Insulin Therapy
Jack L. Leahy, Nathaniel G. Clark, William T. Cefalu in Medical Management of Diabetes Mellitus, 2000
A second intensive insulin program is more frequently used outside the United States, reflecting the use of insulin pens that deliver a single type of insulin per injection. Regular insulin is given premeals and NPH at bedtime, thus four injections. The principle is identical with the foregoing Ultralente program, to deliver insulin in a basal-bolus program. The use of regular insulin is absolute, as its longer action over lispro is needed to preserve glucose control between meals (the prolonged effect of regular provides the basal insulin need between meals). The major positives of this regimen are the ability to use insulin pens at each injection, which for many patients provides convenience, ensures accurate dosing, and avoids having to mix. For those patients who develop nighttime hypoglycemia with Ultralente, switching to this regimen can reduce or eliminate the problem. The negatives are having to use regular insulin instead of lispro so that patients must still inject 30 min before their meal. Also, some patients do not like insulin pens, especially those who have had diabetes for many years and have a schedule and habits with which they are comfortable. Those patients can use this regimen with syringes, but it defeats the purpose, as they will inject four times daily as opposed to three times with the Ultralente regimen. When starting this regimen, the NPH dose is usually 30% of the total, and the regular insulin is divided generally in similar amounts per meal, unless unusual dietary practices suggest some other balance. Doses are then adjusted based on HBGM.
Care of Older Adults with Diabetes During Hospitalization
Medha N. Munshi, Lewis A. Lipsitz in Geriatric Diabetes, 2007
Prandial insulin is usually administered at mealtime. In patients eating consistent carbohydrate meals, a fixed dose of nutritional insulin may be calculated with a correction for premeal blood sugar, which can be easily accomplished in the form of an insulin scale. For patients practicing self-management, “carbohydrate counting” may be employed to allow more flexibility in the meal plan. The rapid-acting insulin analogues are excellent prandial insulins and may even be administered immediately after eating when it is unclear how much food is to be consumed. This is not recommended with regular insulin, which has a rather delayed onset of action. If rapid-acting analogues are utilized and food is not consumed in a timely fashion after administration, severe hypoglycemia may result.
Communication skills
Kate Tatham, Kinesh Patel in Complete OSCE Skills for Medical and Surgical Finals, 2018
Explain:The pathophysiology of type 1 diabetes: that the pancreas, which secretes insulin to control blood sugar levels, has stopped producing insulinHow the pancreas usually responds to a meal by releasing insulin into the bloodThat as the pancreas is not working properly, the patient will need regular insulin to prevent them from becoming very unwellThat the dose of insulin can be tailored to what the patient has eaten, just as the pancreas would respond to the size of the mealThat regular blood sugar monitoring will be needed in order to make sure that good glucose control is achieved, and the reasons for this
Improving the treatment of patients with diabetes using insulin analogues: current findings and future directions
Published in Expert Opinion on Drug Safety, 2021
Eveline Lefever, Joke Vliebergh, Chantal Mathieu
The major mismatch in action profile is seen with the use of the human insulins. Rapid-acting regular insulin has the same structure as human insulin and consists of six monomers of insulin, organized in a hexamer. To exert its function, an insulin hexamer has to dissociate into monomers to interact with the insulin receptors on target tissues. Injecting regular insulin into the bloodstream leads to immediate dissociation into monomers and consequently an almost immediate onset of action. Nevertheless, regular insulin is normally injected into subcutaneous tissue and has to dissociate into monomers before absorption into the bloodstream is possible. This leads to a delayed onset of action (15–30 minutes) and a variable action profile, which causes postprandial hyperglycemia and delayed hypoglycemia. To overcome the delayed onset of action, people are advised to inject insulin 15–30 min before mealtime, which is inconvenient in daily life [5,13].
The role of Recent Pharmacotherapeutic Options on the Management of Treatment Resistant Type 2 Diabetes
Published in Expert Opinion on Pharmacotherapy, 2022
Jeffrey M. Kroopnick, Stephen N. Davis
Pre-mixed insulin typically includes an intermediate-acting insulin, such as NPH, and either short-acting regular insulin or a rapid-acting insulin. Given its individual components, premixed insulin is typically dosed twice daily, with breakfast and dinner. These insulins do not provide greater glycemic control compared to a basal-bolus regimen. In a 3-year open-label, multicenter trial consisting of approximately 700 participants aged 18 or older with at least a 12-month history of insulin-naive type 2 diabetes with HbA1c 7–10% despite taking maximally tolerated metformin and a sulfonylurea for at least 4 months, subjects were randomly assigned to pre-mixed biphasic insulin aspart (NovoMix 30), prandial insulin aspart three times daily, or once daily detemir (twice daily if needed). There was no difference in median A1c among the three groups (7.1%, 6.8%, and 6.9%, respectively). However, more patients in the basal (43.2%, p = 0.03) and prandial groups (44.7%, p = 0.006) achieved HbA1c less than or equal to 6.5% compared to the biphasic aspart group [37].
Strategies for implementing effective mealtime insulin therapy in type 2 diabetes
Published in Current Medical Research and Opinion, 2018
Mark Peyrot, Timothy S. Bailey, Belinda P. Childs, Gérard Reach
When a mealtime insulin regimen is being initiated, rapid-acting insulin analogs are preferable to regular insulin, as they provide better control of post-mealtime glucose levels, along with lower rates of hypoglycemia, and increased flexibility in the timing of insulin dosing60,61. Current ADA guidelines recommend a patient-centered approach to determine the best treatment options for the individual patient. However, it is common to discontinue sulfonylureas, DPP-4 inhibitors, and GLP-1 RAs once more complex insulin treatment regimens are introduced10. It is also important to balance basal and bolus insulin to minimize the risk of hypoglycemia and avoid over-basalization. Ideally, mealtime insulin represents ∼50% of the daily insulin dose, with basal insulin reducing fasting plasma glucose (FPG) levels, while mealtime insulin acts to normalize post prandial glucose (PPG) levels.
Related Knowledge Centers
- Diabetes
- Glucose
- Hyperkalemia
- Hyperosmolar Hyperglycemic State
- Type 1 Diabetes
- Type 2 Diabetes
- Insulin
- Gestational Diabetes
- Diabetic Ketoacidosis
- Subcutaneous Administration