Type 2 diabetes mellitus occurs due to metabolic disorders. This situation arises due to insulin not performing its functions, as cell resistance to it develops. It is commonly believed that insulin is used to treat type 1 diabetes, but this is not true. Type 2 diabetes can also become insulin dependent. When insulin is prescribed for type 2 diabetes, we will look into it below.
What doctors say about diabetes mellitus
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Why inject hormones for type 2 diabetes
The occurrence of diabetes mellitus due to improper interaction of insulin with tissues when it is sufficient is classified as the second type. Most often, this disease manifests itself in middle age, usually after 40 years. Initially, the patient gains or loses significant weight. During this period, the body begins to experience a lack of insulin, but all the signs of diabetes do not appear.
Upon examination, it is revealed that the cells that produce insulin are present in large numbers, but gradually they are depleted. For proper treatment you need to administer insulin for diabetes, but first calculate the number of insulin injections and its volumes.
Insulin for type 2 diabetes mellitus is indicated for the following conditions:
- uncorrectable glycemia while taking hypoglycemic drugs;
- development acute complications(ketoacidosis, precoma, coma);
- chronic complications (gangrene);
- extreme sugar levels in people with newly diagnosed diabetes;
- individual intolerance to drugs to reduce sugar;
- decompensation;
- diabetes in pregnant and lactating women;
- during surgical interventions.
Insulin for type 2 diabetes is used when patients already become insulin dependent and their own hormone is not enough. You can follow a diet and exercise, but without injections your sugar level will still be high. Complications may arise and any chronic disease may worsen. The insulin dose should be calculated by an endocrinologist.
But it is very important that the doctor teaches diabetics how to correctly calculate the dose and switch to insulin painlessly. You can tell which insulin is better using the selection method. After all, for some, only the extended option will be enough, and for others, a combination of extended and short acting.
Exist following criteria, the presence of which requires switching a patient with type 2 diabetes to insulin:
be careful
According to WHO, every year 2 million people die from diabetes and its complications around the world. In the absence of qualified support for the body, diabetes leads to various kinds of complications, gradually destroying the human body.
The most common complications are: diabetic gangrene, nephropathy, retinopathy, trophic ulcers, hypoglycemia, ketoacidosis. Diabetes can also lead to the development cancerous tumors. In almost all cases, a diabetic either dies fighting a painful disease or becomes a real disabled person.
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- if the development of diabetes is suspected, the person’s glucose level is more than 15 mmol/l;
- glycated hemoglobin increases by more than 7%;
- the maximum dosage of drugs that lower sugar is not able to maintain fasting glycemia below 8 mmol/l, and after meals below 10 mmol/l;
- Plasma C-peptide does not exceed 0.2 nmol/l after a test with glucagon.
At the same time, be sure to constantly and regularly monitor your blood sugar levels and count carbohydrates in your diet.
Is it possible to switch back to pills?
The cause of type 2 diabetes is poor sensitivity of body cells to insulin. In many people with this diagnosis, the hormone is produced in large quantities in the body. If it is determined that sugar increases slightly after eating, you can try replacing insulin with tablets. Metformin is suitable for this. This drug is able to restore the functioning of cells, and they will be able to perceive the insulin that the body produces.
Many patients resort to this method of treatment in order to avoid having to take daily insulin injections. But this transition is possible provided that a sufficient portion of beta cells are preserved that could adequately maintain glycemia against the background of glucose-lowering drugs, which happens with short-term administration of insulin in preparation for surgery or during pregnancy. In the event that when taking pills the sugar level still increases, then injections cannot be avoided.
Reception scheme
Our readers write
Subject: Conquered diabetes
From: Lyudmila S ( [email protected])
To: Administration my-diabet.ru
At the age of 47, I was diagnosed with type 2 diabetes. In a few weeks I gained almost 15 kg. Constant fatigue, drowsiness, feeling of weakness, vision began to fade. When I turned 66, I was already steadily injecting myself with insulin, everything was very bad...
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When choosing insulin for diabetes, you need to take into account diet and physical activity that the patient experiences. If you are on a low-carbohydrate diet and light exercise, you need to self-monitor your sugar levels for a week, which is best done with a glucometer and keep a diary. The best option is to switch to insulin therapy in a hospital.
The rules for administering insulin are presented below.
- It is necessary to find out whether to give hormone injections at night, which can be determined by measuring your sugar levels at night, for example, at 2-4 am. The amount of insulin taken can be adjusted during treatment.
- Determine morning injections. In this case, you need to give injections on an empty stomach. For some patients, it is enough to use an extended-release drug, which is administered at a rate of 24-26 units/day once in the morning.
- You need to figure out how to inject before meals. A short-acting drug is used for this purpose. Its amount is calculated based on the fact that 1 unit covers 8 grams of carbohydrates, 57 grams of protein also requires 1 unit of the hormone.
- Doses of ultra-rapid insulin should be used as an emergency aid.
- In obese patients, the level of drug administered often needs to be increased compared to the average dosage in people of normal weight.
- Insulin therapy can be combined with glucose-lowering drugs, which should only be determined by a doctor.
- Measure blood sugar levels and use the selection method to find out how long before meals you need to inject insulin.
The patient must understand that the intake of carbohydrates must be compensated by the administration of insulin. If a person uses a combination of glucose-lowering tablets and insulin, then the hormone not only enters the body, but also the tissues adequately absorb glucose.
Currently, insulins are distinguished by the time of their action. This refers to how long it will take for the drug to lower blood sugar levels. Before prescribing treatment, it is imperative to individually select the dosage of the drug.
Stories from our readers
Conquered diabetes at home. It's been a month since I forgot about sugar spikes and taking insulin. Oh, how I used to suffer, constant fainting, calls to the ambulance... How many times have I gone to endocrinologists, but they only say one thing - “Take insulin.” And now it’s been 5 weeks and my blood sugar levels are normal, not a single injection of insulin, and all thanks to this article. A must read for anyone with diabetes!
Read the full article >>>- Those that act very quickly are called ultrashort, which begin to perform their function in the first 15 minutes.
- There is a definition of “short”, which means that the impact does not occur so quickly. They should be calculated before eating. After 30 minutes their effect appears, reaching its peak within 1-3 hours, but after 5-8 hours their influence fades.
- There is the concept of “medium” - their effect is about 12 hours.
- Insulins long acting, which are active during the day, are administered 1 time. These insulins create a basal level of physiological secretion.
Currently, they produce insulin, which is developed on a genetic engineering basis. It does not cause allergies, which is very good for people prone to it. The calculation of the dose and intervals between injections should be determined by a specialist. This can be done in an inpatient or outpatient setting, depending on the general condition patient's health.
At home, it is important to be able to control the amount of sugar in your blood. Adaptation to treatment for type 2 diabetes should only be done under the guidance of a doctor, and it is better to do this in a hospital setting. Gradually, the patient himself can calculate the dose and adjust it.
