Insulin in diabetes: when appointed, calculating the dose, how to stab?

The hormone insulin produced by the pancreas is necessary to maintain glucose homeostasis, regulate carbohydrate and protein metabolism, and energy metabolism. When this hormone is not enough, chronic hyperglycemia develops, often indicative of diabetes mellitus, and then insulin is prescribed for diabetes.

Treatment with insulin for diabetes

What is insulin for diabetes? The problem solved by  insulin treatment in diabetes is to provide the body with this hormone, because in type 1 diabetes, pancreatic β cells do not perform their secretory function and do not synthesize insulin. Endocrinologists call regular injections of insulin in diabetes of this type by substitutive insulin therapy, aimed at fighting hyperglycemia - an increased concentration of glucose in the blood.

And the main indications for the use of insulin preparations are insulin-dependent diabetes mellitus. Can I give up insulin for diabetes? No, to prick insulin in type 1 diabetes is necessary, since in the absence of an endogenous hormone, it is the only way to regulate the concentration of blood glucose and avoid the negative consequences of its increase. In this case, the pharmacological action of insulin, that is, insulin preparations, exactly reproduces the physiological effect of insulin produced by the pancreas. It is for this reason that the addiction to insulin in diabetes does not develop.

When is insulin prescribed for diabetes mellitus, not related to the dependence on this hormone? Insulin in type 2 diabetes - with increased insulin requirements due to the stability of the receptors of some tissues to the circulating hormone in the blood and a violation of the metabolism of carbohydrates - is used when β-cells of the pancreas fail to meet this need. In addition, the progressive dysfunction of β-cells in many obese patients leads to prolonged hyperglycemia, despite the use of drugs to reduce blood sugar levels. And then switching to insulin in type 2 diabetes can restore glycemic control and reduce the risk of complications associated with progressive diabetes (including diabetic coma).

Studies published in 2013 in the journal The Lancet Diabetes & Endocrinology demonstrated the effectiveness of the use of intensive short-term insulin therapy in 59-65% of patients with type 2 diabetes.

Insulin injections for diabetes of this type can be prescribed for a limited period of time in connection with surgical intervention, severe infectious pathologies or acute and urgent conditions (primarily in stroke and heart attack).

Insulin is used for diabetes of pregnant women (so-called gestational diabetes mellitus) - if you normalize carbohydrate metabolism and curb hyperglycemia, you can not use the diet. But during pregnancy, not all insulin preparations (but only human insulin) can be used: the right endocrinologist should choose the right remedy - taking into account the contraindications of drugs and the blood sugar level in a particular patient.

Release form

Insulin preparations are available in the form of a solution and a suspension for injection. These are either ordinary glass bottles (hermetically sealed) - for administration of the solution with an insulin syringe, or vials of cartridges (penfill) - for administration by means of special syringes.

Names of insulin group preparations: the best insulins for diabetes

To date, all manufactured drugs of the insulin group are classified according to the speed with which they begin to act after administration and the duration of this action.

The names of high-speed drugs similar to human insulin: Insulin aspart, Humalog, NovoRapid Penfill (NovoRapid FlexPen), Apidra (in other variants - Epaidra). These drugs have an ultrashort effect at the very beginning (already 10 minutes after injection); maximum (peak) effect is observed no later than 1.5-2 hours, and the hypoglycemic effect after a single administration is maintained for about three to five hours.

Insulin preparations of short action, such as Insulin C, Actrapid, Apidra SoloStar, Iletin, Insuman Rapid, Insulrap, Monosuinsulin MK, Gansulin R, Homorop, Humalog, Humodar R, etc., the duration of the antiglikemic effect is 7-8 hours, and they begin to act 20-30 minutes after the injection of insulin in both types of diabetes.

Such drugs as Actrafan NM, Inuzofan (Isofaninsulin NM, Protofan NM), Insuman Bazal, Insular Stabil, Lente, Iletin II Lente, Monotard, Homolong 40, Khumulin NPH, belong to insulin with an average duration of action (within 14-16 hours ), while they begin to act only a half to two hours after the injection.

