Medication Treatment of Diabetes Mellitus

Insulin is available in four basic forms, divided by speed of onset and duration of action:

• includes lispro, aspart, and glulisine insulins. They are the fastest of all, reaching maximum activity in about 1 hour and working for 3 to 5 hours. Rapid-acting insulins are injected at the beginning of a meal or up to 15 minutes beforehand.

• such as regular insulin, begins acting slightly more slowly and lasts longer than rapid-acting insulin. Regular insulin reaches its maximum activity in 2 to 4 hours and works for 6 to 8 hours. It is injected 30 minutes before eating a meal.

• such as insulin isophane (sometimes known as neutral protamine Hagedorn or NPH) or U-500 insulin, starts to work within 0.5 to 2 hours, reaches its maximum activity in 4 to 12 hours, and works for 13 to 26 hours depending on which intermediate-acting insulin is used. This type of insulin may be used in the morning to provide coverage for the first part of the day or in the evening to provide coverage during the night.

• such as insulin glargine, insulin detemir, U-300 insulin glargine or insulin degludec, has very little effect during the first few hours but provides coverage for 20 to 40 hours depending on which of these types is used.

Both rapid-acting insulin and short-acting insulin are often used by people who take several daily injections and need extra insulin for meals.

Some combinations of insulin are available already mixed. In addition, concentrated insulins are available for people who require high doses of insulin.

Inhaled insulin is available for use in some situations for people who are unable or unwilling to take insulin injections. Inhaled insulin is available as an inhaler (similar to an asthma inhaler), and people inhale the insulin into the lungs for absorption. Inhaled insulin works similar to rapid-acting insulin and needs to be taken several times per day. People also need to take injections of long-acting insulin. While people are using inhaled insulin, doctors check their lung function every 6 to 12 months.

Insulin preparations are stable at room temperature for up to 1 month, allowing them to be carried, brought to work, or taken on a trip. Insulin should not, however, be exposed to extreme temperatures and should be refrigerated if being stored for longer than 1 month.

The choice of insulin is complex. Doctors consider the following factors when deciding which insulin is best and how much insulin to use:

• How well the body responds to the insulin it makes

• How much the blood glucose level rises after meals

• Whether other antihyperglycemic medications can be used instead of insulin

• How willing and able people are to monitor their blood glucose levels and adjust their insulin dosage

• How often people are willing to inject insulin

• How varied daily activity is

• How likely a person is to have symptoms of hypoglycemia (low blood glucose levels)

Doctors sometimes have people combine two insulins—a rapid-acting and an intermediate-acting insulin—in one morning dose. A second injection of one insulin or both may be taken at dinner or at bedtime.

Some people take the same amount of insulin every day. Other people, especially people with type 1 diabetes, need to adjust the insulin dose, especially doses taken around mealtime, depending on their diet, exercise, and blood glucose patterns. In addition, insulin needs may change if people gain or lose weight or experience emotional stress or illness, especially infection.

One adjustable regimen involves injecting a long-acting insulin in the morning or evening along with several additional injections of rapid-acting insulin during the day with meals. Adjustments are made as insulin needs change. Measuring blood glucose levels at various times during the day helps determine the adjustment. This regimen requires people to have a lot of knowledge about diabetes to pay close attention to the details of their treatment.

The most common complication of insulin treatment is low blood glucose levels (hypoglycemia). Hypoglycemia occurs more often in people who try to strictly control blood glucose levels.

Symptoms of mild or moderate hypoglycemia include headache, sweating, palpitations, light-headedness, blurred vision, agitation, and confusion. Symptoms of more severe hypoglycemia include seizures and loss of consciousness. In older adults, hypoglycemia may cause stroke-like symptoms.

People who have frequent hypoglycemia may be unaware of hypoglycemic episodes because they no longer experience symptoms (hypoglycemia unawareness).

Doctors teach people how to recognize symptoms of hypoglycemia and how to treat these symptoms. Usually, a person can eat something sweet such as candy or juice to raise their blood glucose level quickly. People may also carry glucose tablets to take in the event of hypoglycemia. Because people with hypoglycemia may be too confused to recognize they are hypoglycemic, it is important for other members of their household and trusted others to be familiar with signs of hypoglycemia.

In very rare cases, the body produces antibodies to injected insulin because injected insulin is not exactly like the insulin the body manufactures. These antibodies may interfere with insulin’s activity, requiring very large doses.

Insulin injections can affect the skin and underlying tissues. An allergic reaction, which occurs rarely, causes pain and burning, followed by redness, itchiness, and swelling around the injection site for several hours. Very rarely, a person may have an anaphylactic reaction after injection of insulin.

Insulin injections may cause fat deposits, making the skin look lumpy, or destroy fat, causing indentation of the skin. Although this skin reaction is not an allergic reaction, it can decrease the absorption of injected insulin. It is, therefore, important to rotate the injection sites, for example, using the thigh one day, the stomach another, and an arm the next, to avoid these problems.

Diabetes Insulin Injection Sites (Front of the Body)

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Diabetes Insulin Injection Sites (Back of the Body)

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