Insulin therapy regimens
In order to carry out adequate treatment type 2 diabetes mellitus and transfer it to insulin, you should choose a regimen of administration and dosage of the drug for the patient. There are 2 such modes.
Standard dose regimen
This form of treatment means that all dosages have already been calculated, the number of meals per day remains unchanged, even the menu and portion size are set by a nutritionist. This is a very strict routine and is prescribed to people who, for some reason, cannot control their blood sugar levels or calculate their insulin dosage based on the amount of carbohydrates in their food.
The disadvantage of this regimen is that it does not take into account the individual characteristics of the patient’s body, possible stress, poor diet, and increased physical activity. Most often it is prescribed to elderly patients. You can read more about it in this article.
Intensive insulin therapy
This regimen is more physiological and takes into account the nutritional and stress characteristics of each person, but it is very important that the patient takes a meaningful and responsible approach to calculating dosages. His health and well-being will depend on this. Intensive insulin therapy can be studied in more detail at the link provided earlier.
Treatment without injections
Many diabetics do not resort to injections because they cannot be eliminated later. But such treatment is not always effective and can cause serious complications. Injections allow you to achieve normal levels of the hormone when pills can no longer cope. With type 2 diabetes, there is a possibility that switching back to pills is quite possible. This happens in cases where injections are prescribed for a short period of time, for example, in preparation for surgical intervention, when carrying a child or lactation.
Hormone injections can take the load off them and the cells have the opportunity to recover. At the same time, following a diet and healthy image lives will only contribute to this. The likelihood of this option exists only if you fully comply with the diet and doctor’s recommendations. Much will depend on the characteristics of the organism.
conclusions
Type 2 diabetes can be treated with diet or other medicines, but there are cases when insulin therapy cannot be avoided.
Injections can be prescribed:
- if the maximum doses of medications used do not produce the desired effect;
- during an operation;
- during pregnancy, lactation;
- if complications arise.
It is necessary to calculate the dose and time between injections. To do this, research is carried out throughout the week. The drug is selected individually for each patient.
Drawing conclusions
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In the natural progression of type 2 diabetes mellitus (DM), a progressive failure of pancreatic beta cells develops, leaving insulin as the only treatment that can control blood glucose in this situation.
IN AND. Pankiv, Doctor of Medical Sciences, Professor, Bukovinian State Medical University, Chernivtsi
Treatment strategy for progression of type 2 diabetes mellitus
About 30-40% of patients with type 2 diabetes require long-term insulin therapy for constant glycemic control, but it is often not prescribed due to certain concerns of both patients and doctors. Early initiation of insulin when indicated is important in reducing the incidence of microvascular complications of diabetes, including retinopathy, neuropathy and nephropathy. Neuropathy is the leading cause of non-traumatic amputations in adult patients, retinopathy is the leading cause of blindness, nephropathy is the main factor leading to terminal renal failure. The UK Prospective Diabetes Study (UKPDS) and the Kumamoto study demonstrated a positive effect of insulin therapy in reducing microvascular complications, as well as a strong trend toward improved outcome in terms of macrovascular complications.
The DECODE study assessed the relationship between overall mortality and glycemia, especially postprandial glycemia. The Diabetes Control and Complications Trial (DCCT) in Type 1 Diabetes established stringent standards for glycemic control. The American Association of Clinical Endocrinology (AACE) and the American College of Endocrinology (ACE) have established an HbA1c target of 6.5% or less, and fasting glucose targets of 5.5 and 7.8 mmol/L for postprandial glycemia (through 2 hours after eating). Quite often these goals are difficult to achieve with oral monotherapy, so insulin therapy becomes necessary.
Consider prescribing insulin as initial therapy for all patients with type 2 diabetes. It is well known that glucose toxicity may be a factor in the difficulty of achieving adequate glycemic control. Insulin therapy almost always controls glucose toxicity. As the toxic effect of glucose is leveled out, the patient can either continue monotherapy with insulin, or switch to combination therapy with insulin in combination with tableted glucose-lowering drugs, or to oral monotherapy. Lack of strict control of diabetes mellitus leads to an increased risk of complications in the future, in addition, there is speculation and evidence that timely and early control ensures the effectiveness of therapy in the future in terms of achieving better control.
Problems of early prescription of insulin therapy
Both the patient and the doctor have many concerns before starting insulin therapy. The patient's fear of injection is the main barrier to insulin therapy. The doctor’s main task is to choose the right insulin, its dose, and teach the patient the injection technique. The instructions for performing this manipulation are relatively simple, so it does not take much time to master them. New insulin injection systems and pens make injections easier and even less painful than finger pricking for glycemic monitoring. Many patients believe that insulin therapy is a kind of “punishment” for poor glycemic control. The doctor should reassure the patient that insulin therapy is necessary due to the natural progression of type 2 diabetes, it allows for better control of the disease and more wellness patient if symptoms are associated with prolonged hyperglycemia. Patients often wonder why they had to wait so long to start insulin therapy, because when using it they begin to feel much better.
Patients' fears about the development of complications in the near future and a worsening prognosis of the disease with insulin therapy are completely unfounded. The doctor needs to reassure them that insulin therapy does not predict a poor prognosis, but rather a significantly better prognosis.
Weight gain and hypoglycemia are considered complications of insulin therapy, but these effects can be minimized by properly selecting insulin doses, following dietary recommendations, and self-monitoring of the patient's glycemia. Doctors are often concerned about severe hypoglycemia, but it is relatively rare in type 2 diabetes and occurs much more frequently with some long-acting sulfonylureas than with insulin. A significant increase in the incidence of severe hypoglycemia was correlated with control rate in the DCCT study, but this was in patients with type 1 diabetes. Treatment goals for patients with type 2 diabetes should be consistent with the AACE/ACE recommendations listed above.
Men often worry that insulin therapy may cause erectile dysfunction and/or loss of libido. Although erectile dysfunction occurs quite frequently in patients with type 2 diabetes, there is no evidence that insulin plays any role in this. The UKPDS study showed no adverse effects of any kind associated with insulin therapy. The role of insulin has been proven safe drug in the management of type 2 diabetes, it is most often prescribed as an adjunct to oral combination therapy when monotherapy with oral antihyperglycemic agents (ALADs) does not achieve good glycemic control. Prescribing a third tablet drug in combination with previous oral therapy, as a rule, does not reduce HbA1c levels by more than 1%. PSSPs provide adequate postprandial control when fasting blood glucose levels are reduced to normal levels using long-acting insulin. Insulins average duration action, long-acting or ready-made mixtures of insulins are used in evening time simultaneously with oral therapy. If a single insulin injection regimen does not allow for adequate control, the patient is recommended to use ready-made insulin mixtures in a two- or three-time injection regimen. You can combine 1-2 injections of long-acting insulin with short-acting analogues administered at each main meal.
