Insulin is a hormone produced by an organ in our body called the pancreas. It helps move a sugar called glucose from the blood vessels into the body’s cells for use as energy. Diabetes occurs when the body cannot produce or respond to insulin, as a result, glucose accumulates in the blood. High blood glucose can affect the kidneys, eyes, blood vessels, and other parts of the body.

Patients with type 1 diabetes and some with type 2 diabetes may be required to administer insulin daily. These methods of administration include syringe injections, insulin pumps, and insulin pens.

1. What is diabetes and what are the types?2. Who gets diabetes and what are its symptoms?3. What tests are available for diabetes?4. What are common complications associated with diabetes?5. What happens as a result of poor blood sugar management?6. What is gestational diabetes?7. What is “hypo” and hyperglycemia?8. What is low blood sugar?9. What are the medications available to treat type 1 diabetes?10. What are the medications available for treating 2 diabetes?11. Can a patient take more than one diabetes pill at a time?12. How does a patient know if their medication is working?13. Which patients require insulin with type 2 diabetes?14. How much insulin is needed in type 2 diabetes?15. How long are patients with type 2 diabetes required to take insulin?16. What types of insulin options are available?17. Does insulin work the same at all times?18. Where is insulin injected?19. How and when should I inject insulin?20. How is insulin stored?21. Demonstrate techniques for mixing and drawing up insulin.22. How to identify appropriate injection sites.23. Instructions for insulin injection.24. What problems arise through insulin injections?25. When & how should insulin doses be increased/decreased?26. Explain insulin adjustments using blood sugar records.27. What factors affect blood sugar; and what are the appropriate insulin adjustments?28. What are “sliding” scales for insulin adjustments and who should use them?29. Do the needs of insulin change with seasons?30. Are there other devices to inject insulin?31. What is an insulin pump?32. Are there any other ways to take insulin apart from injections?33. What are the recent advances in diabetes medication?34. Will I have to take pills/insulin indefinitely?35. What is a skin patch?36. What is an oral spray?36. What is inhaled insulin?37. What is glucose monitoring?

Common Concepts about Diabetes

1. What is diabetes and what are its types?

Diabetes or diabetes mellitus is a disorder characterized by a reduced ability of the body to handle blood glucose. Insulin is essential for glucose to move from the blood to the inside of the cells. Unless glucose enters cells, the body cannot use it for energy. Excess glucose not utilized by the body remains in the blood and is then removed by the kidneys.

In normal health, blood glucose levels are maintained at a comparatively constant level, although it does vary a little. Blood glucose levels are mainly controlled by the action of insulin, a hormone produced by the pancreas. Insulin facilitates the uptake of glucose, amino acids, and fat from the blood into the tissues for use. It also promotes the storage of excess blood glucose in the liver and muscles in the form of glycogen. Through this mechanism, insulin prevents glucose levels from becoming too high in the blood. If the body produces less insulin or becomes insensitive to insulin, this condition is called diabetes.

Types of diabetes:

  • Type 1 diabetes is when the body does not produce adequate amounts of insulin and hence requires total insulin replacement. Also called insulin-dependent diabetes (IDDM) or juvenile diabetes, the condition affects mostly at a young age. In this form of diabetes, the beta cells of the pancreas are destroyed by the body’s immune system and are incapable of producing insulin.
  • Type 2 diabetes is related to the body’s lack of ability to respond to insulin appropriately, a condition called insulin resistance. Initially, the pancreas keeps up with the added demand by producing more insulin. In time, however, it loses the ability to secrete enough insulin in response to meals. This type of diabetes, well known as non-insulin dependent diabetes is seen mostly in obese people with a sedentary lifestyle.
  • Gestational diabetes occurs during the late stages of pregnancy. Although this form of diabetes usually goes away after the baby is born, a woman who has had it is prone to develop type 2 diabetes later in life. Gestational diabetes is caused by the hormones of pregnancy or by a shortage of insulin

2. Who gets diabetes and what are its symptoms?

Diabetes does not affect everybody. Factors that increase the risk of developing diabetes include:

  • Being overweight or obesity
  • Age greater than 45 years
  • Family history of diabetes
  • Race/ethnicity- African-Americans, Hispanic-Americans, and Native Americans all have high rates of diabetes
  • High blood pressure
  • HDL cholesterol of less than 35 and/or triglyceride level of greater than 250
  • History of gestational diabetes
  • Sedentary lifestyle

Symptoms of diabetes

People at risk of developing diabetes should look for the following symptoms:

  • Frequent urination or polyuria
  • Excessive thirst or polydipsia
  • Unexplained weight loss
  • Extreme hunger or polyphagia
  • Sudden vision changes
  • Tingling or numbness in hands or feet
  • Fatigue
  • Very dry skin
  • Slow-healing sores
  • Increased frequency of infections
  • Erectile dysfunction in men

3. What tests are available for diabetes?

People manifesting any symptoms that indicate diabetes should contact their doctor. Basic blood tests are done to diagnose diabetes. These diagnostic tests are:

Fasting plasma glucose (FPG) test: The FPG is the preferred test for diagnosing diabetes due to convenience and is most reliable when done in the morning. It measures your blood glucose after you have gone at least 8 hours without eating. A level of 126 mg/dL or above, confirmed by repeating the test on another day, means that you have diabetes.

