When will you give insulin in type 2 diabetes.

The term diabetes means there is increased blood sugar level above the normal range.
There are mainly two type of diabetes .
Type 1 diabetes - Which is due to reduced insulin level in the body
Type 2 diabetes - Where the basic defect is not the reduction of insulin but due to reduced action of insulin.
In Type 1 diabetes treatment of choice is only insulin.
In Type 2 diabetes initial treatment of choice is anti diabetic tablets. Insulin is given only in the following situations

(a) Newly diagnosed symptomatic type 2 diabetes with severe hyperglycemia.
(b) Poor glucose control while taking maximal doses of a combination of oral medications.
(c) Intercurrent illness (eg - myocardial infarction, infection) or operation.
(d) Pregnancy.
(e) Kidney disease.
(f) Liver disease.
(g) Allergy to or inability to tolerate oral antidiabetic medication.

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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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Insulin use - Practical points

Diabetes mellitus is a progressive, metabolic disorder where there are disturbances in carbohydrate, lipid and protein metabolism. It results from insulin deficiency and / or insulin resistance. As the global burden of diabetes is increasing number of patients on insulin also increases. All those who are on insulin must know the following practical points.

Storage of insulin

1. Stored in a cool and dark place, otherwise their potency is lost (Temperature dependent).
2. Do not keep in a freezer compartment. 
3. The vial in current use can be easily kept at room temperature in a dark place without losing any potency. 
4. Cold insulin if injected is painful.

Insulin injection sites

• Absorption of insulin shows regional difference
  Absorption of insulin is maximum from abdominal region followed by upper outer arms, buttocks and upper outer thighs.
• Abdominal region > upper outer arm and buttocks > upper outer thighs
• The site of injection should be rotated within the same area.
• Depth of injection – subcutaneous with insulin syringe.
• Intravenous injection (direct injection into vein), Intravenous infusion , or Intramuscular routes (direct injection into muscle ) are used only during, emergency such as  ketoacidosis or stressful conditions.
• Same site is used for at least one month and rotation is done within the same site rather than rotating to different sites.
• Using same site decreases variability in day to day absorption. 
• Rotation within the same area prevents lipodystrophy.
• Avoid a site with open wounds or blisters.

Injection technique

• If site is clean, there is no need to clean the site with alcohol or spirit. 
• In thin or averagely built person, lift or grasp a fold of skin between thumb and index finger and inject at 45° or 90°.
• In obese person, full length injection at 90° is recommended.
• Mixing – usually available as premixed form.
• Regular insulin can be mixed with all other preparations.
• Insulin glargine should not be mixed with other insulin.

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