Why insulin is given in diabetes?

Diabetes is a state of insulin deficiency. In adult diabetes is treated with either oral anti diabetic tablets or with insulin. 

Insulin has got the following advantages

1. To stop the severe catabolic state & regain lean body mass.

2. Decreases frequent infections.

3. Reduce  fetal & maternal complications  in pregnancy.

4. Prevent & delay complications of diabetes.

5. Eliminate symptoms of hypoglycemia.

6. Prevent DKA(diabetic ketoacidosis).

Principles of insulin therapy

1. To supply  sufficient insulin throughout 24 h to cover the  basal requirements

2. To provide higher boluses of insulin to match the high glucose levels  following meals .

Treatment strategies

Appropriate insulin regimen is planned based on

1. Patient’s lifestyle.

2. Age.

3. Motivation.

4. General health.

5. Self management skills.

6. Goals of treatment.
Before initiating insulin patient should be given appropriate education & support about the care & use of insulin, detection & management of  hypoglycemia.

Treatment strategies in type 1

1. Multiple Daily Injections.

2. Twice daily injections are not recommended in Type 1 DM.

3. Complementary education & support.

4. Most newly diagnosed patients with type 1 diabetes may be started on a total daily dose of 0.2 to .0.4 u/ kg / day, most will ultimately require 0.6 to 0.7 u/ kg / day.

6. During puberty > 1 IU/kg per day insulin is given

Type 2 DM (Diabetes mellitus) 

1. Initial management does not include insulin.

2. Given for patients unable to achieve good blood sugar  control with a combination of diet, exercise and OHA.

3. Goals of insulin treatment is  similar to Type1 DM

Achronym's used
DM - Diabetes mellitus.
IU/kg - Units of Drug per Kilogram of body weight.
OHA - oral hypoglycemic agents.
DKA - diabetic ketoacidosis.

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Causes of hypoglycemia in diabetic patients

Hypoglycemia is common problem seen in diabetic patients on insulin. It is due to imbalance between insulin requirement and administration. Highest risk is just before meals and during night. All patients on insulin and oral hypoglycemic agents should be aware of the causes  of hypoglycemia and try to avoid them.

Causes of hypoglycemia in diabetes 

Relative or absolute insulin excess.

Increased dose of insulin or insulin secretagogue (agents that help to increase insulin secretion) such as sulfonylureas and meglitinides which stimulate insulin secretion.

Intake of glucose is reduced.

• Missed or delayed meals.
• Insufficient carbohydrate in meals.

Increased glucose utilization.

• Vigorous exercises.

Increased sensitivity to insulin.              

• With improved glycemic control, late after exercise, in the middle of the night, weight loss. All this situation causes increased sensitivity to insulin.

Deceased glucose production.

• Alcohol intake.

Reduced clearance of insulin.

Renal failure.

Poorly decoded insulin regimen.

Lipohypertrohy at injection sites - Erratic insulin absorption from areas of fat

Gastroparesis

Malabsorption diseases

Risk  factors of hypoglycemia in diabetic patients

1. Impaired awareness of hypoglycemia-Patient fail to recognize the clinical features of hypoglycemia.
2. Strict glycemic control.
3. Extremes of age group.
4. Long duration of dm.
5. Type 2 DM treated with sulfonylureas, insulin.
6. Somogyi phenomenon.

Early morning hypoglycemia (at 3 am) followed by hyperglycemia resulting in elevated fasting blood glucose. This phenomenon is due to increased night dose of insulin.

Management of hypoglycemia

1. Primary prevention
2. Patient education
3. Frequent self monitoring
4. Use flexible drug regimens
5. Professional guidance

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Clinical manifestations of hypoglycemia in diabetic patients

Hypoglycemia is a major side effect of insulin treatment. It is a cause of anxiety in patient and the care givers. Hypoglycemia occur more during night and before meals. This  is due to imbalance between insulin administration and requirement.

Recently there is an increase in incidence as an attempt to achieve tight glycemic control. Hypoglycemic episodes are more in those patients whose blood glucose levels are reasonably well controlled. There is a person to person variation in the blood levels at which each patient  experience symptoms of hypoglycemia. Those patients whose glycemic control is poor experience symptoms at somewhat higher level of blood glucose. Thus patients should take extraprecaution during driving ,swimming etc .Patients on insulin are always advised to carry some form of sugar with them.Incidence of hypoglycemia is less in patients taking anti-diabetic drugs.

Hypoglycemia is  defined as plasma glucose level <45-50 mg/dl.Whipple’s triad forms an important frame work for diagnosis of hypoglycemia.

Whipple’s triad include the following 

Symptoms consistent with hypoglycemia

• Low plasma glucose concentration.
• Relief of symptoms after plasma glucose level is raised.
• clinical manifestations of hypoglycemia.

Clinical manifestation vary from mild tiredness to  unconsciousness .Most of the patients experience warning symptoms before severe manifestation occur .Sugar intake at this level can terminate further progression.  Warning symptom may be absent in patients on longstanding diabetes ,In such patients detachment from environment occur that can be easily detected by caregivers ..Most common warning symptoms are tremor and sweating. But periodical numbness is the most specific symptom. Manifestations of hypoglycemia can be neurogenic or neuroglycopenic. Symptoms of decreased glucose availability(neuroglycopenic symptoms) occur  only at later stages.

Symptoms of hypoglycemia

Early warning symptoms

• Adrenergic symptoms
• Palpitations(pounding heartbeat)
• Tremor
• Anxiety
• Cholinergic symptoms 
• Sweating
• Hunger
• Pins and needles in lips and tongue
• Headache (occasionally)

Neuroglycopenia symptoms 

Mild

• Double vision
• Slurring of speech
• Difficulty in concentrating

More advanced 

• Confusion
• Truculence
• Change of behaviour in the form of clumsiness ,irritability  or aggressiveness
• Naughtiness in children

Unconsciousness 

• Restlessness with sweating
• Hemiplegia, especially in older people (but rare)
• Convulsion

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