Insulin Management Of Type 2 Diabetes Mellitus
ALLISON PETZNICK, DO, Northern Ohio Medical Specialists, Sandusky, Ohio
Am Fam Physician. 2011 Jul 15 84:183-190.
Insulin therapy is recommended for patients with type 2 diabetes mellitus and an initial A1C level greater than 9 percent, or if diabetes is uncontrolled despite optimal oral glycemic therapy. Insulin therapy may be initiated as augmentation, starting at 0.3 unit per kg, or as replacement, starting at 0.6 to 1.0 unit per kg. When using replacement therapy, 50 percent of the total daily insulin dose is given as basal, and 50 percent as bolus, divided up before breakfast, lunch, and dinner. Augmentation therapy can include basal or bolus insulin. Replacement therapy includes basal-bolus insulin and correction or premixed insulin. Glucose control, adverse effects, cost, adherence, and quality of life need to be considered when choosing therapy. Metformin should be continued if possible because it is proven to reduce all-cause mortality and cardiovascular events in overweight patients with diabetes. In a study comparing premixed, bolus, and basal insulin, hypoglycemia was more common with premixed and bolus insulin, and weight gain was more common with bolus insulin. Titration of insulin over time is critical to improving glycemic control and preventing diabetes-related complications.
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Analogue insulin is as effective as human insulin but is associated with less postprandial hyperglycemia and delayed hypoglycemia.
Titration And Timing Of Basal Insulin
After the recent unexpected finding of increased mortality in the intensive glucose-lowering therapy group of the ACCORD study, which might be partly related to the rate of the reduction in A1C , clinicians may now be more reserved to lower glucose levels promptly. However, we still feel that in addition to timely initiation, rapid titration of the dose is indispensable for successful insulin therapy. The ACCORD study solely included patients at high risk for cardiovascular disease, in whom low A1C levels were reached by using up to four or five different classes of glucose-lowering drugs. In contrast, in less selected patients treated with stable doses of one or two oral agents, simple titration algorithms targeting fasting plasma glucose 100 mg/dl can safely achieve A1C of 7.0% . A patient-driven algorithm, with patients increasing their insulin dose by 2 or 3 units every 3 days, as long as their fasting plasma glucose remains above target, constitutes a practical approach that has been shown to be equally or more effective than physician-led titration .
Newly Diagnosed With Type 2 Diabetes
Knowing where to get started following a type 2 diagnosis can be a challenge. You may feel overwhelmed, but its important to know there isnt a one-size fits all approach to managing the condition.
As well as using the information on this page to understand your condition, you can meet other people with type 2 diabetes in our Learning Zone. Youll hear advice from others in your position, and get practical tools to help you feel more confident managing your condition.
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Learn How To Inject Insulin
Insulin can be injected using a syringe, but most people use insulin pens. Insulin pens are similar in size and shape to a writing pen. They make measuring and injecting your insulin easier and are easy to carry around. Insulin pens are not pre-fitted with needles. A suitably sized needle has to be attached to the pen. Insulin should be injected into the fatty tissue under your skin. Your abdomen or tummy area, about 5 cm away from your belly button, is usually a good place. It is easy to reach and insulin absorbs well from this site. Read more about how to inject insulin.
Myths About Insulin And Type 2 Diabetes
When you hear the word insulin, do you picture giant needles or pop culture portrayals of insulin users with low blood sugar ?Either way, most people think of insulin as a difficult, painful, or potentially scary medical treatment.The problem is that if you have type 2 diabetes, you need to know the real deal before you can make an informed choice about whether or not this potentially lifesaving therapy is right for you.Here, we take a look at the facts and fiction about insulin when it comes to treating type 2 diabetes.
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Why Insulin Can Become Necessary For A Person With Type 2 Diabetes
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
- Guilt
- Impression that this is the last resort
- Fear of hypoglycemic attacks
- 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.
