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INSULIN THERAPY IN TYPE 2 DM


A JUDICIOUS USE OF INSULIN THERAPY MAY BE NECESSARY FOR OPTIMAL MANAGEMENT IN MANY PEOPLE WITH TYPE 2 DIABETES!

A table listing some of the types of T2DM patients who should receive insulin is given in Appendix 6a

Types of INSULINS available for clinical use:

Although animal insulins made from beef and pig pancreas may still be found, the vast majority of the insulins used now are of the "human" variety. Recently there has been an increasing emphasis on the use of the newly available insulin analogs and the clinical question is to place them correctly in the therapeutic armamentarium.

It would not be correct to totally replace the use of human insulins with analogs in routine therapy, especially as one has to factor in the costs to the patient and in many cases the use of human insulins would offer good control.

Table Showing Commonly used Insulin Preparations:

Type of Insulin Human Analogues
Long acting   Detemir, Glargine
Intermediate acting NPH  
Short acting Regular Human Insulin Insulin Aspart, Lispro, Glulisine
Premixed Biphasic Human Insulin (30/70,50/50) Biphasic Insulin Aspart (30/70), Biphasic Insulin Lispro (25/75 and 50/50)

Long acting analogs

They exhibit a relatively constant glucose-lowering profile over 24 hours that permits once-daily dosing, although some patients may do better with a twice daily dose of levemir insulin. Clinically, its potency is approximately the same as human insulin and it does not lead to a better glycemic control.

Rapid acting analogs

Their use in place of the human insulins does not always lead to a better control, but their rapid onset and short duration of action make them of particular use in some clinical situations.

For a list of some clinical scenarios where it may be better to use insulin analogs, see Appendix 6b

"ONCE A CLINICAL DECISIONS TAKEN THAT THE PATIENT REQUIRES INSULIN FOR OPTIMAL MANAGEMENT, ALL EFFORTS SHOULD BE MADE TO USE THE GENETICALLY DERIVED PURE HUMAN INSULINS. IN A SIGNIFICANT NUMBER OF CLINICAL SCENARIOS, PATIENTS WOULD DO BETTER WITH THE USE THE ANALOG INSULINS, IF FEASIBLE."


TIME-ACTIVITY CHARACTERISTICS


  Begins Working Peaks At Ends Working Lows Occur At
Insulin-Lyspro 15-20 minutes 30-90 min 3-4 hours 2 to 4 hr
Insulin- aspart 15-20 minutes 40-50 min 3-4 hours 2 to 4 hr
Regular 30-60 minutes 80-120 min 4-6 hours 3 to 7 hr
NPH 2-4 hours 6-10 hours 14-16 hours 6 to 12 hr
Lente 3-4 hours 6-12 hours 16-18 hours 7 to 14 hr
Ultralente 4-6 hours 10-16 hours 18-20 hours 12 to 24 hr
Insulin Glargine/Levemir 2-3 hours almost no peak 18-26 hours 4 to 24 hr

However, each person responds to insulin in his or her own way. That is why onset, peak time, and duration are given as ranges.

It is important to have an understanding of the time-activity characteristics of the available insulins. When blood glucose levels are not well controlled at certain times during the day, or if hypoglycemic reactions are occurring, the knowledge of the action and characteristics of each insulin being taken will help to determine where changes need to be made.
Fortunately, the picture becomes much more clear, if it is realised that from a practical and clinical viewpoint, human insulins can be divided into two main groups, depending on their time course of action. These are the "short-acting (SAI)" and the "intermediate acting (IAI)" insulins.

INSULIN TREATMENT SCHEME



* Rosiglitazone should not be used along with insulin and the dose of pioglitazone should not exceed 30mg/day.

In most patients with a significant degree of symptoms, or in whom the fasting blood glucose values are higher than 250-300mg%, insulin therapy, if indicated in a particular patient, may be started along with the diet and exercise prescription.

Start with a small dose and gradually titrate upwards depending on the time characteristics of the insulins used as well as the individual response of a patient.

With increasing use, it would be possible to cut out some of the initial steps outlined above and start with a twice daily mixture of SAI and IAI insulins, especially in insulin requiring patients.

The most commonly used regimen is the Premixed regimen:

It is the most convenient and effective insulin regimen for initiation of insulin therapy. In this there is dual coverage as it is a combination of short acting and intermediate acting insulin preparations in fixed ratio like 30:70 or 50:50 respectively (options for different food habits). So the same preparation is able to give both basal and meal related coverage and helps to mimic physiology to a great extent. There for these are considered as the effective and compliant insulin preparations for initiation as well as intensification of insulin therapy.



* Rosiglitazone should not be used along with insulin and the dose of pioglitazone should not exceed 30mg/day.

Other Regimens

Basal Only Regimen:

In this patients on OHAs who are not optimally managed are supplemented with just basal insulin. This is done with the help of NPH or the modern insulins. With NPH patients usually require 2 doses per day where as with insulin analogues with one injection per day you can achieve the desired targets in most of the patients, if chosen appropriately.

Basal Bolus Regimen:

Very rarely required for T2DM patients, but may be necessary in certain clinical scenarios. In this a basal insulin supplementation given with the help of long acting insulins either two or one (with insulin analogues) injections and then three meal related short acting insulin injections.

INJECTION SITES



The sites where the injections can be given. Efforts must be made to rotate the site of the injection throughout the permissible areas and not inject only into one region.

COMMONLY SEEN SIDE EFFECTS

Hypoglycemia

Edema

Allergy

Lipodystrophy and scar formation

The use of insulin therapy is often required to achieve optimal blood glucose control. In most T2DM patients this should be accompanied by using insulin sensitizers, which would lower the insulin resistance seen in the patients with T2DM and allow a much smoother control at the minimal possible dosages.


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