Overview:

Insulin is a hormone produced by an organ called the pancreas. Insulin 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 make or respond to insulin and glucose builds up in the blood. High blood glucose can injure the kidneys, eyes, blood vessels and other parts of the body.

People with type 1 diabetes and some people with type 2 diabetes must administer insulin to themselves daily. Methods of administration include syringe injections, insulin pumps and insulin pens.

Common Concepts about Diabetes

1. Describe insulin and what it does in the body?
2. What is diabetes and what are its types?
3. Who gets diabetes and what are its symptoms?
4. What are the tests available for diabetes?
5. What are the complications of diabetes?
6. What happens if there is poor blood sugar management?
7. What is diabetes during pregnancy and how to manage it?
8. What is hypo and hyperglycemia?
9. What is low blood sugar?

Role of Medical Therapy in Diabetes

10. What are the medicines available for type I diabetes?
11. What are the medicines available for type II diabetes?
12. Can one take more than one diabetes pill at a time?
13. How to know if the medicines for diabetes are working?

Insulin Therapy in Diabetes

14. Who needs insulin in type II diabetes?
15. How much insulin is needed in type II diabetes?
16. For how long is insulin required in type II diabetes?
17. What types of insulin are available?
18. Does insulin work the same for all times?
19. Where to Inject the Insulin?
20. How and when to inject insulin?

Managing Your Insulin and Medications

21. How to store insulin?
22. Demonstrate techniques for mixing and drawing up insulin.
23. Identify age-appropriate injection sites.
24. Instruct injection technique.

Fine-tune Your Insulin Therapy

25. What problems arise through insulin injections?
26. Describe when and how to increase or decrease insulin doses?
27. Explain insulin adjustments using blood sugar records.
28. List two factors which affect blood sugars and the appropriate insulin adjustments.
29. What does “sliding” scales for insulin adjustments and who should use them mean?
30. Do the needs for insulin change with the seasons?

Recent Advances in Insulin Therapy

31. Are there other devices to inject insulin?
32. What is an insulin pump?
33. Are there any other ways to take insulin apart from injections?
34. What are the recent advances in diabetes medication?
35. What are insulin pills?
36. Will I have to always take pills/insulin?
37. What is a skin patch?
38. What is an oral spray?
39. What is inhaled insulin?
40. What is glucose monitoring?

Common Concepts about Diabetes

1. Describe insulin and what it does in the body?

Insulin is a hormone released by the pancreas in response to increased levels of blood sugar or glucose in the blood. When we eat, our bodies break food down into organic compounds, one of which is glucose. The cells of our bodies need glucose as a source of energy for movement, growth, repair, and other functions. But before the cells can use glucose, it must move from the bloodstream into the individual cells. Insulin facilitates the process of blood sugar moving into the cells.

Insulin allows glucose from the food we eat, to get into our cells for energy. Without insulin, glucose and other nutrients from food cannot be used properly and glucose levels rise in the blood. Insulin steps up the uptake of glucose into peripheral tissue, thereby lowering blood glucose concentrations.

2. 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 gets into 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, the blood glucose levels are maintained at a comparatively constant level, although it does vary a little. Blood glucose levels are controlled largely 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 the body 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

3. 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

4. What are the tests 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.

5. What are the complications of 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.

6. What happens if there is 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.

7. What is diabetes during pregnancy and how to manage it?

Diabetes during pregnancy, also called gestational diabetes, is 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.

8. 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 level 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.

9. 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

10. What are the medicines available for type I 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.

11. What are the medicines available for type II 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 pancreas to make more insulin. e.g. Nateglinide, Repaglinide
  • D-phenylalanine: Derivatives of this compound help the pancreas make more insulin quickly.

12. Can one 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

13. How to know if the medicines for diabetes are 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

14. Who needs insulin in type II 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.

15. How much insulin is needed in type II 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.

16. For how long is insulin required in type II diabetes?

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.

17. What types of insulin 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 human. 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.

18. Does insulin work the same for all times?

Insulin does not work the same at all times. The time period for insulin action varies with the type of insulin used. With due course of time, 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

19. Where to Inject the Insulin?

Insulin injections are given subcutaneously or just under the skin. You can inject insulin into several areas on 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

20. How and when to 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

21. How to store insulin?

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.

22. 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.

If you use 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.

If you use 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.

23. Identify age-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 people 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.

24. Instruct injection technique.

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 wipe 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 tune Your Insulin Therapy

25. 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.

26. Describe when and how to increase or decrease insulin doses?

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 infe