How Should Glycemic Targets Be Altered
The simplest and most often discussed modification of usual therapy for people thought to be at high risk is to modify the HbA1c target range. Instead of seeking HbA1c< 53 mmol/mol , higher-risk individuals are commonly advised to aim for between 53 and 64 mmol/mol . Although this was the target range for the standard treatment arm in ACCORD, evidence arguing that this range is always the most appropriate remains limited. For example, individuals with limited life expectancy and having HbA1c of 7586 mmol/mol probably have little to gain from strenuous efforts to reduce this value to < 64 mmol/mol . Similarly, people with serious medical illnesses requiring complex treatments, such as those with cancer undergoing treatment with cytotoxic regimens, might not need to seek even a relaxed HbA1c target range . However, very high HbA1c levels are associated with an acute risk of increased infection and vascular thrombosis as noted above , as well as tiredness, weight loss, and inconvenient polyuria.
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Continuous Subcutaneous Insulin Infusion
In patients with type 2 diabetes already using at least one daily insulin injection, the introduction of intensive insulin therapy with continuous subcutaneous insulin infusion resulted in comparable glycemic control, weight gain, and hypoglycemia risk as multiple daily injection therapy . Although continuous subcutaneous insulin infusion was associated with greater improvements in treatment satisfaction in one study , we recommend that its use be restricted to selected patients in experienced centers only.
When Should Insulin Be Started
Q. Will my patient with type 2 diabetes require insulin?
A. It varies from patient to patient. However, type 2 diabetes is a progressive disease marked by gradual loss of beta cell function and most patients will eventually require insulin therapy.1 This should be viewed as part of the pathophysiology of the disease and not as a failure on the part of the patient or healthcare provider.
Insulin should be discussed early with patients who are beginning to show progression of their diabetes to ease the transition when the time to start insulin therapy arrives. This time should be considered part of a larger conversation between provider and patient, and not seen as a turning point down a path to the many severe complications of diabetes.
Q. Is there a specific hemoglobin A1c at which insulin must be started?
A. No. Insulin, like all treatments for diabetes, should be started and adjusted to achieve a reasonable goal HbA1c for the patient. The American Diabetes Association previously recommended that a patients HbA1c not be allowed to exceed 8%, creating an action point for escalation of therapy.
Insulin therapy will often need to be started if the initial fasting plasma glucose is greater than 250 or the HbA1c is greater than 10%.4_________________________________________________________________________________________________________________________________________________________________________________________________________________
References:
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How Can This Category Of Patients Be Defined And Identified
Where response to initial insulin therapy is poor, or is initially satisfactory but then deteriorates with time due to progressive islet -cell failure, the multitude of insulin types do offer various ways to improve clinical results. However, where basal insulin alone is being used, a first action is to ensure the dose has been titrated to usual fasting plasma glucose targets. Use of more extended self-monitoring can then establish the pattern of daytime and nocturnal glucose levels, allowing an informed decision as to the addition of one or more mealtime insulin doses. If simplicity but less flexibility is judged desirable, a switch to premix insulin may be preferred. Coprescription of a GLP-1RA is another option.
When Do People With Type 2 Diabetes Start Insulin
After 10 to 20 years, many people with type 2 diabetes will begin insulin therapy, although every persons journey with type 2 diabetes is different. This happens when lifestyle changes and medications arent keeping your glucose levels in your target range. It is important that you start treatment as early as possible to avoid persistent hyperglycemia , which can lead to long-term health complications affecting your heart, kidneys, eyes, and other organs.
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How To Get Free Prescriptions For Diabetes Medicine
You’re entitled to free prescriptions for your diabetes medicine.
To claim your free prescriptions, you’ll 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 it’ll 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.
