INSULIN
Insulin is the hormone produced in our body by the pancreas that helps in the proper utilization of glucose. In type 1 diabetes, the pancreas fails to produce insulin completely, so the required insulin has to be injected. Whereas in type 2 diabetes, the pancreas is producing some insulin but this insulin is not effective so there are medicines that will help this insulin to work better. Initially, animal insulins were used, derived from beef or pork, they caused allergic reactions. Nowadays only genetically engineered human and synthetic insulins are used that have literally no side effects. Insulin cannot be taken as a pill as it will be destroyed by enzymes in our stomach so it has to be injected in the fat under the skin from where it is gradually released. Types of Insulin: Depending on the onset, and duration of action there are the following types of insulin
Intermediate-acting
Action starts in 2-4 hours, peak action at 4-12 hours, duration of action 12- 18 hours NPH insulin is an example of intermediate-acting insulin
How to inject insulin
In Pakistan, almost all the insulins are dispensed as U-100, which means 100 unit/ml. The most commonly practiced method is the use of an insulin syringe to inject insulin. Insulin injection sites are around the umbilicus in a 2-inch diameter area, front and outer sides of thighs, the outer side of the upper arm. Do not inject on scar tissue or pigmented lesions. Keep on rotating sites so that injecting on the same site daily does not produce a sore area. Insulin syringe can be reused( BY THE SAME PERSON) up to 5 times. But you have to keep the syringe clean and cap if you intend to reuse it. Do not share needles with another patient. After using discard the sharps and needles in proper containers.
Insulin Pump
Pump is a device attached to the patient's belly with a catheter inserted under the skin, the pump injects small doses of short-acting insulin throughout the 24 hours period. It is used mostly in type 1 patients. It alleviates the need to calculate and fill syringes and inject them 3-4 times a day. Although it is easier to use, pumps require special care to prevent skin infections which can be serious in diabetics.
Insulin in Type 2 diabetes
Initially type 2 diabetics are treated with pills. Later on, when the disease progresses and the pancreas stops producing insulin as it was producing in the initial stages of the disease, type 2 diabetics will also require insulin injection in combination with pills. However, they will require a lesser number of injections in a lesser dose.
Oral Hypoglycemics
The drugs that are used to lower blood glucose levels. These are not used in type 1 diabetics. When used in type 2 diabetics these pills either help in the release of insulin from the pancreas or they help in assisting the action of insulin in other parts of the body where it is required for the transfer of glucose into body cells. There are 5 groups of oral medicines currently in use for diabetes
Oral Hypoglycemics
The drugs that are used to lower blood glucose levels. These are not used in type 1 diabetics. When used in type 2 diabetics these pills either help in the release of insulin from the pancreas or they help in assisting the action of insulin in other parts of the body where it is required for the transfer of glucose into body cells. There are 5 groups of oral medicines currently in use for diabetes
Incretin
These are the latest class of insulin sensitizers. The GLP-1 ( exenatide injectable)and DPP-4 inhibitors (vildagliptin and sitagliptin). They enhance the action of insulin by inhibiting the hormone glucagon. And increasing GLP1.Glucagon is naturally present in the body that has the opposite action to insulin.
Lipid-lowering drugs
Most diabetics are obese and suffering from a syndrome of diabetes, hypertension, and hyperlipidemia. Most of them have high triglyceride and LDL cholesterol levels, which is a risk for heart attack. They are not only advised dietary changes to lower lipid levels but medicines are also needed sometimes. Commonly used medicines in this group are simvastatin, atorvastatin, rosuvastatin, and gemfibrozil(fibrates group)
Neuropathy treatment
When diabetic neuropathy develops, it is very difficult to reverse. Pain relievers, gabapentin, pregabalin, anti-depressants, and methylcobalamin have been tried in various cases.
Rapid-acting
Starts acting in 5-10 min, reaches peak action in 1 hour and total duration of action is up to 2 hours These include lispro, aspart, and glulisine insulin
Short-acting
Action starts in 25-30 min after injection, reaches peak action in 2 hours, complete duration of action is around 5-6 hours This type includes Regular human insulin
Long-acting
Ultra Lente starts to work in 6-10 hours and has a duration of action lasting 20-24 hours Glargine and detemir have a total duration around 20-24 hours, they have no peak of action, they maintain a basal level of insulin in the blood at all times A new form of insulin, Degludec has recently been approved for use, it has a duration of action of 36 hours.
Easy steps to inject insulin:
- Fill required dose of insulin units in the syringe
- Clean the site of injection
- Hold a 2-3 inch thickness skin fold with your left hand
- Insert the needle vertically (90-degree angle) into the skin fold
- Keep the needle inside for 5 seconds then remove gently and press the site with cotton for few seconds.
Precautions:
- Do not keep insulin in extreme heat, sunlight, or extreme cold
- Do not keep it in the freezer
- Do not keep in the glove compartment of your car
- Check expiry date before using
- Do not use insulin if you see some floating particles in the insulin bottle
Insulin Pens
Insulin pens are devices that have made insulin injection easier. They have prefilled insulin cartridges, so there is no hassle to fill the syringe, just dial the required dose on the pen and inject with the plunger. A single pen is used multiple times till the whole insulin in the cartridge is used.
Insulin in pregnancy
When a diabetic woman gets pregnant, most of the pills are contraindicated in pregnancy so she is switched to short-acting insulin along with a diet and exercise plan.
Sulphonylureas
The drugs that increase the release of insulin from the pancreas. Examples include glibenclamide, glimepiride, gliclazide. They are taken before meals once or twice a day. Their major side effect is hypoglycemia( low blood glucose level)
Alpha-glucosidase inhibitors
Acarbose and meglitine .This group prevents the breakdown of carbohydrates in the intestine and delays the absorption of glucose from the gut after eating meals. They are taken with the first bite of a meal. They will cause flatulence (gas) trouble.
Thiazolidinediones
Pioglitazone and rosiglitazone also known as insulin sensitizers, act on PPARy receptors and increase the action of insulin already present in the body of type 2 patients. They should be used in caution with heart disease and liver problems.
Aspirin
Low dose aspirin (75-100mg) daily is recommended to be used in all diabetics. It makes the blood thin and reduces the risk of a heart attack. It should be avoided in allergies, bleeding disorders, or liver damage.
ACE inhibitors
A class of drugs called Angiotensin-converting enzyme inhibitors are used in the early stages of diabetic nephropathy, microalbuminuria. There are many studies that prove their role in delaying the progression of kidney damage caused by diabetes.
Flu and pneumonia shots
Diabetic patients are prone to infections. If they contract pneumonia or flu-like illness, it can disturb the blood glucose control a lot by increasing stress hormones. So it is better to prevent these intercurrent illnesses by proper vaccination against them in both type 1 and type 2.