Description
A number of landmark randomized clinical trials established that insulin therapy reduces microvascular complications . In addition, recent follow-up data from the U.K. Prospective Diabetes Study (UKPDS) suggests that early insulin treatment also lowers macrovascular risk in type 2 diabetes . Whereas there is consensus on the need for insulin, controversy exists on how to initiate and intensify insulin therapy. The options for the practical implementation of insulin therapy are many. For the management of type 2 diabetes, this resulted in the recommendation to “maintain glycemic levels as close to the nondiabetic range as possible” . However, in contrast to the UKPDS, the Kumamoto study observed a threshold, with no exacerbation of microvascular complications in patients with type 2 diabetes whose A1C was <6.5%, suggesting no additional benefit in lowering A1C below this level
Résumé
- Insulin initiation is often a challenge for non-specialist doctors, stemming from doubts about insulin types, timing, and dosage. However, it mainly requires an understanding of pharmacodynamics and pharmacokinetics. Familiarity with 3-4 common insulin types is recommended for building confidence.
- Key indications for insulin use include oral drug failure, organ dysfunction (renal, hepatic, cardiac, pulmonary), acute decompensation (DKA, HHS), major surgery, pregnancy/lactation, catabolic states, and symptomatic hyperglycemia. Hospitalization for moderate to major illness usually necessitates insulin therapy.
- Insulins are broadly divided into conventional and analog types. Conventional insulins include regular, NPH, and premixed forms (30/70, 50/50 ratios). Analog insulins involve amino acid sequence changes for fast or long-acting properties, including rapid-acting (lispro, aspart, glulisine, fast-acting aspart) and long-acting (glargine, detemir, degludec) options. Co-formulations combine different insulin types.
- Insulin regimens can start with basal insulin alongside oral drugs, targeting fasting blood sugars. If this is insufficient, rapid-acting insulin can be added before meals (basal-bolus). Premixed insulin can also be used, with the frequency adjusted as needed. The goal is to titrate insulin dosage to achieve target blood sugar levels.
- The "fix fasting first" concept involves using basal insulin to control fasting sugars, which can subsequently improve daytime sugar levels. Practical case scenarios demonstrate how to select insulin type and timing based on individual patient profiles, considering fasting vs. postprandial patterns.
- Rapid-acting analogs offer better postprandial control and reduced risk of hypoglycemia compared to regular insulin, particularly useful in gestational diabetes, renal failure and elderly patients. Long-acting analogs have more consistent effects and a lower hypoglycemia risk than NPH, with no pronounced peak.
- Barriers to insulin use exist among both doctors and patients. Physicians may lack experience, guidelines, or sufficient staff. Patients may fear injections, monitoring, hypoglycemia, and weight gain. Addressing these concerns through education, team-based care, and accessible devices can enhance insulin acceptance. Pen devices, in particular, are well-received by patients due to their ease of use and reduced pain.
Exemple de certificat
À propos des intervenants
Dr Anish Behl
Endocrinologue consultant aux hôpitaux Apollo BGS, Mysore
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