Short-acting human insulins have now largely replaced ultra-short-acting insulins because they have a faster onset of action, earlier peak insulinemia, and faster elimination. These characteristics are more consistent with the concept of “prandial insulin”, which is ideally combined with normal food intake. In addition, the risk of late postprandial hypoglycemia is significantly less with short-acting analogues due to their rapid elimination. In addition, basal insulin can provide intermeal and fasting glycemic control.
Insulin therapy should closely mimic the normal basal-bolus profile of insulin secretion. Typically, the dose of basal insulin is 40-50% of the daily dose, the remainder is administered as bolus injections before each of the three main meals in approximately equal doses. Preprandial glucose levels and carbohydrate content may influence prandial insulin dosing. Syringe pens provide great convenience for administering insulin; they facilitate the injection technique, which, in turn, improves control and increases compliance. The combination of an insulin pen and a glucometer in one system is another option for an easy-to-use injector that allows the patient to determine the level of glucose in capillary blood and administer bolus insulin. Insulin therapy, as a rule, is lifelong therapy, so the convenience and ease of insulin administration are very important from the point of view of the patient’s compliance with the doctor’s recommendations.
If long-acting insulin is used in combination with PSSP, then the starting dose of insulin is low, approximately 10 U/day. In the future, it can be titrated weekly, depending on the average fasting blood glucose, increasing the dose until a value of 5.5 mmol/l is reached. One of the titration options involves increasing the insulin dose by 8 units if fasting blood glucose is 10 mmol/l or higher. If fasting blood glucose is 5.5 mmol/l or lower, the insulin dose is not increased. For fasting blood glucose levels from 5.5 to 10 mmol/l, a moderate increase in the insulin dose by 2-6 units is required. The starting dose of insulin is determined at the rate of 0.25 units/kg body weight. We prefer to start therapy with a lower dose and then increase it, since hypoglycemia in the early stages of treatment may cause distrust of insulin therapy and reluctance to continue it in some patients.
It is best to start insulin therapy on an outpatient basis, since with severe hyperglycemia and symptoms of decompensation, the patient may need inpatient treatment. In the presence of diabetic ketoacidosis, urgent hospitalization of the patient is necessary.
Self-monitoring of glycemia is an important adjunct to insulin therapy. Insulin dosage should be adjusted in advance, not retrospectively. When using prandial insulin, it is important for the patient to self-monitor glycemic levels after meals so that the bolus insulin dose is adequate. Periodic determination of both pre- and postprandial glycemia - necessary condition ideal insulin therapy. The level of postprandial glycemia optimally correlates with the HbA 1c indicator, provided that its level is below 8.5%; with HbA 1c above 8.5%, the best correlation is observed with fasting glycemia.
Insulin therapy for type 2 diabetes is the correct and proven method of managing the disease. The doctor should have no doubts about prescribing insulin therapy; he needs to persistently convince the patient of its necessity, educate him, and then the patient will be an assistant in treatment, and insulin therapy will improve his well-being.
International Diabetes Federation recommendations
In 2005, the International Diabetes Federation published the World Guidelines for Type 2 Diabetes. We provide recommendations for prescribing insulin therapy in patients with type 2 diabetes.
1. Insulin therapy should be initiated when optimized use of oral hypoglycemic agents and lifestyle measures fails to maintain blood glucose control at target.
Lifestyle measures should continue to be used once insulin therapy is started. The initiation of insulin therapy and each increase in the dose of the drug should be considered as an experimental one, regularly monitoring the response to treatment.
2. After diagnosing diabetes, it is necessary to explain to the patient that insulin therapy is one of the possible options, which contribute to the treatment of diabetes, and, ultimately, this method treatment may be best and necessary to maintain blood glucose control, especially when treated over a long period of time.
3. Provide patient education, including lifestyle control and appropriate self-control measures. The patient should be reassured that low initial doses of insulin are used for safety reasons; the required final dose is 50-100 units/day.
Insulin therapy should be initiated before poor glucose control develops, usually when HbA 1c levels (DCCT standard) increase to > 7.5% (if data are confirmed) while taking maximum doses of oral glucose-lowering drugs. Continue treatment with metformin. After starting basic insulin therapy, it is necessary to carry out therapy with sulfonylurea derivatives, as well as alpha-glucosidase inhibitors.
4. Use insulin in the following modes:
basal insulin: insulin detemir, insulin glargine or neutral protamine insulin Hagedorn (NPH) (with the latter there is a higher risk of hypoglycemia) once a day, or
premixed insulin (biphasic) twice daily, especially if HbA 1c levels are higher, or
multiple daily injections (premeal short-acting insulin and basal insulin) when glucose control is suboptimal with other treatment regimens or when a flexible meal schedule is desired.
5. Initiate insulin therapy with a self-titration regimen (increasing the dose by 2 units every 2 days) or with the help of a healthcare professional once a week or more often (with a gradual dose-increasing algorithm). Target glucose level before breakfast and main meal –< 6,0 ммоль/л, если такой уровень не достижим, следует проводить мониторинг в другое время суток для определения причин неудовлетворительного контроля уровня глюкозы в крови.
6. Medical workers must provide patient care over the phone until target levels are achieved.
7. Use pens (prefilled or refillable) or syringes/vials of the patient's choice.
8. Encourage subcutaneous injections of insulin into the abdomen (fastest absorption) or thighs (slowest absorption), with the gluteal region and forearm also being possible injection sites.
Evidence-based guidelines for the use of insulin in type 2 diabetes are based on data from the UKPDS study, which examined insulin among antidiabetic agents, considering them together, which led to a reduction in vascular complications compared with conventional therapy. Since this study, the options for insulin therapy methods have expanded significantly, new drugs and methods of their delivery to the body have appeared. A review of the evidence by NICE found a trend towards lower quality ratings for studies of older drugs, as well as an increase in the amount of evidence from studies of newer insulin analogues. A recent meta-analysis found strong evidence of less severe hypoglycemia with insulin glargine compared with NPH insulin. Insulin glargine has been the subject of specific NICE guidance, which provides recommendations for its use in cases where a sufficient effect is observed with a once-daily injection or when the use of NPH insulin leads to hypoglycaemia. More studies of insulin analogues and comparisons of basal insulin analogues and fixed formulas were later published. The findings suggest that basal insulin analogues are superior to NPH insulin for the combined endpoints (HbA1c + hypoglycemia), with similar benefits for biphasic and basal analogues when high HbA1c levels, hypoglycemia and weight gain are considered together. The risk of hypoglycemia is higher with insulin than with any insulin secretagogue.
In type 2 diabetes, intensive insulin therapy has been proven to improve metabolic control, clinical outcomes, and quality of life. There is currently insufficient data on the results of treatment of type 2 diabetes with the use of infusion pumps to recommend this method, although their use is possible in a very limited group of patients subject to a strict individual approach.