Oral glucose tolerance test (OGTT): The OGTT requires you to be empty stomach for at least 8 hours before the test. The person is made to drink a liquid containing 75 grams of glucose dissolved in water and the plasma glucose is measured immediately before and 2 hours after it. A 2-hour glucose level of 200 mg/dL or above, confirmed by repeating the test on another day, confirms diabetes.

Random plasma glucose test: In a random plasma glucose test, blood glucose is checked irrespective of the meal timing. A random blood glucose level of 200 mg/dL or more, along with an assessment of symptoms, is used to diagnose diabetes but not pre-diabetes.

4. What are common complications associated with diabetes?

High blood sugar is harmful to the body. Diabetes if uncontrolled for many years, may eventually damage the organs leading to serious health problems.

  • Retinopathy – High blood sugar damages the blood vessels within the eye. It is one of the major causes of blindness.
  • Nephropathy – Diabetes can interfere with the function of the kidney, in due course of time leading to kidney failure.
  • Neuropathy- Abnormally increased blood glucose levels inflict nerve damage, particularly to the hands and feet, causing tingling, numbness, and weakness. If not treated, non-healing sores may worsen or lead to other complications.
  • Atherosclerosis – Diabetes accelerates fatty deposits in the blood vessels, thereby narrowing it. This process called as atherosclerosis raises the risk of heart attack, stroke and poor blood flow in the legs.

5. What happens as a result of poor blood sugar management?

Poor blood sugar management is harmful to invariably all parts of the body. Excess glucose is risky for the body’s functions.

Heart and blood vessels – Unutilized glucose in the blood is converted into fats that get deposited in the blood vessels. Over a period of time, it can decrease the lumen of the blood vessels, blocking the blood supply. This blockade is the root cause of heart attacks, strokes, and problems arising out of a shortage of blood supply to the legs.

Eyes – Diabetes is injurious to the retina and lens of the eye resulting in many problems with vision.

Kidney – The kidney is a vital body organ that can get damaged by high blood sugar. The kidneys may no longer be able to filter the blood and excrete toxins out of the body.

Nerves – Damaged nerves, as a complication of high blood sugar, may decrease sensation in feet and hands making them prone to injury. As the blood supply is also compromised, the injury may worsen to non-healing ulcers.

6. What is gestational diabetes?

Diabetes during pregnancy, also called gestational diabetes. This releates to the the presence of high blood glucose during the later stages of pregnancy. This state of abnormal blood glucose subsides after the baby is born; however, it increases the risk of developing diabetes later in life.

During pregnancy, glucose is delivered to the baby for nourishment through the placenta. The other function of the placenta is to produce certain hormones that help the baby develop. Some of these hormones are anti-insulin hormones and prevent the utilization of insulin by the body. During later stages of pregnancy, the placenta increases its production of these anti-insulin hormones. Increased levels of these hormones can hamper the process of glucose moving from the bloodstream into the cells. The pancreas may not be able to keep up with the state of insulin resistance. As a result, too much glucose builds up in the bloodstream, causing gestational diabetes.

High blood glucose is detrimental for the mother and the baby too. It is found more often now because more women have babies after age 35, more women are overweight and more women are tested for diabetes. It is recommended that all pregnant women should have a blood test to check for gestational diabetes between the 24th and 28th weeks of pregnancy.

Managing diabetes during pregnancy

Diabetes during pregnancy should be managed properly to protect the mother and baby from its harmful effects. For this, it is very important to keep blood sugar levels as normal as possible. Gestational diabetes can be managed through the following steps:

  • Daily blood glucose monitoring- Pregnant women with gestational diabetes should learn to check their blood sugar and urine for ketones regularly.
  • Taking insulin- If the blood sugar is not controlled with diet and exercise, insulin may be needed to metabolize excess sugar in the blood.
  • Following a special diet- Eat plenty of fruits, vegetables, and grains because they are healthy and help prevent constipation. Eat three small meals and two or three snacks spread out over the day.
  • Don’t skip meals or snacks. Eat a small breakfast. Blood glucose is most likely to be high first thing in the morning. Pregnant ladies should have foods high in iron every day.
  • Following an exercise program
  • Learn a relaxation or meditation technique.
  • Be positive.

7. What is “hypo” and hyperglycemia?

Hypoglycemia is a condition marked by a lower than normal level of sugar in the blood; characterized clinically by sweating, trembling, palpitation, hunger, and weakness; may result from excessive production of insulin by the pancreas or excessive administration of insulin to a diabetic.

