Insulin therapy

Insulin therapy is a treatment method in diabetology in which an insulin preparation is administered for the treatment of elevated blood glucose in diabetes mellitus, to compensate for the deficiency of the body's metabolic hormone insulin.

Insulin was recognized as the hypoglycemic substance from the pancreas tissue in the first decades of the 20th century and chemically isolated. In 1922 by Frederick Banting, the first therapy with insulin in people with diabetes mellitus type 1

2.1 Conventional insulin therapy ( CT)
2.2 Intensified conventional insulin therapy (ICT )
2.3 Functional insulin therapy ( FIT)
2.4 supplementary insulin therapy ( SIT)
2.5 basal supported oral therapy (BOT)
2.6 Continuous subcutaneous insulin infusion: pump therapy ( CSII)

3.1 Blood glucose self-monitoring
3.2 Protocol guide
3.3 AC layer and unequal diurnal rhythm
3.4 metabolic fluctuations
3.5 Insulin therapy in type 2 diabetes

Ways of insulin delivery

The only licensed opportunity to deliver insulin, the injection using pen, insulin syringe or continuous subcutaneous insulin infusion ( CSII) using an insulin pump is. It is usually made in the subcutaneous adipose tissue ( = subcutaneous), rare intramuscularly or intravenously. In the subcutaneous injection into the subcutaneous tissue, the localization must be changed frequently, because this will cause a lipohypertrophy occur.

Insulin preparations for inhalation are indeed still being studied, the only currently marketed in the EU product ( Exubera ) but was withdrawn by the manufacturer in 2007.

Syringe

Syringes were up to the era of insulin pens the norm. Older type 1 diabetics know yet the reusable syringes and the thick reusable needles, which have long been responsible for the horrors of insulin therapy. Superseded these were disposable syringes with very thin disposable needles. Nowadays in Germany predominantly insulin pens are used. When emergency equipment are disposable syringes and needles still on the market. There are insulin syringes for insulin U40 ( = 40 units of insulin per milliliter Litter ) and insulin U100 (= 100 units of insulin per milliliter).

Length of needles: There are different needle lengths, for example, 6/5 mm for children and adults very slender, further 8 mm, 10 mm and 12 mm.

Insulin

Pens look thicker pens similar and can be equipped with an insulin cartridge. The insulin dose is adjusted on a rotating wheel. There are different sizes of cartridges, the standard capacity is 3 ml ( U100 insulin, or 100 IU per ml). The injection needles with plastic threads are screwed before each injection and are also available in different lengths.

Pre-

Finished or Einwegpens are firmly fitted with an insulin cartridge and be discarded after depletion of insulin.

Insulin pump

Insulin pumps are used for continuous infusion of insulin into the subcutaneous adipose tissue. The amount given in each case for primary care ( basal rate ) is controlled by a time-dependent programmed schedule. The meals insulin is needed additionally retrieved ( bolus ).

Forms of therapy

In recent decades, different treatment variants were developed to insulin therapy, which often each had a specific group of patients or specific problems in the eye of various diabetologists and diabetes clinics. For simplicity was one of the forms of therapy catchy acronyms (CT, ICT, FIT, BOT, SIT, CSII), which are explained briefly below.

Conventional insulin therapy ( CT)

In the conventional insulin therapy, a certain amount of insulin is injected at fixed times. The CT finds its application typically in diabetes mellitus type 1, mainly in the elderly, mainly because they have a fixed daily rhythm. A mixed insulin is two to three times a day usually injected. This form of therapy requires the timely intake of meals with well-defined amount of glucose- effective carbohydrates. Due to the action of insulin and snacks must be met before the morning and afternoon and a late meal. Because this therapy requires a practical remote schematic eating habits, no flexible design of the daily meals is possible. In addition, at Skipping meals is a significant risk of hypoglycaemia.

