain foods and beverages that you should limit if possible. These include:
- foods heavy in saturated or trans fats
- refined baked goods
- high-sugar, highly processed snacks
- sugary drinks
While no one food, enjoyed every so often, should knock you off your healthy path, its a good idea to talk with your doctor about dietary restrictions based on your blood sugar levels. Some people may need to monitor their glucose more carefully than others after eating these foods.
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.
Managing Type 2 Diabetes
Managing type 2 diabetes requires teamwork. Youll need to work closely with your doctor, but a lot of the results depend on your choices.
Your doctor may want to perform periodic blood tests to determine your blood glucose levels. This will help determine how well youre managing the condition. If you take medication, these tests will help gauge how well its working.
Your doctor may also recommend a home monitoring system to test your own blood glucose levels between visits. Theyll explain to you how often you should use it and what your target range should be.
Because diabetes can increase your risk of cardiovascular disease, your doctor may want to monitor your blood pressure and blood cholesterol levels. If you have symptoms of heart disease, you may need additional tests. These tests may include an electrocardiogram or a cardiac stress test.
It may also be helpful to bring your family into the loop. Educating them about the warning signs of blood glucose levels that are too high or too low will allow them to help in an emergency.
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Management Of Critical Illness
Standard practice in intensively ill patients has been to provide tight glycemic control through intensive insulin therapy. Research evidence, however, has called this practice into question.
A meta-analysis found that in critically ill adult patients, tight glucose control is associated with an increased risk of hypoglycemia but not with significantly reduced hospital mortality. A large, international, randomized trial among adults treated in an intensive care unit found that intensive glucose control resulted in higher mortality than did a blood glucose target of 180 mg/dL or less.
However, large, single-center studies using more accurate glucose measurements have shown a benefit to intensive glycemic control in critical illness. This remains an area of important ongoing research.
Results of the Diabetes and Insulin-Glucose Infusion in Acute Myocardial Infarction trial suggested improved outcomes in patients with type 2 diabetes with acute myocardial infarction or stroke who receive constant IV insulin during the acute phase of the event to maintain blood glucose values of approximately 100-150 mg/dL. However, these results were not confirmed in the follow-up trial, DIGAMI-2.
A post-hoc analysis of the DIGAMI-2 study revealed that glucose-lowering drugs impact prognosis differently. Insulin may be associated with increased risk of nonfatal cardiac events, whereas metformin seems to be protective against risk of death.
Joint Consensus Statement On Remission
In a 2021 joint consensus statement from the American Diabetes Association, the Endocrine Society, the European Association for the Study of Diabetes, and Diabetes UK, the term remission, as it applies to type 2 diabetes, is defined as the presence of an HbA1c level below 6.5% at least 3 months after glucose-lowering pharmacotherapy has been halted. This applies whether the remission has been achieved by way of lifestyle, bariatric surgery, or other means.
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Advanced Glycation End Products
Food-derived, pro-oxidant, advanced glycation end products may contribute to insulin resistance in clinical type 2 diabetes mellitus and may suppress protective mechanisms. Advanced glycation end-product restriction may preserve native defenses and insulin sensitivity by maintaining a lower basal oxidative state.
What Are Side Effects Associated With Using Insulin Aspart
Common side effects of Insulin Aspart include:
- thickening or hollowing of the skin where the medicine was injected
Serious side effects of Insulin Aspart include:
- redness or swelling where the injection was given,
- itchy skin rash over the entire body,
- swelling of the tongue or throat,
- swelling,
Rare side effects of Insulin Aspart include:
- none
This is not a complete list of side effects and other serious side effects or health problems may occur as a result of the use of this drug. Call your doctor for medical advice about serious side effects or adverse reactions. You may report side effects or health problems to FDA at 1-800-FDA-1088.
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An Algorithm For Using Insulin
There is no single best way to initiate insulin therapy in patients with type 2 diabetes in whom oral treatments no longer maintain adequate control. Clinicians should consider 10 units of basal insulin at bedtime, supper, or in the morning a safe, effective recommendation for beginning insulin therapy. This dose can then be titrated based on how well a patient has met individual glycemic goals as measured by fasting blood glucose, postmeal glucose levels, and self-monitoring of blood glucose. In obese, insulin-resistant patients, a higher starting dose may be safely used.
provides an algorithm that includes recommendations for the use of insulin therapy in type 2 diabetes.
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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Are Metformin And Insulin Safe To Use While Pregnant Or Breastfeeding
Metformin
- There are no adequate studies in pregnant women. Most experts agree that insulin is the best treatment for pregnant women with diabetes.
- Metformin is excreted into breast milk and can therefore be transferred to the nursing infant. Nursing mothers should not use metformin.
Insulin
- Insulin is the drug of choice for controlling diabetes during pregnancy, that is, it is preferred over oral drugs to reduce blood sugar. NPH, insulin aspart, insulin detemir, and insulin lispro also are used during pregnancy.