Hyperglycemia is a condition of high levels of glucose in the blood. It is a sign that diabetes is out of control. Many things can cause hyperglycemia. It occurs when the body does not have enough insulin or cannot use the insulin it does have to turn glucose into energy. Signs of hyperglycemia are a great thirst, a dry mouth, and a need to urinate often. For people with insulin-dependent diabetes, hyperglycemia may lead to diabetic ketoacidosis.

8. What is low blood sugar?

Low blood sugar or hypoglycemia refers to a pathologic state produced and usually defined by a lower than normal amount of sugar glucose in the blood. Hypoglycemia can produce a variety of symptoms and effects but the principal problems arise from an inadequate supply of glucose as fuel to the brain, resulting in impairment of function. Derangements of function can range from vaguely feeling bad to coma.

Role of Medical Therapy in Diabetes

9. What are the medications available to treat type 1 diabetes?

Patients with type 1 diabetes lack insulin. Their pancreas no longer produces insulin. Hence, in order to facilitate glucose utilization in the body, insulin has to be provided externally or from outside the body. Insulin is taken as injections as prescribed by the physician. The latest development in this field is inhalation insulin which will be available very shortly. The inhaled form of insulin could help people get rid of the painful insulin shots.

10. What are the medications available for treating 2 diabetes?

People with type 2 diabetes can control their blood sugar through proper diet, exercise, and lifestyle changes. However, when these measures are not effective, medicines should be taken to ensure proper utilization of blood glucose.

Many types of diabetes medicines or pills are available to help people with type 2 diabetes lower their blood glucose. The medicines are categorized on the basis of their specific actions. Medicines available for type 2 diabetes are:

  • Sulfonylureas: These drugs stimulate the pancreas to produce more insulin. e.g. glibenclamide or daonil
  • Biguanides: Biguanides reduces the amount of glucose made by the liver. e.g. metformin, glucophage.
  • Alpha-glucosidase inhibitors: These drugs have the property of slowing down the absorption of the starches consumed. e.g. acarbose, miglitol.
  • Thiazolidinedione: Medicines belonging to this category make the body more sensitive to insulin. e.g. Rosiglitazone, Pioglitazone, Troglitazone.
  • Meglitinides: Meglitinides group of drugs fuels the pancreas to make more insulin. e.g. Nateglinide, Repaglinide
  • D-phenylalanine: Derivatives of this compound help the pancreas make more insulin quickly.

11. Can a patient take more than one diabetes pill at a time?

Diabetes medicines are prescribed according to the blood sugar of the person. If the blood sugar is not adequately controlled with one drug, a second pill may be added to bring about effective results. Some diabetes medicines work well when given in combination with other blood-glucose-lowering drugs. Each type of pill has its own way of acting to lower blood glucose. All the combinations do not suit everybody; hence it needs to be re-prescribed.

Some popular combinations are:

  • pioglitazone and a sulfonylurea
  • pioglitazone and metformin
  • rosiglitazone and metformin
  • rosiglitazone and a sulfonylurea
  • metformin and acarbose
  • repaglinide and metformin
  • nateglinide and metformin
  • a sulfonylurea and metformin
  • a sulfonylurea and acarbose

12. How does a patient know if their medication is working?

Patients with diabetes can check whether the medications are working for them. Blood sugar should be checked regularly to confirm if the medications are effective. Learn to test your blood glucose and record the blood glucose test results. Take an opinion from the physician regarding the blood test result. A good blood glucose reading before meals is between 70 and 140 mg/dL.

Another test to determine the effectiveness of diabetes medicines is the result of a blood test called the A1C. It shows your blood glucose control during the past 2 to 3 months. For most people, the target for A1C is less than 7 percent.

Insulin Therapy in Diabetes

13. Which patients require insulin with type 2 diabetes?

People with type II diabetes or non-insulin dependent diabetes can control their blood sugar through proper diet, exercise, and oral medication. In spite of all these measures, if the blood glucose is still high, insulin injections may be required to lower the elevated levels of blood sugar.

14. How much insulin is needed in type 2 diabetes?

The amount of insulin required in type II diabetes depends on the level of blood sugar. The higher the blood sugar the higher the dose of insulin. Note: Do not change dosages without contacting your physician first.

15. How long are patients with type 2 diabetes required to take insulin?

In type II diabetes, insulin is required for as long as the blood sugar does not get in control with lifestyle changes, diet, and exercise.

16. What types of insulin options are available?

There are many types of insulin depending upon the type of action and the source of insulin.

