Type 2 diabetes: treatment guidelines (part 4)

In previous articles, we started discussing the principles of treatment for type 2 diabetes mellitus (DM) using various medications. In this article, we continue the discussion about the treatment of this disease. Insulin     

It is possible to administer insulin to patients with type 2 diabetes with unsatisfactory glycemic control during oral therapy, in acute diseases or surgical interventions, 

and also if the patient has obvious symptoms of hypoglycemia, despite oral therapy.

Benefits: Frequent and timely insulin injections and self-monitoring of glucose in the blood allow patients to achieve the optimal balance between maintaining the desired glucose level, diet and physical activity.

Side effects: insulin is used as a regular injection and can cause hypoglycemia. Patients may refuse insulin therapy for the following reasons:

  •  fear of an increased risk of hypoglycemia;
  • fear of having to inject yourself;
  • fear of weight gain;
  • difficulties associated with calculating the dose of insulin administered before meals.

The following factors increase the risk of developing severe hypoglycemia:

  • lack of knowledge about the possibility of hypoglycemia;
  • detailed stage of autonomic neuropathy;
  • a change in mental state (e.g., dementia); 
  • sedentary lifestyle;
  • lack of social support.

Insulin therapy also leads to an increase in body weight.

Research results

Intensive insulin therapy reduces the number of microvascular complications in patients with diabetes type 2 6 .

Possible benefits for patients

The reasons for which the patient can be prescribed insulin include:

  • ineffective glycemic control, despite the maximum dose of oral antidiabetic drugs;
  • weight loss without the use of diets in patients with reduced or normal weight;  
  • contraindications for taking oral hypoglycemic drugs, for example, renal or liver failure;  
  • pregnancy;
  • myocardial infarction; 
  • marked thirst and polyuria (increased urine formation) with high blood glucose.

Examples of Insulin Syringe Pens

 What is important to remember about insulin therapy

Regimens of insulin

General practitioners should know the different types of insulin and be able to adjust the dose of drugs.

The choice of regimen for the use of insulin for a patient should be determined by the following factors:

  • patient consent for injection or refusal;
  • risk of developing hypoglycemia;
  • Lifestyle;
  • age;
  • aggravating factors (effective glycemic control is necessary to reduce the number of complications, however, a poorly seeing patient is unlikely to be able to inject himself 4 times a day without outside help).

There are 4 main types of insulin:

Types of insulin
Values ​​are in hours unless otherwise indicated.
Action typeAction startMaximum actionDuration of actionChemical nameDrug name
Fast5-10 min30-90 min2-4Lyspro insulinInsulin aspartHumalogueNovorapid
A short30 minutes1-24-6Soluble insulinActrapidHumulin SVelosulin and Insuman Rapid
Intermediate23-618-24Suspension of human zinc insulin (based on recombinant DNA)Isophan-Insulin Suspension / NPH-InsulinHumulin tapeMonotardInsulatardHumulin IInsuman Bazal
Long4 1-38-24 Even action without maximum effect36 12-24Human recombinant insulinSuspension of crystalline zinc-insulinInsulin glargineInsulin detemirUltratardHumulin ZincLantusLevemir

The combination of insulin with other drugs

Typically, patients with type 2 diabetes will sooner or later switch from oral hypoglycemic drugs to insulin injections. It is necessary to tell the patient about insulin therapy immediately after confirming the diagnosis so that it is not perceived as an extreme measure. 

The start of insulin therapy should be carried out by experienced specialists with whom the patient can easily contact, so that you can constantly receive help and recommendations. In the UK in recent years, this function has been performed by public hospital doctors and general practitioners who have received additional training, rather than narrow specialists, as it was before.

The NICE 2 guidelines for the treatment of type 2 diabetes mellitus recommends that the initial stage of insulin therapy be injected with human NPH-insulin before bedtime or 2 times a day, as needed. In patients taking basal or prandial insulin preparations, in addition to oral therapy, glycemic control is more effective than in patients taking combined-acting insulin preparations (biphasic drugs) in addition to oral drugs. In the first case, patients also have less frequent attacks of hypoglycemia, and they gain less weight 24 . 

Ready-made insulin mixtures

Ready-made insulin mixtures are designed to provide more effective glycemic control throughout the day with fewer injections. Various types of such mixtures are available in which fast-acting insulin and intermediate-acting insulin are contained in different proportions. The patient can be prescribed biphasic human insulin (ready-made mixture of insulin) 2 times a day, especially if the level of hemoglobin HbA 1c exceeds 9.0%. To start insulin therapy, a drug intended for administration once a day may be suitable.  