It is believed that the best insulin in diabetes are those that can be pricked once a day. Such a long-lasting effect of insulin in diabetes mellitus (practically within 24-28 hours) and its stable concentration is provided by Lantus preparations (Lantus Optiset, Lantus SoloStar), Humulin ultralente, Insulin Superente, Tudzheo SoloStar, Ultratard NM, Levemir Penfill (Leveemir FlexPen).

[1], [2], [3], [4], [5]

Pharmacodynamics

After the injection of insulin drugs, they enter the systemic circulation. Their pharmacologically active substances bind to globular plasma proteins (usually more than 25%), and then are quickly removed from the blood and interact with insulin receptors on the cell membranes - to improve intracellular glucose metabolism, which helps to lower its level in the blood.

Splitting of exogenous insulin occurs by hydrolysis under the action of liver and kidney enzymes; Elimination - with urine and bile.

The pharmacokinetics of long-acting insulin preparations are somewhat different, since their substance is released much more slowly. In addition, some synthetic insulins break down into active metabolites that promote prolonged hypoglycemic action.

[6], [7], [8], [9], [10],

Dosing and administration

Absolutely all patients the choice of insulin in diabetes mellitus of both types is carried out by the attending physician-endocrinologist individually: according to the results of blood tests for fasting glucose and overnight, for  glycosylated hemoglobin  and urine analysis for sugar (glucosuria); taking into account the age, lifestyle, mode and nature of nutrition, as well as the intensity of ordinary physical activity.

Calculation of insulin in diabetes is carried out on the same principles with a correlation of the type of diabetes. And the optimal dose of insulin in diabetes is established on the basis of determining the production of endogenous insulin and the daily requirement for a given hormone - an average of 0.7-0.8 units per kilogram of body weight for type 1 diabetes, and for type 2 diabetes, 0.3- 0,5 units / kg.

In cases of excess of blood sugar level of 9 mmol / l, dose adjustment is necessary. It should be borne in mind that with the introduction of 1 unit of insulin of average duration of action or prolonged insulin, blood glucose is reduced by about 2 mmol / l, and high-speed drugs (ultrashort action) are much stronger, which must be taken into account when they are dosed .

How, where and how many times do I inject insulin with diabetes?

Insulin preparations are administered subcutaneously; injections of insulin in diabetes are usually done in the subcutaneous tissue on the abdomen (on the front abdominal wall), on the front of the thigh, the upper part of the buttocks or in the shoulder (below the shoulder joint - in the area above the deltoid muscle). The drug should not be cold (this significantly slows the onset of its action).

When using insulin of medium duration, a standard scheme is used, in which the injections are done twice during the day: in the morning, no later than 9 hours (30-40 minutes before meals), 70-75% of the total daily dose should be administered, and the rest - not later than 17 hours (also before meals). Diabetic nutrition on insulin is very important: 5-6 meals a day should be clearly timed.

A single injection of insulin in type 2 diabetes may be appropriate if the daily requirement for insulin in the patient does not exceed 35 units, and there are no sharp fluctuations in the level of glycemia. For such cases, long-acting insulin preparations are used, which should be taken every four hours, including two hours before bedtime.

Since it is believed that the use of insulin once a day in patients with type 1 diabetes mellitus does not reflect the physiology of the action of this hormone, a scheme of its administration, called intensive insulin therapy, has been developed.

According to this scheme, insulin preparations can be used as a short-acting or long-acting insulin combination. If the first (administered before meals) should cover the need for insulin after meals, the latter (used in the morning and before bedtime) provide other biochemical functions of insulin in the body. In general, this leads to the need to inject different drugs up to four to six times a day.

[14], [15], [16], [17], [18], [19], [20], [21]

Contraindications

Among the contraindications to the use of insulin, there is a hormone-active tumor of pancreatic islet β-cells (insulinoma), acute pancreatitis, acute viral hepatitis, severe hepatic and / or renal insufficiency, as well as peptic ulcers of the gastrointestinal tract during their exacerbation.

What is dangerous for insulin in diabetes?

In addition to such side effects as the appearance of local allergic reaction (flushing and itching of the skin), swelling, muscle aches and atrophy of subcutaneous tissue at the injection site, with an unbalanced dosage, the damage to insulin in diabetes can manifest as hypoglycemia.