  • Regular insulin is fast-acting and lasts a short time in the body. It is extracted from pork, beef, or human. Because of its fast action, it is used before meals to control the post-meal rise in blood sugar and to lower blood sugar quickly when an immediate correction is needed.
  • Semi-Lente insulin also has a short duration of action but is twice as long as regular insulin. it is prepared from beef or pork insulin. It is sometimes used to control post-meal rises in blood sugar and may be combined with Lente insulin.
  • NPH insulin is an intermediate-acting insulin. It is added with protamine for delayed effect. NPH insulin is extracted from beef, pork, beef pork, or humans. It provides a basal amount of insulin requiring two injections a day.
  • Lente insulin prepared from beef, pork, or human insulin is similar to NPH. However, it contains added zinc, which gives it an intermediate-acting effect. Lente insulin also provides a basal amount of insulin and two injections a day are usually prescribed.
  • Ultralente insulin provides the steadiest basal amount of insulin. Extracted from beef or human, it contains a lot of added zinc to give it the longest-acting effect. Ultralente insulin is used in combination with Regular insulin before meals.
  • Insulin Lispro, also called Humalog, is man-made insulin but similar in action to naturally occurring human insulin. It has a more rapid onset and a shorter duration of action than human regular insulin. They should be injected under the skin within 15 minutes before you eat. You have to remember to eat within 15 minutes after you take a shot. These insulins start working in five to 15 minutes and lower your blood sugar most in 45 to 90 minutes. It finishes working in three to four hours.
  • Human insulin called 70/30 Insulin is a combination of 70% NPH and 30% Regular insulin. Two injections a day are usually recommended.
    Very shortly inhaled insulin will be available that could be taken through inhalation.

17. Does insulin work the same at all times?

Insulin does not work the same at all times. The time period for insulin action varies with the type of insulin used. In due course, the insulin user gets to know when the insulin starts to work, when it peaks in action to lower blood glucose, and when the action is finished. Depending on that, people with diabetes can learn to match the mealtimes and exercise times to the time when each insulin dose works in the body.

The effectiveness of insulin depends on:

  • the place on the body where insulin is injected
  • the type and amount of exercise you do and the length of time between your shot and exercise

18. Where is insulin injected?

Insulin injections are given subcutaneously or just under the skin. You can inject insulin into several areas of your body. Injection sites for insulin include the abdomen, outer upper arms, thighs, buttocks, or hip areas. Take precautions, not to inject insulin near bony places or joints. Do not give injections closer than 1 inch apart. Insulin absorption and duration of action may vary depending on the site. The best absorption site is the abdomen. A few years back, it was necessary to change the insulin site daily to prevent building up lumpy areas. With newer insulins, this is less of a problem.

Insulin Injection Areas

19. How and when should I inject insulin?

Insulin is a protein and has to be taken through injections. To make injections less messy and painful, it is available in different deliverable devices.

  • Insulin pens – Insulin pens are handy and convenient to carry. An insulin pen looks like a cartridge pen with replaceable cartridges of insulin. However, some are disposables also. The tip of the pen has a fine, short needle. Users turn a dial to select the desired dose of insulin and press a plunger on the end to deliver the insulin.
  • Insulin jet injectors – These send a fine spray of insulin through the skin by a high-pressure air mechanism instead of needles. These are great for people, who fear needles. The device is expensive and you have to boil and sterilize the units frequently.
  • External insulin pumps – These connect to narrow, flexible plastic tubing that ends with a needle inserted just under the skin near the abdomen. The insulin pump is about the size of a deck of cards, weighs about 3 ounces, and can be worn on a belt or in a pocket. Users set the pump to give a steady trickle or basal amount of insulin continuously throughout the day. Most pumps have the option of setting several rates. If you use an insulin pump, it’s really important to monitor your blood sugar frequently so you can determine the right dose and also to be sure that the insulin is being delivered.

You should take insulin 30 minutes before a meal if you take regular insulin alone or with longer-acting insulin. If you take rapid-acting insulin, you should take your shot just before you eat.

Managing Your Insulin and Medications

20. How is insulin stored?

Insulin is a protein that tends to break down and become ineffective if gets too hot or cold. So, keep opened bottles of insulin at room temperature. Do not leave insulin vials on a sunny window sill or in the freezer. Store unopened bottles in the refrigerator, and rotate your supply, so that you use the oldest bottles first.

If you use a whole bottle of insulin within 30 days, keep that bottle of insulin at room temperature. On the label, write the date that is 30 days away. That is when you should throw out the bottle with any insulin left in it. Keep at least one extra bottle of each type of insulin you use in your house.

21. Demonstrate techniques for mixing and drawing up insulin.

PeoTechnique of mixing and drawing up insulin depends on whether you use one type of insulin or a combination of insulins.

For patients using one type of insulin:

Always wash your hands before starting the procedure. This lessens the risk of infection. Do not shake the bottle. Mix it by turning the insulin bottle on its side and rolling it between your palms. Wipe the top of the insulin bottle with an alcohol wipe. Pull the syringe plunger to draw in enough air to equal your insulin dose. Push the needle through the bottle top and inject the drawn air into the bottle. Keeping the needle in the bottle, turn it upside and pull the plunger to fill the syringe past your dose of insulin. Push slowly to the line of your correct dose of insulin. Check for air bubbles. If bubbles are present, tap the syringe to make them rise. After the air bubbles are removed. Remove the needle from the bottle, and carefully rest the syringe so that the needle touches nothing.