Intensified conventional insulin therapy (ICT )

(see also basal-bolus insulin therapy)

Intensive conventional insulin therapy (ICT ) is being applied mainly in type 1 diabetic patients, with insufficient Insulinsekrektion or advanced disease also in type 2 diabetics. It consists of a so-called two - syringe therapy, ie the one hand, rapid-acting insulin is injected with meals and to correct (bolus ), on the other hand, the body needs, regardless of the supplied carbohydrates, a basic supply of insulin, which is guaranteed to delay insulin (base). This basal-bolus principle mimics insulin secretion from the healthy pancreas. The basal insulin is injected on the day depending on the type of insulin and blood glucose curve once to three times; the bolus insulin with meals or at too high blood sugar levels.

The basal rate needs to be adapted to different physical loads.

The ICT enables a more variable life than the conventional therapy, since better adaptations to the current situation (exercise, resting, work, sports, etc.) can be made. In conjunction with metabolic control (blood glucose measurement) and the logging of all influencing the glucose metabolism factors together, there is a rapid implementation of modified results and adaptation.

Functional insulin therapy ( FIT)

The Austrian diabetologist Kinga Howorka coined the term Functional insulin therapy, which has a maximum independence of type 1 diabetic to the destination. It substantially corresponds to the nowadays applied ICT.

Supplementary insulin therapy ( SIT)

The supplementary insulin therapy is primarily aimed at diabetics who still have their own insulin. When diabetics type 2 one is faced primarily with the problem that a disorder of insulin action exists, and thus much too much insulin is present. But insulin also plays a role in fat metabolism and can - because just too much - lead to even more overweight, so a supplementary treatment with oral antidiabetic agents such as metformin is performed. Under mahlzeitenbezogenem use of a rapid-acting lnsulins it comes to mimic the normal insulin secretion of healthy people. This blood sugar spikes are cut reliably and effectively after meals. The optimized lnsulinanpassung to the meal improves metabolism and reduces the risk of a hypo. Since snacks can be omitted, the weight loss is relieved. The administration of oral hypoglycemic agents reduced the required dose of insulin.

Basal supported oral therapy (BOT)

The type 2 diabetes, for example, receives at the beginning of therapy, oral antidiabetic agents. Then, as shown in particular in the early hours elevated fasting blood sugar levels, a basal insulin is administered in the evening hours, which suppresses the endogenous hepatic gluconeogenesis in the early morning hours.

Continuous subcutaneous insulin infusion: pump therapy ( CSII)

Insulin pump therapy is employed predominantly for type 1 diabetics in question can be considered the most advanced form of therapy be considered. Its main problem is that it is significantly more expensive than the total ICT. Therefore, the health insurance companies require a clear justification why the attending physician this type of therapy recommended by his patients. But long term, it saves by the reduction of late effects also money for the coffers.

The advantages over other forms of therapy are:

Low insulin depots in the subcutaneous adipose tissue ( lower Unterzuckerungsrisiko );
Easier to adjust to movement differences by lowering or raising the basal rate;
Accurate metering of the basal and the meal-related insulin;
Better control of Dawn phenomenon ( Morning Twilight phenomenon = morning hormonal increase in insulin resistance);
Better possibilities for intervention (especially inconspicuous ) in metabolic fluctuations;
Ideal insulin reduction options prior to sporting events with much less weight gain by meals related forced carbohydrates to compensate for an increased efficiency of the basal insulins / improvement in the effect on the receptors ( basal rate can be switched off or reduce ); Example of a profile with subsidence
Less Hypoglykämieepisoden by lowering the current supplied to insulin at the same time low already present in the body insulin depots, which now no longer have to be absorbed by the inclusion of additional carbohydrates.
Sometimes assistance in determining the amounts of insulin for a meal with documentation support; Not all pumps.

