विवरण
Insulin is used in the treatment of patients with most types of diabetes. In general, the need for insulin depends upon the degree of insulin deficiency. All patients with type 1 diabetes need insulin treatment; many patients with type 2 diabetes will require insulin as their beta-cell function declines over time.
सारांश
- **Indications for Insulin Use in Type 2 Diabetes:**
- Common reasons include failure of oral antidiabetic drugs (OADs) after trying three medications, organ failure (renal, hepatic, respiratory, cardiac), acute decompensation (severe hyperglycemia, DKA, HHNS), hospitalization for intercurrent illness, perioperative periods, pregnancy/lactation, catabolic states, and short-term use to reduce glucotoxicity in newly diagnosed patients with severe hyperglycemia.
- **Types of Insulin Available:**
- Two broad categories exist: conventional human insulin (produced via recombinant DNA) and insulin analogs (modified to enhance specific properties). Conventional insulins include regular insulin (short-acting), NPH insulin (intermediate-acting), and premixed insulins (combinations of regular and NPH in varying ratios like 30/70, 25/75, or 50/50). Analog insulins consist of rapid-acting (lispro, aspart, glulisine, fast-acting aspart) and long-acting (glargine, detemir, degludec, glargine 300) options, as well as premixed analog insulins (combining rapid-acting and protaminated rapid-acting) and co-formulations (rapid-acting and long-acting insulins in one product).
- **Initiating Insulin Therapy:**
- Strategies include starting with basal insulin once daily, usually at bedtime, and titrating the dose based on fasting blood glucose levels. Another approach involves initiating premixed insulin once daily and adjusting the dosage based on the patient's response. Both strategies can be uptitrated to basal-bolus regimens as needed to achieve optimal glycemic control.
- **ADA and ACE Guidelines for Insulin Initiation:**
- Both the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (ACE) recommend starting with basal insulin at a dose of 10 units daily or 0.1-0.2 units/kg, titrating based on fasting blood glucose levels. If fasting sugars are controlled but daytime sugars remain elevated, a rapid-acting bolus injection before the major meal or a GLP-1 receptor agonist can be added, or the regimen can be switched to premixed insulin.
- **Case-Based Approach to Insulinization:**
- Practical cases illustrate the importance of individualizing insulin therapy based on the pattern of hyperglycemia. Patients with predominantly high fasting glucose require basal insulin at bedtime. Patients with primarily postprandial hyperglycemia benefit from premixed insulin before breakfast. Patients with both high fasting and postprandial glucose often require twice-daily premixed insulin. Meal timing and patient preferences (e.g., eating only twice a day) should also influence insulin selection.
- **Managing Oral Antidiabetic Drugs During Insulin Initiation:**
- Metformin is generally continued due to its insulin-sensitizing effects. Pioglitazone can be continued cautiously due to weight gain concerns. Sulfonylureas may be continued initially, but may need to be withdrawn later. Newer drugs like gliptins or SGLT2 inhibitors can be used in combination with insulin.
- **Advantages of Insulin Analogs:**
- Rapid-acting analogs provide better postprandial control and lower risk of hypoglycemia than regular insulin. Long-acting analogs offer more consistent fasting glucose control and reduced nocturnal hypoglycemia compared to NPH insulin. Analog insulins are particularly useful in brittle diabetes, gestational diabetes, and patients prone to hypoglycemia.
- **Barriers to Insulin Initiation and Strategies to Overcome Them:**
- Physician-related barriers include lack of experience, complex titration protocols, and limited support staff. Patient-related barriers include fear of hypoglycemia, weight gain, inconvenience, negative perception of insulin, and needle phobia. Strategies to address these barriers involve education, improved doctor-patient communication, use of social media to address negative perceptions, and simplifying insulin regimens with pen devices.
- **Overcoming Inertia:**
- Encouraging doctors to initiate insulin early and addressing patient concerns are crucial. Dispensing a pre-filled pen device and instructing the patient and a support person on its use at the initial visit can improve acceptance. A well-trained support staff can provide education and ongoing support to patients on insulin therapy.
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