For patients using more than one type of insulin:

When you use insulin in combination, always draw the regular insulin and then the other insulin. As with any other procedure, wash your hands and wipe the tops of both insulin bottles with an alcohol wipe. Turn the NPH or Lente insulin bottle upside down and roll it between your hands to mix. Take care not to shake the bottle. Pull the plunger to draw in enough air to equal your NPH or Lente insulin dose. Push the needle through the top of the NPH or Lente insulin bottle and inject air into the bottle. Remove the empty syringe and needle from the bottle. Pull the plunger to draw in enough air to equal your Regular insulin dose. Push the needle through the top of the Regular insulin bottle and inject air into the bottle. With the needle in the bottle, turn it upside and pull to fill the syringe past your dose of Regular insulin. Push slowly to the line of your correct dose of insulin. Check for air bubbles. If bubbles are present, tap the syringe to make them rise. Remove the needle from the bottle with Regular insulin in the syringe. Push the needle through the top of the NPH or Lente insulin bottle and carefully pull the plunger back to your total dose of insulin. Remove the needle from the bottle, and carefully rest the syringe so that the needle touches nothing.

22. How to identify appropriate injection sites.

You can inject insulin into several places on your body. The most common injection site is the abdomen. The back of the upper arms, the upper buttocks or hips, and the outer side of the thighs are also used. These sites are the best to inject into because they have a layer of fat just below the skin to absorb the insulin, but not many nerves; which means that injecting there will be more comfortable than injecting in other parts of your body. Insulin injected near the stomach works fastest. Insulin injected into the thigh works slowest. Insulin injected into the arm works at medium speed.

Some patients prefer injecting in the abdomen because the insulin absorbs well there. But injecting in the abdomen isn’t right for everyone, especially young children or people who are so thin and/or heavily muscled that they can’t pinch up a half-inch of fat. Your body absorbs insulin differently depending on where it is injected. Insulin is absorbed fastest when injected into the subcutaneous tissue in the abdomen (stomach), and somewhat less quickly in the upper arms, thighs, and buttocks/hips.

23. Instructions for insulin injection.

Draw the required amount of insulin into the syringe. Choose your injection site. Wipe the area with alcohol to clean it. Grasp a large pinch of skin between your thumb and fingers. Push the needle straight into the skin. Press the plunger in. Holding the alcohol wipes next to the injection, pull out the needle. Wipe the area with the alcohol wipe.

Tips for insulin injection

  • Use different spots for different shots. Take advantage of the fact that insulin is absorbed differently at the various injection sites.
  • Move around within one area. If it’s more comfortable to inject in one body area, be sure to move around within that area, giving each injection at least an inch and a half away from the previous one. This technique will help you avoid fat hypertrophy or atrophy.
  • Move to a new injection site every week or two. Inject in the same area of the body, making sure to move around within that area with each injection, for one or two weeks. Then move to another area of your body and repeat the process. Use the same area for at least a week to avoid extreme blood sugar variations.

Fine Tuning Insulin Therapy

24. What problems arise through insulin injections?

Sometimes insulin may induce mild allergic reactions.

  • Insulin injection can cause an itchy small, hard red area at the injection site. There is nothing to worry about this as it goes away in a day or so.
  • A generalized allergy to insulin causes rashes and itchy skin over other parts of the body. Usually, this disappears by itself. If the itching continues, consult your doctor.
    In rare cases, insulin edema or swelling may develop when you start insulin therapy. It is usually not severe. You may notice swelling in your legs, ankles, feet, hands, or face. This will go away in a few weeks.
  • In the past, insulin caused the formation of firm, lumpy scar tissue in areas that have been repeatedly used for injection. Insulin absorption is changed in this area as a result. This condition is called Lipohypertrophy however has become rare with newer and purer insulin.
  • Lipoatrophy, although rare, results from loss of fat in the area due to repeated injections with impure insulins giving rise to pitted areas.

25. When & how should insulin doses be increased/decreased?

Blood sugar does not remain the same all throughout the day. This implies that the dose of insulin also changes. There are many reasons for blood sugar fluctuations, which include:

  • Changes in exercise or activity level
  • Snacks added or omitted
  • Delayed meals or a change in the type or amount of food eaten
  • Illness or infection
  • Alcohol consumption
  • Insulin injected into a lumpy area or an exercising arm or leg
  • Over-treatment of an insulin reaction
  • Skipped insulin injection

These conditions may require adjustment of insulin doses. Monitor your blood sugar and record the findings. Once you identify a pattern of high or low blood sugars at the same time on three successive days, determine what insulin should be working at that time. Adjust the insulin dose according to the blood sugar findings.