Achieving compensation for type 2 diabetes mellitus
Diabetes is a special kind of disease in which the needs of patients are constantly changing. A clear understanding of the progressive nature of type 2 diabetes determines the choice of the most optimal treatment at each stage of its development.
The pathogenesis of type 2 diabetes includes two main components: deficiency of insulin secretion and insulin resistance. Therefore, treatment of the disease should be aimed at correcting these defects. An important feature of type 2 diabetes is the progressive decline in beta cell function over the course of the disease, while the degree of insulin resistance does not change. A large number of patients already have a marked decline in beta cell function by the time diabetes is diagnosed. Data from recent studies show that this decrease is of a very specific nature: while maintaining basal secretion, the postprandial response of beta cells is reduced and delayed in time. This fact dictates the need to choose drugs for the treatment of patients with type 2 diabetes that can restore or imitate the physiological profile of insulin secretion.
The progressive deterioration of beta cell function (over time) requires the initiation of additional therapy immediately after diagnosis (Fig. 1). This is confirmed by the results of the UKPDS study, which showed that with dietary therapy alone, only 16% of newly ill patients achieved optimal control within 3 months, by the end of the first year of the disease this number had decreased to 8%.
Before starting drug therapy, special attention must be paid to diet and lifestyle changes of the patient. In most patients, treatment begins with PSSP monotherapy, which brings positive results only in the first stages of the disease. Then there is a need to prescribe combination therapy aimed at correcting both insulin deficiency and insulin resistance. Most often, two or more oral drugs are prescribed, complementary to each other in their mechanism of action. This strategy provides glycemic control for a number of years, but approximately 5 years after the diagnosis of diabetes, a progressive decrease in insulin secretion leads to the ineffectiveness of complex therapy for PSSP. Despite the fact that the patient's health may remain relatively satisfactory, indicators of carbohydrate metabolism convincingly prove that it is necessary to prescribe insulin therapy.
When should insulin therapy be started for type 2 diabetes?
1. Insulin therapy is prescribed when PSSP is combined with physical activity can no longer adequately control glycemic levels.
2. In case of pronounced side effects of PSSP, lifestyle features, taking medications for the treatment of concomitant diseases and progression of type 2 diabetes, it is advisable to evaluate the possibility of prescribing insulin therapy.
3. Transfer to insulin therapy should be considered if the HbA1c level is persistently above 7% during PSSP therapy.
4. The combination of oral medications and insulin therapy provides better long-term control and less likelihood of weight gain than insulin monotherapy.
The relevance of timely administration of insulin therapy
Results from the Prospective Diabetes Study (UKPDS) and the Diabetes Control and Complications Trial (DCCT) provide convincing evidence that achieving good glycemic control significantly reduces the risk of macro- and microvascular complications. However, strict requirements for carbohydrate metabolism indicators are not an end in themselves for either the doctor or the patient. The International Diabetes Federation, focusing the attention of diabetologists on the prevention of various types of complications, has developed degrees for assessing the risk of developing macro- and microvascular complications. The main parameters for calculating risk include HbA 1c, fasting plasma glucose and, most importantly, the level of postprandial glycemia (PPG). To reliably reduce the risk of developing macrovascular complications, stricter control over the parameters of carbohydrate metabolism is required compared to microvascular risk. At the same time, for patients with type 2 diabetes, it is primarily important to reduce the risk of macrovascular complications, i.e., heart attacks and strokes - the most common reasons premature death. It follows that patients with type 2 diabetes need careful adherence to glycemic control goals, so it is necessary to regularly evaluate cardiovascular and metabolic risk factors that determine the prognosis of diabetes in order to promptly prescribe corrective therapy.
Numerous studies and extensive clinical experience have proven that prescribing insulin analogues to patients with type 2 diabetes provides:
improvement of control of carbohydrate metabolism in case of unsuccessful PSSP therapy;
more effective maintenance of optimal control of carbohydrate metabolism than with PSSP therapy;
the opportunity for patients to lead a more active lifestyle, which increases their motivation to follow the doctor’s recommendations.
It is important for patients to know that after starting insulin therapy to improve glycemic control parameters, the obvious benefit of this therapy is observed within 3-6 months.
Thus, previously existing concerns about a possible increase in cardiovascular risk during insulin therapy are refuted. Weight may increase with insulin therapy, but the combination of metformin and insulin usually reduces the risk of weight gain in obese patients. Psychological barriers to initiating insulin therapy can be partially overcome by trial injections after diagnosis. This will reassure patients that insulin injections using modern thin needles are less invasive and painful than those used for vaccination.
Indications for prescribing insulin for type 2 diabetes
If glycemic control is unsatisfactory, the possibility of prescribing insulin is first considered. Early identification of such patients is possible with regular monitoring of HbA 1c levels. In a fairly wide range of patients, there are restrictions regarding increasing the PSSP dose, contraindications to certain or most PSSPs. These patients primarily include:
with complications due to PSSP;
receiving concomitant therapy with drugs that have side effects similar to PSSP;
with renal and liver failure.
In addition, insulin therapy is prescribed to patients seeking greater freedom from regimen restrictions and at the same time wanting to achieve the best levels of carbohydrate metabolism.
A well-designed insulin regimen eliminates the nutritional restrictions associated with many oral medications.
Short courses of insulin therapy should be prescribed to patients with type 2 diabetes in the event of concomitant diseases, pregnancy, myocardial infarction and corticosteroid therapy. In such situations, blood glucose is a more accurate indicator of glycemic control than HbA1c and should be monitored daily to determine the appropriate insulin dose.
At what level of HbA 1c can one switch to insulin therapy?
The results of a North American study involving 8 thousand patients with type 2 diabetes suggest that insulin therapy is especially effective in reducing HbA 1c if its level exceeds 10% (normal HbA 1c = 4.5-6%). However, waiting until glycemic control becomes so poor would be inappropriate. International guidelines recommend that clinicians review therapy and consider prescribing insulin (possibly in combination with PSSP) if the patient's HbA 1c level consistently exceeds 7%.
Is it possible to switch a patient from a diet directly to insulin therapy without first prescribing PSSP?
In some cases, in patients with ineffective metabolic control, diet in combination with lifestyle changes can initiate insulin therapy without prescribing a PSSP. This treatment option is considered in patients with underweight, with identified antibodies to glutamate decarboxylase, indicating the likelihood of LADA diabetes (latent autoimmune diabetes of adults), as well as in patients with steroid diabetes. Some doctors, taking into account clinical experience, prefer to immediately transfer patients with severe hyperglycemia to insulin therapy. Research is currently ongoing to evaluate the effectiveness of such a strategy in slowing disease progression (Fig. 2).