In the UK, ready-made mixtures are usually used to start insulin therapy, including 30% quick-acting insulin and 70% intermediate-acting insulin. Many patients with type 2 diabetes for adequate glycemic control will need only 2 injections of the finished mixture of insulin per day, however, some patients will need more intensive insulin therapy in order to achieve good performance.

When transferring a patient with therapy with a drug containing metformin, in combination with other oral antidiabetic drugs to insulin therapy using a ready-made mixture of insulin, it is necessary to continue taking metformin. In some cases, it is advisable to continue therapy with one of the sulfanilurea preparations.

According to the recommendations for determining the initial dose, patients who have not previously used insulin should be given 6 units of the finished insulin mixture at breakfast and 6 units during the evening meal. The dose of insulin must be adjusted every week, in accordance with indicators of blood glucose over the past 3 days, obtained by the patient on his own using a glucometer.   

Long-acting insulin preparations intended for administration once a day

Insulin analogues

Insulin glargine and insulin detemir

These drugs are analogues of long-acting human insulin. They can be administered once a day, but usually two injections are required. They maintain a basal blood insulin level.

The use of long-acting insulin preparations intended for administration once a day is especially useful in the following cases 25 :

  • the patient needs outside help in order to inject an insulin;
  • repeated symptomatic attacks of nocturnal hypoglycemia significantly limit the patient’s lifestyle; 
  • otherwise, the patient would need to take insulin injections 2 times a day in combination with oral hypoglycemic drugs.

In 2011, the World Health Organization (WHO) tested data on the benefits of prescribing insulin analogues 26 . It was concluded that in the treatment of patients with type 2 diabetes, the difference between the HbA 1c hemoglobin level in patients taking insulin analogues (glargine and detemir) and in patients receiving human insulin preparations was minimal (0.03%) and did not have clinical significance. The use of insulin analogues has reduced the number of attacks of nocturnal hypoglycemia. However, many studies excluded patients with a history of severe episodes of severe hypoglycemia, and the researchers were unable to determine whether a reduction in the number of cases of nocturnal hypoglycemia in patients with type 2 diabetes could be expected. 

WHO reports that insulin analogues (glargine and detemir) have no advantages over human NPH-insulin.

When switching to insulin therapy after treatment with drugs containing metformin, in combination with one of the sulfanylurea preparations, it is necessary to continue taking both drugs in parallel with long-acting insulin. If the patient took other oral hypoglycemic drugs before insulin therapy, they can be canceled.

If the administration of insulin 1 time per day does not allow achieving effective glycemic control, the patient should be transferred to the finished mixture of insulin administered 2 times a day, or start additionally administering fast-acting insulin to him.

According to the recommendations developed by the INITIATE study, patients who have not previously taken insulin should be given 12 units of long-acting insulin at bedtime. The dose of insulin must be adjusted every week, in accordance with indicators of blood glucose over the past 3 days, obtained by the patient on his own using a glucometer. The increase in the daily dose of insulin should not exceed 10 units or 10% of the current dose.

In what cases should the patient be referred to a specialist?

The patient must be referred to a narrow specialist in the following cases 28 :

  • uncontrolled hyperglycemia while taking maximum doses of drugs;
  • uncontrolled arterial hypertension; 
  • constant proteinuria (excretion of protein in the urine);
  • creatinine level> 150 μmol / l;
  • retinopathy (retinal pathology) or visual impairment; 
  • painful form of neuropathy, mononeuropathy or amyotrophy;
  • risk of foot damage (patients with foot ulcers should be referred to a specialist immediately);
  • the patient needs to start insulin therapy, but there is no opportunity for this (however, if there are such conditions in the primary care institution, the patient can go there to help him start insulin therapy);
  • the patient has psychological problems due to a diagnosis of diabetes (e.g., depression); 
  • if a patient with type 2 diabetes is planning a pregnancy. 

In the following cases, patients should be referred to the emergency department:

  • prolonged vomiting or ketoacidosis
  • blood glucose> 25 mmol / L and the presence of ketone bodies in the urine.

Prognosis for patients

Patients with diabetes often develop micro- and macrovascular complications and their life expectancy is reduced.

Active monitoring of blood glucose, blood pressure and blood lipids reduces long-term morbidity and mortality from diabetes.

Leave a Reply

Your email address will not be published. Required fields are marked *