  • Adjust your dose of insulin only by 1-2 units
  • Increase insulin for high blood sugar
  • Decrease insulin for low blood sugar
  • Change only one type of insulin at a time.
  • Check the effect of your insulin adjustment for 3 days before making another adjustment.

You can help in the process of achieving control of your diabetes by watching for high and low blood sugar patterns and keeping track of them as part of your overall blood glucose monitoring routine. A pattern occurs when your blood sugar is in a certain range at the same time of day for three consecutive days.

26. Explain insulin adjustments using blood sugar records.

When your blood glucose level fluctuates, try to identify the cause of the high or low blood glucose measurement. There are only three causes of fluctuations in blood sugar levels: changes in diet, exercise, or insulin. Regular insulin is fast-acting and is usually recommended as a supplement to correct high blood sugars. The exact amount depends on how high your blood sugar is and how you usually respond to Regular insulin. A child or thin adult may be able to lower blood sugar with 1 unit of Regular insulin; a larger adult or a person on large doses of insulin may need 2 to 4 units.

A pattern occurs when your blood sugar is in a certain range at the same time of day for three consecutive days. Look for a pattern in readings over a few days or longer. Three days of readings above the target range or two days of readings below the target range at the same time of day should make you think about the need for adjustment. Although the numbers are different each day, you can see a pattern. Morning blood sugars are all over 150 and afternoon blood sugars are all under 100. In this case, your healthcare provider might recommend an increase in evening NPH (or Lente) insulin to lower your blood glucose in the morning.

Guidelines for insulin adjustment

  • Identify the insulin that is acting to regulate readings at this time of day. For example, the pre-breakfast reading is mostly regulated by the previous evening’s long-acting insulin.
  • Adjust the appropriate insulin.
  • Adjust only one insulin at a time. Adjusting more than one at a time can be confusing.
  • Wait a few days to assess the effect of the insulin adjustment.
  • Insulin adjustment is by cautious stepwise dose changes based on blood glucose monitoring. The amount by which the dose is changed depends on the current dose.
  • Doses are adjusted by about 10 percent of the current dose. If you are unsure‚ make smaller cautious changes‚ wait for several days of blood glucose readings to decide on further adjustments.
  • During periods of insulin adjustment more frequent monitoring of blood sugar levels is very helpful.
  • Doses to be adjusted should be adjusted in parts.
    • For 10 units or less: Adjust 1 unit. In some children on doses of less than 5 units ‚ 0.5 unit changes are often used
    • For 10–20 units: Adjust 1–2 units
    • For 20–30 units: Adjust 2 units
    • For more than 30 units: Adjust 2–4 units
    • back to index

27. What factors affect blood sugar; and what are the appropriate insulin adjustments?

Among the many factors that cause blood sugar fluctuations, diet and activity are the most important.

  • Sports and activities: Exercise and activity increase glucose utilization in the body decreasing blood sugar levels. This requires the insulin dose to be reduced. When children are more active‚ the first principle is to eat some extra carbohydrates to cover the extra activity. However‚ sometimes this is not enough or not suitable‚ so insulin doses can also be lowered to adjust for this. Which doses are lowered will depend on the time of the day the sport is played and which insulins are mainly acting then. For days when the activity levels will be continually high all doses may need to be lowered and this is usually a reduction by 10 to 30 percent‚ depending on the individual. Also, in order to reduce the chances of overnight hypoglycemia, reduce the nighttime dose of insulin after very high-energy days.
  • Diet: If you know that you are to eat substantially more or less at a certain meal, the insulin dose before that meal can be adjusted accordingly. For example‚ you may know that your child always eats a lot and ends up with a high blood glucose level after a party ‚ so giving some extra short-acting insulin to help cover the meal will help this. Or‚ you may know that your child eats poorly if they have to get up earlier than usual so you may give a little less short-acting insulin that morning. Remember that these are temporary adjustments only and the regular dose is usually resumed for the next dose.

28. What are “sliding” scales for insulin adjustments and who should use them?

Blood sugar changes widely during activities and so does the need for insulin. Sliding scales generally refer to giving different dosages of insulin depending on the level of blood sugar. They should not be used for intermediate-acting or long-acting insulins but for regular insulin such as Humalog. The blood sugar level, food intake, and exercise must all be considered before each insulin dose is chosen. Insulin doses need to be adjusted after thinking about food intake, exercise, stress, illness, or other factors. Some people even need a different scale for their morning compared with their evening dosage of short-acting insulin. It should always be remembered that the scale may have to be reduced if heavy exercise has just been done or is about to be done. In order to fine-tune your insulin doses and normalize your blood sugar levels, your doctor may prescribe all or part of your insulin on a sliding scale basis.