Combination therapy is the first step when oral therapy is ineffective
Numerous studies have found that when the effectiveness of PSSP therapy decreases, the first step may be to add one injection of insulin to the existing PSSP regimen: this strategy provides more effective glycemic control compared to switching to insulin monotherapy. This benefit was found in both obese and non-obese patients. In addition, it has been confirmed that the administration of insulin leads to improvement lipid profile in patients with hyperglycemia undergoing PSSP therapy. It should be noted that combination therapy has less effect on body weight dynamics and is less likely to cause hypoglycemia compared to insulin monotherapy.
The reduced risk of obesity with combination therapy is due to a lower total dose of insulin compared to insulin monotherapy. In Hong Kong, a study was conducted in 53 patients with ineffective oral therapy who were divided into groups, one of which continued taking PSSP with the addition of one injection of insulin at bedtime, the other was switched to insulin therapy with two injections. As a result, patients in both groups showed equivalent improvements in long-term glycemic control, but weight gain and insulin dosage were significantly lower in the first group receiving combination therapy. A Finnish study conducted over 3 months included 153 patients with type 2 diabetes who were divided into five groups receiving various options combination therapy. In this study, all patients receiving insulin therapy experienced similar improvements in glycemic control. Weight gain was minimal in the group receiving a combination of oral therapy and an evening injection of NPH insulin, compared with patients who were prescribed a combination therapy: a morning injection of NPH insulin or insulin therapy with two or three injections per day.
The advantage of prescribing intermediate-acting insulin in the evening was also proven in an American study of patients with resistance to sulfonylurea derivatives. Patients who received combination therapy with insulin injection in the evening had fewer episodes of hypoglycemia compared to those who used insulin injection in the morning. The recent FINFAT trial confirmed the particular benefit of metformin in preventing weight gain when given in combination with insulin. This study, which involved 96 patients with type 2 diabetes and poor control during treatment with maximum doses of sulfonylurea derivatives, showed that the administration of intermediate-acting insulin before bedtime in combination with metformin once a day provided a more pronounced decrease in HbA 1c levels and less weight gain body and fewer episodes of hypoglycemia compared with a combination of insulin with glyburide + metformin or insulin therapy with two injections per day.
It is important to emphasize that the practical aspects of insulin therapy in patients with type 2 diabetes differ from those in patients with type 1 diabetes. Initiating insulin therapy in patients with type 2 diabetes does not mean the need for additional meals and counting bread units, as is recommended for type 1 diabetes. However, limiting calorie intake is very important for all overweight patients. Patients with severe glycosuria should remember the critical importance of dietary restrictions and adherence to physical activity when transferring to insulin therapy. Failure to adhere to strict dietary restrictions and exercise regimens may increase the risk of weight gain due to cessation of calorie loss while glycosuria decreases while glycemic control improves. Concern about possible hypoglycemia forces some patients to take extra food and avoid physical activity, so the doctor needs to explain the situation and ensure that the patient understands all aspects of the prescribed therapy.
How to start insulin therapy for type 2 diabetes?
When starting insulin therapy, it is important to follow the following recommendations.
1. The ongoing oral therapy can be continued by adding one insulin injection per day.
2. The choice of insulin depends on the level of residual insulin secretion, duration of diabetes, body weight and lifestyle of the individual patient.
3. Self-monitoring of glycemia is very important.
Many patients perceive the start of insulin therapy as a failure of the therapy, which causes them great anxiety. It is very important that the doctor explain to the patient the benefits of insulin therapy soon after diagnosis. It is extremely important that the patient understands that decreased pancreatic function is a natural course of type 2 diabetes. Consequently, at a certain stage in the course of type 2 diabetes, insulin therapy is inevitable. And when the maximum doses of PSSP no longer ensure the achievement of target glycemic values, the administration of insulin therapy cannot be postponed. It may improve glycemic control and thus the long-term prognosis of diabetes. Oral medications can be maintained or insulin monotherapy can be chosen.
Most clinicians believe that when initiating insulin therapy, it is necessary to continue therapy with PSSPs, which, in combination with insulin, prevent a sharp drop in glycemic levels, which significantly reduces the risk of hypoglycemia, and also limits significant fluctuations in blood glucose levels during the day. Metformin has particular advantages in limiting weight gain during insulin therapy. As glycemic control stabilizes with combination therapy, the physician should decide whether to continue oral therapy and discuss this with the patient. When transferring a patient to insulin therapy, it is necessary to take into account his individual characteristics.
Once the decision to initiate insulin therapy has been made, the physician must choose a strategy that will achieve the most effective therapeutic goals. There are no fixed dose titration schemes; at the initial stage, insulin doses should be titrated based on glycemic control indicators and the individual characteristics of the patient.
Basal insulin therapy in the mode of one or two insulin injections. There are several options for basal insulin therapy regimens. NPH insulin (isophane insulin) is given as one injection at bedtime or two or more throughout the day. The evening injection is most often combined with oral therapy; long-acting insulin therapy can be used as monotherapy. In patients with BMI< 30 кг/м 2 инсулинотерапию можно начинать с 10 ЕД инсулина НПХ перед сном, не отменяя пероральную терапию. Такая стартовая доза достаточно удобна, так как, не вызывая большого риска развития гипогликемии, обеспечивает быстрое улучшение гликемического контроля у большинства пациентов. Больным с ИМТ >30 kg/m2 prescribe ready-made insulin mixtures. Combination therapy with PSSP in combination with NPH insulin once a day maintains target glycemic control parameters for 1-2 years in most patients.
The development of new basal insulin preparations culminated in the creation of long-acting insulin analogues, insulin detemir and insulin glargine, which provide a more physiological and stable insulin profile than currently used long-acting insulins.
Ready-made insulin mixtures consist of bolus and basal insulin pre-mixed in a fixed proportion by adding a buffer suspension of protaminated insulin to an insulin solution of the same type. When starting insulin therapy, ready-made insulin mixtures are prescribed once or twice a day, both in combination with PSSP and as monotherapy. Therapy with mixed insulins generally results in significant improvements in glycemic control. Ready-made insulin mixtures can be prescribed to patients on PSSP when this therapy becomes ineffective.
For some patients, ready-made insulin mixtures are prescribed immediately after diet therapy. In patients with a BMI > 30 kg/m2, adding 10 units of a ready-mixed insulin 30/70 before dinner to oral therapy has a good effect. The dose is usually titrated by 2-4 units every 3-4 days and even more often. It is important that the use of mixed types of insulin practically does not change the patient’s lifestyle; in addition, it does not require frequent monitoring of glycemia - it is enough to monitor the blood glucose level once a day before breakfast and periodically carry out additional tests at night.
The ability to limit yourself to two insulin injections reduces the invasiveness of therapy compared to an intensive regimen and helps patients overcome the fear of multiple injections. Proportion accuracy is also important for patients who have difficulty mixing insulin on their own. Currently, it is customary to divide the daily dose of mixed insulin equally between morning and evening injections, but some patients achieve better results when prescribed 2/3 of the daily dose before breakfast and 1/3 before dinner.