This decrease in glucose level is below the physiologically adequate level, which is manifested by such symptoms: pallor of the skin, cold sweat, lowering of blood pressure and rapid heart rate; headache and blurred vision; increased fatigue or general weakness and drowsiness; nausea and temporary changes in taste; tremors and cramps; nervousness and anxiety; decreased concentration and loss of orientation.

With a severe degree of hypoglycemia, the brain stops receiving glucose, and a coma occurs that threatens not only irreversible degenerative changes in the brain cells, but also a fatal outcome.

[11], [12], [13]

Overdose

When an insulin overdose develops hypoglycemia (see above). Also, prolonged excess doses of insulin preparations in patients with type 1 diabetes can lead to the development of Somogy's syndrome, which is also called ricochet hyperglycemia.

The essence of a chronic overdose of insulin is that in response to a decrease in the level of glucose in the blood, the so-called counterinsulin hormones (adrenaline, corticotropin, cortisol, somatotropin, glucagon, etc.) are activated.

As a result, the content of ketone bodies can significantly increase in urine (ketonuria is manifested by acetone odor of urine) and ketoacidosis develops with a significant increase in diuresis, excruciating thirst, rapid weight loss, dyspnea, nausea, vomiting, abdominal pain, general retardation, loss of consciousness right up to coma.

[22], [23], [24], [25], [26],

Interactions with other drugs

Insulin in diabetes potentiates the effect of hypoglycemic drugs for internal use; sulfonamides; tetracycline antibiotics; antidepressants of the MAO inhibitor group; preparations of calcium and lithium.

Antiviral drugs, GCS, thiazitic diuretics, preparations of heparin and ephedrine, antihistamines should not be used for insulin injections. Interaction with non-steroidal anti-inflammatory drugs (NSAIDs) and preparations containing salicylic acid and its derivatives, enhance the action of insulin.

[27], [28], [29], [30]

Storage conditions

All insulin preparations should be stored in a darkened place in the refrigerator (at a temperature of + 2-8 ° C).

[31], [32], [33]

Shelf life

The shelf life of the drugs is indicated on the packaging, as a rule, it is 24 months.

[34], [35], [36]

Which is better: insulin or a pill with diabetes?

Tablets related to hypoglycemic agents for oral administration have different mechanisms of action, when used only with insulin-independent or insulin-resistant type 2 diabetes. So exactly the type of this disease gives the endocrinologist a reason to prescribe insulin or a pill with diabetes.

Derivatives of sulfonylureas-Glibenclamide (Maninil), Gipizide (Minidiab), Glikvidon, Gliklazid, as well as preparations of the clay group (Repaglinide, Repodiab, Diaglinide, Novonorm) have a stimulating effect on pancreatic β cells, increasing insulin secretion.

And preparations of the biguanide group, whose active ingredient is butylbiguanide hydrochloride - Butylbiguanide, Buformin hydrochloride, Gliiformin, Glybutide, Metformina hydrochloride, Dianormet, etc. - reduce blood glucose in patients with type 2 diabetes by improving the transfer of glucose through the cell membranes of myocytes and fat cells. This affects the metabolism of glucose, and it, firstly, is not produced by another way (from non-carbohydrate compounds), and, secondly, does not enter the bloodstream as a result of blocked splitting of glycogen stores in tissues. In some cases, these drugs are used simultaneously with insulin.

Also see the publication -  Tablets from diabetes mellitus

How to lose weight with diabetes on insulin?

Many people know that the treatment of diabetes with insulin can add extra pounds in the form of subcutaneous adipose tissue, since this hormone promotes lipogenesis.

The above-mentioned hypoglycemic drugs in the form of tablets containing butylbiguanide as an active ingredient contribute not only to a decrease in glycemia, but also to appetite. At their reception (one tablet in day) at diabetics with obesity the weight decreases.

In addition, adequate nutrition is necessary for diabetes on insulin with a daily caloric restriction (within 1700-2800 kcal).

If diabetes is insulin-dependent, it is recommended that you follow a  diet for type 1 diabetes, and a diet for type 2 diabetes is developed for patients with insulin-dependent diabetes  .