Insulin sliding scale

  • If Blood Glucose <180: No Insulin required
  • If Blood Glucose <220: Give 4u Regular insulin
  • If Blood Glucose <260: Give 6u Regular insulin
  • If Blood Glucose <320: Give 8u Regular insulin
  • If Blood Glucose <400: Give 10u Regular insulin If Blood Glucose >400: Give 10u Regular insulin

One problem with set sliding scales is that they have to be updated very regularly or they are out of date. Another problem is that they can make looking for patterns more difficult as the insulin dose is often different each day. Most people use the general principles of a sliding scale without having one written down.

29. Do the needs of insulin change with seasons?

Yes. Insulin may need adjustments according to season, and depending on the activity level. In summer, people tend to increase their activity due to the clear weather and vacations. People on holiday also have increased activity and a relaxed state of mind. With the increased activity, low blood sugars are more likely. Snacks may have to be adjusted and/or insulin doses may need to be lowered. On the contrary, during winter, people go out less and are usually confined to their workplaces. Also, the decreased activity tends to increase blood sugar and hence calls for an increase in insulin doses.

Review Your Concepts in Diabetes

30. Are there other devices to inject insulin?

Yes. There are other devices used to inject insulin. The devices are developed with the aim of reducing injection-related pain as well as making the device easy to carry during travel. The majority of people suffering from diabetes use syringes and disposable insulin pens to inject insulin. However, there are devices that are more convenient.

Insulin pens – An insulin pen is a handy device that looks like a cartridge pen. As it is the size of a pen, it is very convenient to carry. Some pens use replaceable cartridges of insulin and other models are disposable. The tip of the pen has a fine, short needle. It has a dial to select the desired dose of insulin after which a plunger on the end is pressed to deliver the insulin.

Insulin jet injectors – Jet injectors are useful for people who are scared of needles. The injectors produce a fine spray of insulin and deliver it through the skin by a high-pressure air mechanism instead of needles. The device needs maintenance through boiling and sterilizing. Another drawback of this device is that it is very expensive.

External insulin pumps – Insulin pumps are external devices that are light as a feather and can be carried in a pocket or worn around the abdomen. The device delivers a pre-feed insulin amount through narrow, flexible plastic tubing that ends with a needle inserted just under the skin near the abdomen. Users set the pump to give a steady trickle or ‘basal’ amount of insulin continuously throughout the day. Most pumps have the option of setting several rates. Pumps release bolus doses of insulin at meals and at times when blood sugar is too high based on the user’s programming. While using insulin pumps, it is very important to monitor the blood sugar frequently so that the right dose of insulin can be calculated. These pumps can be expensive to buy and maintain.

Inhaled insulin – Insulin in the inhaled form will soon be available on the market. This type of insulin can be inhaled by puffs like any other respiratory inhaler. It is absorbed quickly through the lungs. Inhaled insulins can eliminate the need for injected insulin.

31. What is an insulin pump?

An insulin pump is made up of a pump reservoir, like a regular syringe filled with insulin, a small battery-operated pump, and a computer chip that allows the user to control exactly how much insulin the pump delivers. It is all contained in a plastic case about the size of a beeper.

The pump reservoir delivers insulin to the body through a thin plastic tube called an infusion set. The set has a cannula at the end, through which the insulin passes. The cannula is inserted just under the skin, usually on the abdomen. The infusion set is changed approximately every two to three days. The pump is intended to be used continuously and delivers insulin 24 hours a day according to a programmed plan unique to each pump wearer. A small amount of insulin is given continually. This insulin keeps blood glucose in the desired range between meals and overnight. When food is eaten, the user programs the pump to deliver a bolus dose of insulin matched to the amount of food that will be consumed.

insulin pump

Advantages of insulin pumps

  • Pumps use faster-acting insulin which is much more predictable than long-acting insulin.
  • The Pump delivers insulin in micro-drops that are continuous and accurate.
  • You can eat when you want.
  • Live a more normal life

32. Are there any other ways to take insulin apart from injections?

Yes. There are alternative routes of taking insulin apart from injections. The methods are less painful and may lead to better patient compliance and improved glucose control. However, these routes are less utilized as there are barriers to the absorption of insulin.

Intranasal insulin

Intranasal insulin can be used for preprandial dosing. While intranasal insulin has been shown to achieve significant decreases in plasma glucose concentrations, its bioavailability is poor, and the dose needed to reach glycemic control markers is significantly higher than for insulin that is administered subcutaneously.

Oral insulin pills

Oral insulin has always been an attractive but untenable concept because insulin is broken down in the digestive system. Research has focused on overcoming this limitation by stabilizing the degradation, improving the permeability, and adding absorption promoters to protect the insulin as it passes through the stomach.

Buccal/sublingual spray

The buccal inhaler delivers a high-pressure stream of insulin to the back of the throat. Like the nasal mucosa, the buccal mucosa offers limited surface area. Because the mucosa has low permeability, many puffs may be required for effective dosing.