Typically, 10-15 years after the diagnosis of diabetes, it becomes necessary to replace therapy with ready-made insulin mixtures with more intensive insulin therapy regimens. The decision on this is made by the doctor and the patient during a joint discussion.
Bolus insulin therapy with three injections per day. In some patients with partially preserved basal insulin secretion, bolus insulin injections 3 times daily may provide satisfactory glycemic control for 24 hours. This regimen does not cover the need for basal insulin secretion, so regular glycemic monitoring is necessary to identify patients whose reduced level of endogenous basal insulin secretion does not allow continued bolus insulin therapy. For some patients, the regimen of three prandial insulin injections per day is a transitional stage to its more intensive variants, prescribed for severe deficiency of insulin secretion.
Basis-bolus insulin therapy. A significant decrease in the endogenous secretion of basal insulin leads to the need to prescribe a combination of bolus and basal insulin (intensive insulin therapy). This regimen is prescribed in cases where other treatment options are ineffective. However, the question is when to prescribe intensive care, remains controversial: some doctors prefer to consider the possibility of prescribing it already in the early stages of the disease.
Thus, the goal of prescribing insulin in patients with type 2 diabetes is to avoid symptoms associated with hyperglycemia and late complications diseases. The use of insulin for type 2 diabetes can significantly improve the quality of life of patients.
The level of sugar (glucose) in the blood is one of the main indicators of the normal state of the body's self-regulation system.
For an adult, the norm is considered to be 3.3-6 mmol/l, for children (up to 4 years) – up to 4.7 mmol/l. A deviation in the blood test is a signal to start treatment.
If you are diagnosed with type 1 diabetes mellitus (insulin deficiency), the need for injections is beyond doubt. However, there are many more patients diagnosed with type 2 diabetes (up to 90% of all diabetics), and their treatment is possible without the use of insulin.
Diabetes and insulin
For the last process to proceed smoothly, you need:
- Sufficient amount of insulin in the blood;
- Sensitivity of insulin receptors (sites of cell penetration).
For glucose to enter the cell unhindered, insulin must bind to its receptors. If they are sufficiently sensitive, this process makes the cell membrane permeable to glucose. 
When the sensitivity of the receptors is impaired, insulin cannot contact them or the insulin-receptor binding does not lead to the desired permeability. As a result, glucose cannot enter the cell. This condition is typical for type 2 diabetes mellitus.
For what sugar readings is insulin prescribed?
Important! You can restore the sensitivity of insulin receptors with diet and medication. For some conditions that only a doctor can determine, insulin therapy (temporary or permanent) is needed. Injections can increase the amount of sugar penetrating cells even with reduced sensitivity by increasing the load on them.
Insulin therapy may be required if there is no or reduced effect of treatment medications, diet and healthy lifestyle. When patients follow the doctor’s recommendations, such a need arises quite rarely.
An indication for insulin therapy may be a glucose value (an indicator of blood sugar) on an empty stomach in capillary blood above 7 mmol/l or above 11.1 mmol/l 2 hours after a meal. The final prescription, depending on the individual indications of the patient, can only be made by the attending physician.
Conditions when drug injections can shift blood sugar levels downwards can be caused by the following reasons:
Important! Temporary insulin therapy can be prescribed for exacerbation of chronic infections (cholecystitis, pyelonephritis, etc.), the use of corticosteroids, and insulin deficiency (polyuria, weight loss, etc.). The duration of use of the drug can vary from 1 to 3 months. and subsequently be cancelled.
For what sugar level is insulin prescribed during pregnancy?
The onset of pregnancy in a patient with diabetes mellitus or gestational diabetes ( hormonal disbalance, leading to insulin resistance) can cause a situation in which nutritional correction and a healthy lifestyle do not bring the desired result. Sugar levels remain elevated, which threatens the development of complications in the child and mother.
An indication for insulin therapy during pregnancy may be increasing polyhydramnios and signs of fetopathy in the child, identified during an ultrasound scan, which is performed at the following times:
When symptoms of hyperglycemia appear, the endocrinologist prescribes measuring the pregnant woman’s sugar level 8 times a day and recording the results. Depending on the individual health status, the norm for pregnant women can be 3.3-6.6 mmol/l.
During pregnancy, insulin is the only antihyperglycemic drug approved for use.
The basis for prescribing insulin injections may be the results of sugar levels:
- In venous blood: above 5.1 units. (on an empty stomach), above 6.7 units. (2 hours after eating);
- In blood plasma: above 5.6 units. (on an empty stomach), above 7.3 units. (2 hours after eating).
Before prescribing insulin therapy, a pregnant woman should:
- In a hospital setting, gain self-care skills and the necessary knowledge to monitor your condition;
- Get tools for self-monitoring or take the necessary measurements in a laboratory.
The main goal of insulin therapy during this period is to prevent possible complications. Regardless of the type of disease, the optimal treatment option is the administration of short-acting insulin before meals and a medium-acting drug before bedtime (to stabilize glycemia at night). 
The distribution of the daily dose of insulin occurs taking into account the need for the drug: at night - 1/3, during the day - 2/3 of the amount of the drug.
Important! According to statistics, type 1 diabetes is most common during pregnancy, as it develops in childhood and adolescence. Type 2 disease affects women over 30 years of age and is milder. In this case, there is a high probability of achieving normal indicators diet, fractional meals and moderate physical activity. Gestational diabetes is very rare.
At what sugar level should you inject insulin?
There is no specific blood sugar value at which injections of the drug are prescribed, since such a decision is made based on several factors. Only an endocrinologist can take them into account.
It is inevitable to introduce insulin therapy at readings of 12 mmol/l after there is no effect from the use of pills or a strict diet. Without additional research (only on sugar levels), insulin is injected for conditions that threaten the health or life of the patient.
When a patient is faced with a choice (inject insulin and continue a normal life or refuse and wait for complications), everyone can make a decision independently.
It should be understood that timely treatment started in combination with other measures (diet, feasible physical activity) can eventually eliminate the need for insulin therapy. And refusal of injections recommended by a doctor for some will be the beginning of the development of complications and even disability.
Insulin is a hormone produced by the pancreas. It is responsible for regulating blood sugar levels. When insulin enters the body, oxidative processes are launched: glucose is broken down into glycogen, proteins and fats. If an insufficient amount of this hormone enters the blood, a disease called diabetes mellitus develops.
In the second type of diabetes, the patient needs to compensate for the constant lack of hormone with injections. At correct use Insulin brings only benefits, but it is necessary to carefully select its dose and frequency of use.
Why do diabetics need insulin?
Insulin is a hormone designed to regulate blood glucose levels. If for some reason it becomes low, diabetes mellitus forms. In the second form of this disease, compensate for the deficiency only with tablets or proper nutrition fails. In this case, insulin injections are prescribed.