If Not Controlled At The Right Time Diabetes Can Lead To Kidney Failure Partial Or Complete Blindness Nerve Problems Loss Of Limbs And Increase The Risk Of A Heart Attack
Insulin, which is produced by the pancreas in the body, helps control the bodys blood sugar level. Regular insulin intake along with a proper diet and exercise plan is recommended for type 2 diabetes patients to help maintain their blood sugar level. If not controlled at the right time, diabetes can lead to kidney failure, partial or complete blindness, nerve problems, loss of limbs and even increase the risk of a heart attack. However, there are several myths around injecting insulin due to lack of awareness.
A study, published in the American Medical Associations biomedical journal JAMA Network Open, also found that the relative risk of death due to diabetes itself was much stronger among individuals who were underweight. The findings suggest that there is an urgent need to develop diabetes management programs that are tailored to Asian populations and the subsequent strong implementation of these programs in Asia.
Why do Type 2 diabetics need insulin?
The pancreas, that produces digestive enzymes, is also responsible for producing insulin, a hormone that helps regulate blood sugar levels. Insulin helps the body use the carbohydrates in food for energy. If a patient develops Type 2 diabetes, their pancreas stop producing sufficient insulin that is required for the body to control blood sugar level, said Dr Roopak Wadhwa, consultant, department of diabetes endocrinology and metabolism at Fortis Hospital.
Tips while taking insulin injections
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Insulin Blood Sugar And Type 2 Diabetes
Insulin is a key player in developing type 2 diabetes. This vital hormoneyou cant survive without itregulates blood sugar in the body, a very complicated process. Here are the high points:
- The food you eat is broken down into blood sugar.
- Blood sugar enters your bloodstream, which signals the pancreas to release insulin.
- Insulin helps blood sugar enter the bodys cells so it can be used for energy.
- Insulin also signals the liver to store blood sugar for later use.
- Blood sugar enters cells, and levels in the bloodstream decrease, signaling insulin to decrease too.
- Lower insulin levels alert the liver to release stored blood sugar so energy is always available, even if you havent eaten for a while.
Thats when everything works smoothly. But this finely tuned system can quickly get out of whack, as follows:
- A lot of blood sugar enters the bloodstream.
- The pancreas pumps out more insulin to get blood sugar into cells.
- Over time, cells stop responding to all that insulintheyve become insulin resistant.
- The pancreas keeps making more insulin to try to make cells respond.
- Eventually, the pancreas cant keep up, and blood sugar keeps rising.
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.
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Getting Started With Insulin If You Have Type 2 Diabetes
New to insulin? Learn about insulin dosing and timing and how often to test your blood sugar levels if you have type 2 diabetes.
If you have type 2 diabetes, it is likely that your treatment regimen will change over time as your needs change, and at some point, your healthcare professional may suggest that you start taking insulin. While this might feel scary, there are millions of others living with type 2 diabetes and taking insulin, so its definitely manageable.
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.”
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Guidelines For Starting Insulin
Know your health care provider’s plan up front. Ask what A1C and blood glucose measures are used and how you will start taking insulin.
Think short-term, not long-term. Start taking insulin when your health care provider recommends it, and notice if you feel better and have more energy. Don’t try to put it off from appointment to appointment.
Ask to be referred to a diabetes education program to learn the ins and outs of taking insulin and get the support you need.
Have a plan with your health care provider to be in touch regularly to increase your dose until you hit your blood glucose targets.
Get the inside scoop from people who have successfully transitioned to insulin. Try attending a support group or connecting with people willing to support you in one or more of the diabetes online communities.
Explore your options for insulin delivery — using the traditional vial and syringe, or using the more contemporary and convenient pens or possibly an insulin pump. Check your health insurance plan to see what it covers.
Continue to eat well and exercise regularly.
Strive for consistency. Take your insulin and eat at similar times every day when possible.
Store insulin properly. Keep the pen or vial of insulin at room temperature , and store extras in the refrigerator.
Carry a source of carbohydrate to treat low blood sugar, such as glucose tablets or hard candy. Start by using 15 grams of carbohydrate.