- Insulins are considered safe to use by nursing mothers.
Pramlintide Is An Injected Medicine For People With Diabetes
In type 1 diabetes, Pramlintide can be taken in addition to insulin to help control mealtime blood sugars.
If you have type 2 diabetes, and lifestyle changes are not enough to control your blood sugar, typically, your provider will first start you on a single medicine. For people who are overweight, metformin is usually the first medicine prescribed.
If the single therapy doesnt work, additional medicines can be added. Many people require treatment with 2, 3 or more different medicines. If pill combinations dont work, an injected medicine such as an incretin-based medicine, amylin analog or insulin may be prescribed. Medicine combinations are used because different drugs target different parts of your bodys sugar regulation system.
Rarely, and usually due to other medical conditions, it may be necessary to start medical treatment of type 2 diabetes with insulin therapy. Usually, however, insulin therapy is the last treatment prescribed and is added only after the oral medications or non-insulin injections dont work.
In this section, you will learn about the non-insulin treatment options for glucose control in type 2 diabetes including the different medicines, how they work, doses, and side effects.
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How Much Insulin And At What Time
For practical purposes, the patient can always be commenced on 10 units of intermediate-acting insulin, given just before bedtime and as late as possible. This timing allows the insulin to exert its maximum action just before dawn rather than at 2-3 a.m. when it is most likely to cause hypoglycaemia. If the patient is very nervous or reluctant and it is imperative to minimise the risk of hypoglycaemia, however small, then a slightly lower dosage can be used to get the process underway and to gain the patient’s confidence. Patients who have symptoms of hyperglycaemia can start at a higher dose of insulin, but this would rarely need to exceed 20-25 units.
The bedtime dose of insulin is best given as isophane insulin. Currently in Australia, there is only one brand of human isophane insulin available. When it becomes generally available, insulin glargine will probably become the basal insulin of choice as its ‘flatter’ and longer action make it more suitable for this purpose.3
What To Do With The Oral Drugs
The patient is asked to remain on all the oral hypoglycaemic drugs that they are currently taking. The only exceptions are:
- if the patient is taking supra-maximal doses of any of the oral drugs, they are reduced to what is recommended in the product information
- if the patient is suffering from the gastrointestinal adverse effects of metformin, it is reduced to a dose which is tolerated
- if the patient is taking three oral hypoglycaemic drugs including acarbose, the acarbose is stopped as its adverse effects usually outweigh its advantage.
Although the oral drugs have ‘failed’ in the situation of ‘secondary failure’, they are still exerting considerable hypoglycaemic effects. Clinical studies have shown that if either the sulfonylurea or metformin are stopped altogether, then each needs to be replaced by an extra 20-30 units of daily insulin. In other words, the insulin dosage would need to exceed about 60 units a day before improvement in glycaemic control could occur. This would require a more aggressive insulin regimen and titration, making the process of starting insulin much more difficult. If a thiazolidinedione has been used, this could be continued initially at least, as it may also contribute an insulin sparing effect.
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Throwing Away Your Needles And Lancets
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.
Type 2 Diabetes Prevention
Adopting a healthy lifestyle can help you lower your risk of diabetes.
- Lose weight. Dropping just 7% to 10% of your weight can cut your risk of type 2 diabetes in half.
- Get active. Thirty minutes of brisk walking a day will cut your risk by almost a third.
- Eat right. Avoid highly processed carbs, sugary drinks, and trans and saturated fats. Limit red and processed meats.
- Quit smoking. Work with your doctor to keep from gaining weight after you quit, so you don’t create one problem by solving another.
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Choosing The Correct Type Of Insulin
Insulin regimens should be tailored to the patient’s needs and lifestyle. One of the most important considerations is the pharmacokinetics of different insulin preparations 26 . Table 2 defines commonly used terms in insulin therapy.
Pharmacokinetic Profiles of Insulin Therapies
| Insulin type | |
|---|---|
|
Dual |
14 to 24 hours |
*NPH/regular: Humulin 70/30, Novolin 70/30, Humulin 50/50 NPH/lispro or aspart: Humalog 75/25, Novolog 70/30, Humalog 50/50.
Adapted with permission from Endotext.org. Insulin pharmacology, types of regimens and adjustments. . Accessed December 6, 2010.
Pharmacokinetic Profiles of Insulin Therapies
| Insulin type | |
|---|---|
|
Dual |
14 to 24 hours |
*NPH/regular: Humulin 70/30, Novolin 70/30, Humulin 50/50 NPH/lispro or aspart: Humalog 75/25, Novolog 70/30, Humalog 50/50.
Adapted with permission from Endotext.org. Insulin pharmacology, types of regimens and adjustments. . Accessed December 6, 2010.
Onset of action, peak, and duration of exogenous insulin preparations.