It is designed to restore the normal functioning of the regulatory system, which the damaged pancreas can no longer provide. Under influence negative factors this organ begins to thin out and can no longer produce enough hormones. In this case, the patient is diagnosed with type 2 diabetes. This deviation can be caused by:
- Unusual course of diabetes mellitus;
- Extreme high level glucose – above 9 mmol/l;
- Taking sulfonylurea drugs in large quantities.
Indications for taking insulin
Disruption of the pancreas is the main reason why people are forced to take insulin injections. This endocrine organ is very important for ensuring normal metabolic processes in the body. If it stops functioning or does so partially, failures occur in other organs and systems.
The beta cells that line the pancreas are designed to produce natural insulin. Under the influence of age or other diseases, they are destroyed and die - they can no longer produce insulin. Experts note that people with type 1 diabetes also need such therapy after 7-10 years.
The main reasons for prescribing insulin are as follows:
- Hyperglycemia, in which the blood sugar level rises above 9 mmol/l;
- Depletion or diseases of the pancreas;
- Pregnancy in a woman suffering from diabetes;
- Forced drug therapy drugs containing sulfonylurea;
- Exacerbation of chronic diseases affecting the pancreas.
Insulin therapy is prescribed to people who are rapidly losing weight.
Also, this hormone helps to transfer more painlessly inflammatory processes in an organism of any nature. Insulin injections are prescribed to people with neuropathy, which is accompanied by severe pain, as well as atherosclerosis. To maintain normal functioning of the body, insulin therapy is indicated for pregnant and lactating women.
Due to their own ignorance, many patients try not to start insulin therapy for as long as possible. They believe that this is a point of no return, which indicates a serious pathology. In reality, there is nothing wrong with such injections. Insulin is a substance that will help your body work fully and help you forget about your chronic disease. With the help of regular injections, you will be able to forget about the negative manifestations of type 2 diabetes.
Types of insulin
Modern drug manufacturers bring to market great amount drugs based on insulin. This hormone is intended exclusively for maintenance therapy for diabetes mellitus. Once in the blood, it binds glucose and removes it from the body.
Today, insulin comes in the following types:
- Ultra-short action - acts almost instantly;
- Short-acting – characterized by a slower and smoother effect;
- Medium duration - begin to act 1-2 hours after administration;
- Long-acting is the most common type, which ensures normal functioning of the body for 6-8 hours.
The first insulin was developed by humans in 1978. It was then that English scientists forced coli produce this hormone. Mass production of ampoules with the drug began only in 1982 in the USA. Until this time, people with type 2 diabetes were forced to inject themselves with pork insulin. This therapy constantly caused side effects in the form of serious allergic reactions. Today, all insulin is of synthetic origin, so the medicine does not cause any side effects.
Drawing up an insulin therapy regimen
Before consulting a doctor to draw up an insulin therapy regimen, it is necessary to conduct a dynamic study of blood sugar levels.
To do this, you need to donate blood for glucose every day for a week.
After you receive the results of the study, you can go to a specialist. To get the most accurate results, start leading a normal and healthy lifestyle several weeks before taking your blood.
If, while following a diet, the pancreas still requires an additional dose of insulin, it will not be possible to avoid therapy. Doctors, in order to formulate correct and effective insulin therapy, answer the following questions:
- Do you need insulin injections at night?
- If necessary, the dosage is calculated, after which the daily dose is adjusted.
- Do I need long-acting insulin injections in the morning?
To do this, the patient is admitted to a hospital and undergoes an examination. He is not given breakfast and lunch; the body's reaction is being studied. After this, long-acting insulin is administered in the morning for several days, and the dose is adjusted if necessary. - Do you need insulin injections before meals? If yes, then which ones are needed and which ones are not.
- The starting dosage of short-acting insulin before meals is calculated.
- An experiment is being conducted to determine how long before a meal you need to inject insulin.
- The patient is taught to administer insulin to himself.
It is very important that the development of insulin therapy is carried out by a qualified attending physician.
Remember that long-acting and short-acting insulin are two different drugs that are taken independently of each other.
The exact dosage and time of administration are calculated for each patient individually. Some of them only need injections at night or in the morning, while others require constant maintenance therapy.
Constant insulin therapy
Type 2 diabetes mellitus is a chronic, progressive disease in which the ability of the beta cells of the pancreas to produce insulin gradually decreases. It requires constant administration synthetic drug to maintain normal blood glucose levels. Take it into account. What dose active substance needs to be constantly adjusted – usually increased. Over time, you will reach the maximum dose of the pills. Many doctors don't like this dosage form, as it constantly causes serious complications in the body.
When the dose of insulin is higher than that of tablets, the doctor will finally switch you to injections. Keep in mind that this continuous therapy, which you will receive for the rest of your life. The dosage will also change medicine, since the body quickly gets used to changes.
The only exception is when a person constantly adheres to a special diet.
In this case, the same dose of insulin will be effective for him for several years.
This phenomenon usually occurs in those people whose diabetes was diagnosed early enough. They must also maintain normal pancreatic activity, especially the production of beta cells. If a diabetic was able to bring his weight back to normal, he eats right, exercises, and does everything possible to restore the body, he can get by with minimal doses of insulin. Eat right and lead a healthy lifestyle, then you won’t have to constantly increase your insulin dose.
High doses of sulfonylureas
To restore the activity of the pancreas and islets with beta cells, drugs based on sulfonylurea are prescribed. This compound provokes this endocrine organ to produce insulin, which keeps blood glucose levels at an optimal level. This helps maintain all processes in the body in a normal state. The following medications are usually prescribed for this purpose:
- Diabetes;
All these drugs have a powerful stimulating effect on the pancreas. It is very important to follow the dosage prescribed by your doctor, as taking too much sulfonylurea can damage the pancreas. If insulin therapy is carried out without this medicine, pancreatic function will be completely suppressed in just a few years. It will retain its functionality for as long as possible, so you will not have to increase your insulin dose.
Medicines intended to support the body with type 2 diabetes mellitus help restore the pancreas, as well as protect it from the pathogenic influence of external and internal factors.
It is very important to take medications only in those therapeutic doses prescribed by your doctor.
Also, to achieve the best effect, you must follow a special diet. With its help, it will be possible to reduce the amount of sugar in the blood, as well as achieve an optimal balance of proteins, fats and carbohydrates in the body.
Therapeutic effect of insulin
Insulin is an important part of the life of people with type 2 diabetes. Without this hormone, they will begin to experience serious discomfort, which will lead to hyperglycemia and more serious consequences. Doctors have long established that proper insulin therapy helps relieve the patient from negative manifestations diabetes mellitus, and also significantly prolong its life. With the help of this hormone, it is possible to bring the concentration of glucose hemoglobin and sugar to the proper level: on an empty stomach and after meals.