Pulmonary or inhaled insulin

It is the most promising alternate route for insulin delivery because the lung has anatomic advantages over the upper airway. With each branching of the bronchi, the mucosa becomes thinner. By the time the honeycomb-like structures of the alveoli are reached, the surface area available for uptake is tremendous. The inhaled insulin may soon be available for patient use.

Insulin patch

The insulin patch for transdermal administration is still undergoing pharmacologic investigation. A 24-hour patch providing a needle-free basal insulin supply is the goal. One problem in developing the patch is that insulin does not easily pass through the skin due to its high molecular weight.

Other methods

Additional delivery routes for insulin that have been tried in the research setting include nasal, ocular, rectal, and oral administration. However, due to poor absorption, low bioavailability, or barriers such as active proteolytic enzymes, these routes of administration are not practical at this time.

33. What are the recent advances in diabetes medication?

The pharmacological management of type 2 diabetes has changed spectacularly in the past few years with the introduction of many new medications, including [Alpha]-glucosidase inhibitors, a biguanide, the thiazolidinediones, insulin analogs, meglitinides, and d-phenylalanine derivatives. These new agents have dramatically increased the number of alternatives available to providers and patients. Combination therapy has become commonplace for the management of hyperglycemia in patients with type 2 diabetes.

The past few years have brought several new products to market that are useful in the management of type 2 diabetes. The glyburide/metformin combination and the extended-release metformin formulation may be useful for many patients because of their ease of compliance.

The new insulin secretagogue nateglinide is an oral medication that effectively normalizes first-phase insulin response, thus controlling postprandial hyperglycemic excursions without causing a high rate of hypoglycemia. Recent data have also demonstrated that glimepiride may offer some distinct advantages over other sulfonylureas.

Two new insulin products, such as insulin aspart and glargine, each offer distinct characteristics that will make them optimal choices in certain situations. Aspart, a rapid-acting analog, is useful in controlling postprandial hyperglycemic excursions, whereas glargine offers the first true basal analog. A single injection of glargine provides a continuous infusion of insulin into the bloodstream for a 24-h period.

34. Will I have to take pills/insulin indefinitely?

Patients with type I diabetes do not produce insulin in their bodies. As a result, insulin needs to be given from outside the body lifelong. On the contrary, patients with type II diabetes can eliminate the need for insulin through proper control of blood sugar by diet and exercise.

35. What is a skin patch?

The insulin skin patch is a non-invasive method of taking insulin. It could complement other forms of insulin delivery. The skin patch involves a two-step process. First, an electronic adhesive patch, powered by a small battery, is applied to the skin; in a millisecond, it painlessly vaporizes cells on the skin surface, creating microscopic openings. Then a small patch, containing a reservoir of insulin, is applied to the skin. Insulin is steadily absorbed into the body during 12 hours of wear.

36. What is an oral spray?

An alternative to injected insulin is a mouth spray containing insulin that would be absorbed through the lining of the mouth and throat. The insulin oral spray looks like the metered dose inhalers used by people with asthma, but it has been modified so that a liquid aerosol version of insulin, is absorbed by the mucous membranes in the cheeks, tongue, and throat. The benefit of oral sprays is identical to insulin injections in their ability to lower blood glucose levels. Further, it is able to serve as the mealtime boost needed by some people who are failing oral hypoglycemic drugs.

37. What is inhaled insulin?

Inhaled insulin systems deliver a dose of insulin, either in liquid or dry powder form, through the mouth, directly into the lungs, where it enters the blood circulation as rapid-acting insulin. The advantage of inhaled insulin is that the highly permeable alveolar epithelium and large surface area of the lungs provide an effective, efficient portal for macromolecular delivery. The total alveolar surface area in an adult is more than 70 times greater than the surface area of the entire body.

However, unlike inhaled medications for asthma or chronic obstructive pulmonary disease, insulin doses must be delivered precisely to avoid acute hypoglycemia. Neither nebulizers nor metered-dose inhalers are effective for alveolar insulin delivery. In addition, it is necessary to overcome the lungs’ ability to filter particles.

38. What is glucose monitoring?

People with diabetes who take insulin or oral medications must monitor blood glucose levels in order to determine whether treatment goals are being met and to make sure that their medication dosage is correct. Blood glucose monitoring is a measurement of glucose in the blood that can be done at any time on a portable machine. It can be a self-test for the diabetic. The finger is pricked and a drop of blood is put on a reagent strip, which uses a chemical substance to react to the amount of glucose in the blood. The meter then reads the strip and displays the results as a number on a digital display. Newer monitors can use blood from other areas of the body besides the fingers, reducing discomfort.

The test allows the diabetic to carefully monitor blood glucose levels to assure that they are within the normal range. The individual can then respond quickly to high or low blood sugar levels with appropriate intervention. This test can also be a screening test for blood glucose levels.

Glucose Monitoring