Adapted from Hirsch IB. Insulin analogues. N Engl J Med. 2005 352:177.
Figure 2.
Onset of action, peak, and duration of exogenous insulin preparations.
Adapted from Hirsch IB. Insulin analogues. N Engl J Med. 2005 352:177.
Commonly Used Terms in Insulin Therapy
Commonly Used Terms in Insulin Therapy
Analogue Versus Human Insulin
Glucose control, adverse effects, cost, adherence, and quality of life need to be considered when choosing a type of insulin. In general, analogue insulin is similar to human insulin in controlling diabetes, although some trials have found higher mean A1C levels in patients taking analogue insulin compared with human insulin. 17 Analogue insulin usually causes less postprandial hyperglycemia and delayed hypoglycemia. 18,19 In a recent meta-analysis, glycemic control was not improved with analogue insulin compared with human insulin, but nocturnal hypoglycemia was reduced.17
An industry-funded cost-effectiveness analysis found that the increased cost of medication is more than off set by the reduction in hypoglycemic events. 20 However, the analysis assumed a cost differential of 14 percent, which is inconsistent with current pricing . 20,21 Cost-effectiveness analyses have differed regarding the long-term cost savings of using analogue insulin in patients with type 2 diabetes, with industry-sponsored studies finding reduced cost22 and government-sponsored studies finding no cost reduction. 23 Measures of adherence and quality of life have been improved with analogue insulin compared with human insulin. 24,25
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Making The Switch To Insulin
Making the transition is much easier than it used to be because most patients are started on a long-acting insulin that does not need to be matched with food intake.
Insulin pens that are preloaded are replacing insulin that needs to be drawn up into a syringe. Patients may still be worried about giving themselves injections, but because the needle is so tiny the adjustment is often quick.
Toujeo and Lantus are long-acting forms of insulin that are available in a prefilled injectable pen.
There’s also a type of rapid-acting insulin, Afrezza, that can be inhaled through the mouth via an inhaler.
And a new class of medication called sodium-glucose cotransporter 2 inhibitors is also available now, according to Mazhari. “It works via a different pathway that’s not pancreas-dependent, offering another medical therapy option for patients with type 2 diabetes.”
The key to an easy transition to insulin is education.
“Patients need to know how to take their insulin properly since there are many formulations on the market, including short- and long-acting insulin and premixed,” Mazhari said. “Most can be started on a long-acting insulin once a day, though for some patients short-acting or mealtime insulin may be necessary as well. Insulin doses need to be further adjusted depending on blood sugar readings.”
Causes Of Type 2 Diabetes
Insulin is a naturally occurring hormone. Your pancreas produces it and releases it when you eat. Insulin helps transport glucose from your bloodstream to cells throughout your body, where its used for energy.
If you have type 2 diabetes, your body becomes resistant to insulin. Your body is no longer using the hormone efficiently. This forces your pancreas to work harder to make more insulin.
Over time, this can damage cells in your pancreas. Eventually, your pancreas may not be able to produce any insulin.
If you dont produce enough insulin or if your body doesnt use it efficiently, glucose builds up in your bloodstream. This leaves your bodys cells starved for energy. Doctors dont know exactly what triggers this series of events. It may have to do with cell dysfunction in the pancreas or with cell signaling and regulation.
While lifestyle choices are typically what trigger type 2 diabetes, you may be with it if:
- theres a genetic predisposition to developing type 2 diabetes in your family
- theres a genetic predisposition to developing obesity in your family, which can increase the risk of insulin resistance and diabetes
- you are at least 45 years old
- you are Black, Hispanic/Latino, Native American, or of Alaska Native descent
While the definitive trigger of type 2 diabetes is your bodys resistance to insulin, theres usually a combination of factors that increase your risk of that resistance occurring.
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What Should I Know About Storage And Disposal Of This Medication
Store unopened vials of human insulin, unopened disposable dosing devices and unopened human insulin pens in the refrigerator. Do not freeze human insulin and do not use human insulin that has been frozen. Opened vials of human insulin should be stored in the refrigerator but may also be stored at room temperature, in a cool place that is away from heat and direct sunlight. Store opened human insulin pens and opened dosing devices at room temperature. Check the manufacturer’s information to find out how long you may keep your pen or dosing device after the first use.
Unneeded medications should be disposed of in special ways to ensure that pets, children, and other people cannot consume them. However, you should not flush this medication down the toilet. Instead, the best way to dispose of your medication is through a medicine take-back program. Talk to your pharmacist or contact your local garbage/recycling department to learn about take-back programs in your community. See the FDA’s Safe Disposal of Medicines website for more information if you do not have access to a take-back program.
It is important to keep all medication out of sight and reach of children as many containers are not child-resistant and young children can open them easily. To protect young children from poisoning, always lock safety caps and immediately place the medication in a safe location â one that is up and away and out of their sight and reach.