Insulin for diabetics is the only remedy that will help them feel good and forget about their illness. Properly selected therapy can stop the development of the disease and also prevent the development of serious complications. Insulin in the right doses is not capable of harming the body, but an overdose can cause hypoglycemia and hypoglycemic coma, which requires urgent medical attention. Therapy with this hormone causes the following therapeutic effect:
- Reducing blood sugar levels after meals and on an empty stomach, getting rid of hyperglycemia.
- Increased production of hormones in the pancreas in response to food intake.
- Decreased metabolic pathway, or gluconeogenesis. Thanks to this, sugar is quickly removed from non-carbohydrate components.
- Decreased lipolysis after meals.
- Reduction of glycated proteins in the body.
Complete insulin therapy has a beneficial effect on metabolic processes in the body: lipid, carbohydrate, protein. Also, taking insulin helps activate the suppression and storage of sugar, amino acids and lipids.
Thanks to insulin, it is possible to achieve active fat metabolism. This ensures the normal removal of free lipids from the body, as well as accelerated production of proteins in the muscles.Everyone with type 2 diabetes fears it terrible word - insulin. “They’ll put me on insulin, that’s it, this is the beginning of the end” - such thoughts probably appeared in your head when the endocrinologist told you about your unsatisfactory tests and the need to change treatment. It's not like that at all!
Your future prognosis is determined by your sugar levels, your so-called “compensation” for diabetes. Do you remember what glycated hemoglobin is? This measure reflects what your glucose levels have been over the past 3 months. There are large-scale studies that show the relationship between the incidence of strokes, heart attacks, diabetes complications and the level of glycated hemoglobin. The higher it is, the worse the prognosis. According to the recommendations of the ADA/EASD (American and European Diabetes Associations), as well as Russian Association endocrinologists HbA1c (glycated hemoglobin) should be less than 7% to reduce the risk of developing diabetes complications. Unfortunately, if you have type 2 diabetes, there may come a time when your own beta cells stop producing enough insulin and the pills cannot help. But this is not the beginning of the end! Insulin, when used correctly, will lower blood sugar levels and prevent the development of complications of diabetes. In the arsenal of treatments, this is the most powerful drug and, moreover, this is the so-called “physiological” method of treatment; we give the body what it lacks. Yes, there are certain inconveniences, since insulin is still administered by injection, but this is not as scary as it seems at first glance. In this article we will look at when insulin therapy is indicated, how to adjust insulin doses and several other key aspects that are worth paying attention to in this matter.
Attention! This article is for informational purposes only and should not be taken as a direct guide to action. Any changes in therapy are possible only after agreement with your attending physician!
What blood sugar and glycated hemoglobin levels should you have?
If your sugars do not fit within these limits, treatment adjustments are required.
BUT : for people who have had severe hypoglycemia in the past, the very elderly, those with severe comorbidities, severe complications of diabetes, and for people who are unable to control themselves (due to mental, social problems or with visual impairment) less stringent treatment goals are set, glycated hemoglobin should not exceed 8%. Why? Low sugar blood in this case is more life-threatening than slightly elevated blood sugar levels.
Why is insulin therapy not always prescribed on time?
Mostly due to the sharp denial of the need for insulin therapy by the patient and due to the inertia of the doctor, too much effort needs to be expended and too much has to be explained to prescribe such treatment. Considering that it takes 10-15 minutes to see a patient at a clinic doctor, it often ends with the doctor simply prescribing the previous therapy. And diabetes remains decompensated, sugar levels are high, and diabetes complications are approaching faster and faster.
When do you start insulin therapy?
If your treatment - glucose-lowering drugs and lifestyle changes - is ineffective, then it is time to add insulin to your therapy.
Compatibility of oral hypoglycemic drugs and insulin.
Metformin should be continued (of course, in the absence of contraindications, for example, renal failure).
If you use short-acting insulin before meals, then taking secretagogues (drugs that stimulate insulin secretion by the pancreas) is canceled.
If you use only basal insulin, then the dose of sulfonylurea drugs should be reduced, or it is better not to use this class of drugs at all in conjunction with insulin due to high risk hypoglycemia ( low sugar blood).
Let's look at the different insulin therapy regimens and how you can change the doses.
Basal insulin and hypoglycemic drugs.
As a rule, the starting dose of insulin is 10 units or 0.1-0.2 units/kg of ideal body weight.
Dose adjustment is based on fasting sugar levels. Your blood sugar goal is determined by your healthcare provider. The insulin dose is changed every 3 days. You evaluate the average fasting sugar over these 3 days and, depending on its value, change the insulin dose.
Mixed insulin or biphasic.
Perhaps your endocrinologist will prescribe you a similar insulin, for example Novomix or Humulin M3. The initial dose is 12 units before dinner. You can also start with 2 insulin injections before breakfast and dinner, 6 units each.
It should be noted that it is necessary to discontinue sulfonylurea drugs; metformin can be left in the absence of contraindications.
The insulin dose is changed 1-2 times a week.
If your HbA1c level is unsatisfactory, then your doctor may add a 3rd injection of biphasic insulin before lunch (2-4 units), the effectiveness of this dose will need to be assessed by sugar before dinner.
Basis-bolus insulin therapy.
If, despite prescribing insulin therapy with basal or biphasic insulin, your blood glucose level remains off target, your endocrinologist will most likely offer you a similar treatment option. Basis is basal insulin, bolus is “meal” insulin.
The issue of insulin titration can be solved in two ways, ideal and correct, and the second.
It is ideal to navigate not only by the glucose level before and after meals, but also by the amount of carbohydrates eaten. But for this you will need to have some knowledge and understand how to count grain units. You can see this method in the corresponding section about type 1 diabetes and calculating insulin doses. Moreover, with type 2 diabetes mellitus, all relationships and proportions are usually very simple and do not change depending on the time of day, for example, approximately 1 unit of insulin is required to absorb 1 unit of bread.
The second method requires that you eat a certain, stable amount of carbohydrates for breakfast, lunch and dinner.
Dose titration is based on postmeal blood glucose levels, meaning if you want to change your insulin dose for breakfast, you should assess your blood glucose before lunch. Insulin doses are changed once every 3 days until the target glucose values are reached. Based on fasting glucose levels, the dose of basal insulin is adjusted.
If your glucose level is high or low, you should change your basal (long-acting) insulin dose before breakfast rather than injecting bolus insulin at dinner.
Remember, based on your morning fasting glucose level, you will change your basal insulin dose.
Evaluation of treatment effectiveness.
It is necessary to monitor your blood glucose levels at least 4 times a day to achieve target blood glucose levels and reduce the likelihood of hypoglycemia (low blood sugar).
And in conclusion, I would like to say that, at first glance, everything probably seems very complicated and confusing to you. Understanding comes gradually; it would be better if you worked closely with your endocrinologist, and would be “more than one warrior in the field.” Remember, you can and should ask questions; if some prescriptions seem illogical and confusing to you, ask your endocrinologist.
