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Innsulin 2 PDF
Innsulin 2 PDF
Diabetes Mellitus
ALLISON PETZNICK, DO, Northern Ohio Medical Specialists, Sandusky, Ohio
Insulin therapy is recommended for patients with type 2 diabetes mellitus and an initial A1C level greater than
9 percent, or if diabetes is uncontrolled despite optimal oral glycemic therapy. Insulin therapy may be initiated as
augmentation, starting at 0.3 unit per kg, or as replacement, starting at 0.6 to 1.0 unit per kg. When using replace-
ment therapy, 50 percent of the total daily insulin dose is given as
basal, and 50 percent as bolus, divided up before breakfast, lunch,
and dinner. Augmentation therapy can include basal or bolus insu-
lin. Replacement therapy includes basal-bolus insulin and correction
or premixed insulin. Glucose control, adverse effects, cost, adher-
ence, and quality of life need to be considered when choosing therapy.
Metformin should be continued if possible because it is proven to
reduce all-cause mortality and cardiovascular events in overweight
patients with diabetes. In a study comparing premixed, bolus, and
basal insulin, hypoglycemia was more common with premixed and
I
nsulin is secreted continuously by beta needles are now available to help decrease
cells in a glucose-dependent manner pain. Weight gain associated with insulin
throughout the day. It is also secreted therapy is due to the anabolic effects of insu-
in response to oral carbohydrate loads, lin, increased appetite, defensive eating from
including a large first-phase insulin release hypoglycemia, and increased caloric reten-
that suppresses hepatic glucose production tion related to decreased glycosuria. In the
followed by a slower second-phase insulin U.K. Prospective Diabetes Study, patients
release that covers ingested carbohydrates1 with type 2 diabetes who were taking insulin
(Figure 12). gained an average of 8 lb, 13 oz (4 kg), which
Type 2 diabetes mellitus is associated with was associated with a 0.9 percent decrease in
insulin resistance and slowly progressive A1C level compared with patients on con-
beta-cell failure. By the time type 2 diabe- ventional therapy.5
tes is diagnosed in patients, up to one-half of Hypoglycemia may occur from a mis-
their beta cells are not functioning properly.3 match between insulin and carbohydrate
Beta-cell failure continues at a rate of about intake, exercise, or alcohol consumption.
4 percent each year.4 Therefore, patients with Hypoglycemia has been associated with an
type 2 diabetes often benefit from insulin increased risk of dementia and may have
therapy at some point after diagnosis. implications in cardiac arrhythmia.6,7 All
patients should be instructed on the symp-
Concerns About Insulin Therapy toms and treatment of hypoglycemia. Amer-
Pain, weight gain, and hypoglycemia may ican Diabetes Association (ADA) guidelines
occur with insulin therapy. Pain is associ- recommend that the blood glucose level be
ated with injection therapy and glucose checked if hypoglycemia is suspected (glu-
monitoring, although thinner and shorter cose level lower than 70 mg per dL [3.89
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Insulin Management
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Insulin Management
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Insulin Management
Detemir
compared with basal-bolus insulin.30 NPH
is combined with regular insulin or short-
acting analogue insulin and is administered
two or three times daily. Fewer injections
NPH are needed, but patients are more restricted
in their eating habits and schedule. Patients
must eat breakfast, lunch, dinner, and pos-
sibly midmorning and bedtime snacks to
Breakfast Lunch Dinner Bedtime
prevent hypoglycemia. If used, correction
Figure 3. Augmentation therapy with basal insulin. Pharmacokinetic insulin must be administered separately with
profile of using once-daily glargine, detemir, or NPH therapy. a short-acting insulin. This may increase the
Adapted with permission from Diabetes Education Online. University of California, San Fran- number of injections compared with basal-
cisco. http://www.deo.ucsf.edu. Accessed December 10, 2010. bolus therapy (Figure 52).
186 American Family Physician www.aafp.org/afp Volume 84, Number 2 ◆ July 15, 2011
Insulin Management
Insulin effect
by using weight-based equations. Equations Detemir
July 15, 2011 ◆ Volume 84, Number 2 www.aafp.org/afp American Family Physician 187
Insulin Management
188 American Family Physician www.aafp.org/afp Volume 84, Number 2 ◆ July 15, 2011
Insulin Management
Address correspondence to Allison Petznick, DO, Northern Ohio Medi- 18. Ross SA, Zinman B, Campos RV, Strack T;Canadian Lispro Study Group.
A comparative study of insulin lispro and human regular insulin in
cal Specialists, 1200 W. Strub Rd., Ste. 230, Sandusky, OH 44870 (e-mail:
patients with type 2 diabetes mellitus and secondary failure of oral
apetznick@gmail.com). Reprints are not available from the author.
hypoglycemic agents. Clin Invest Med. 2001;24(6):292-298.
Author disclosure: No relevant financial affiliations to disclose. 19. Glucose tolerance and mortality: comparision of WHO and American
Diabetes Association diagnostic criteria. The DECODE study group. Euro-
pean Diabetes Epidemiology Group. Diabetes epidemiology: collabora-
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190 American Family Physician www.aafp.org/afp Volume 84, Number 2 ◆ July 15, 2011