Other indications may be:

Strongly fluctuating blood sugar levels as pronounced dawn phenomenon (pronounced rise of blood glucose in the early morning hours),
Lower insulin needs (small children, people with high levels of physical exercise during the day ),
Shift work
Terrible adjustable blood sugar is too high HbA1c
Pregnancy with otherwise not adjustable blood sugar metabolism

Important aspects of

In all forms of therapy, certain common aspects to consider in order to successfully apply the therapy.

Blood glucose self-monitoring

With a blood glucose meter of diabetics can control their blood sugar even. Always for type 1 diabetics, but often also for type 2 diabetics to measure one's own blood sugar is essential during insulin treatment for therapy. In insulin -dependent patients, the cost of blood glucose self-monitoring by the statutory health insurance funds will be reimbursed.

Record keeping

The protocol is a feasible framework contain all data that are necessary to a correct assessment of metabolic development and thus to appropriate insulin dose. This is usually only when all the blood sugar influencing factors are noted. Apart from the actual blood glucose value primarily include the exact time of measurement, whether before or after a meal, as well as information on the calorie content of the food ingested. In addition, those data are important, which lead to lower blood sugar levels, such as periods of intense exercise (sports ), sweating, but also factors such as workload or stress. The more reliable are these entries, the more reliable are the conclusions that can be drawn from such a protocol (BE- factors Basalratenveränderungen, estimates of food, etc ).

The protocol can be performed electronically, on paper or using special, so-called diabetes management software; numerous blood glucose meters can store the measured values together with additional information, manage, and transferred via interface cable or via bluetooth or email to a computer and / or into a patient record on the Internet, which offers the advantage of remote monitoring: the patient may the physician to access the data allow, for example, what is useful for telephone consultations and emergency situations.

Rotating shifts and unequal diurnal rhythm

A changing daily rhythm complicates insulin therapy especially if it causes sleep disturbances. This can cause the body is insulin- insensitive (up to about 40%). In particular, change layer can - if she has insomnia result - bring increased problems with metabolic control with it.

To note this would be particularly a shifted Dawn and Dusk phenomenon ( caused by time of day rhythm, elevated, hormononelle blood sugar spikes in the morning or in the evening).

Metabolic fluctuations

Insulin therapy without metabolic fluctuations is not feasible. The blood sugar can - depending on the influence factor and intensity - even within one hour are subject to major changes. In general, these fluctuations but by the diabetic self- explainable and predictable over a certain period so that they are predictable or estimated within certain bandwidths ( expectations). Causes for high blood sugar fluctuations may be due to processes such as the dawn phenomenon or the Somogyi effect. As Brittle Diabetes (English swaying ) is called a hard adjustable diabetes due to unsystematic, unexplained blood sugar fluctuations.

Insulin therapy in type 2 diabetes

In type 2 diabetes is to start before an absolute lack of insulin, but a disorder of insulin action (insulin resistance) or a relative insulin deficiency due to excess weight, so here's a insulin therapy is indicated only in third place. The initial treatment consists of a training and nutritional counseling to achieve through a change in lifestyle with regular exercise and a diet adapted improve blood sugar levels and possibly a reduction in body weight. If unsuccessful, secondarily oral Antidibetika be used only in case of failure of this therapy is insulin added in addition.

Insulin therapy in Type 2 diabetes often leads as an undesirable side effect to an increase in body weight, which in turn can lead to increased insulin resistance. In this respect, the obese type 2 diabetics have to try to normalize his body weight and maintain a adequate nutrition, regular exercise and, if necessary, oral antidiabetic agents, the required insulin dose as low as possible.

In type 2 diabetics can soon prove that primarily affects the first phase of insulin secretion after food intake, a relative insulin deficiency. The first blood sugar spike after a meal is partly responsible for the emergence of consequential damages such as coronary heart disease ( CHD), vascular damage, such as micro-and macroangiopathies, kidney failure, eye damage (diabetic retinopathy, blindness ) and nerve damage ( neuropathy).

Criteria of insulin sensitivity

Insulin requirements fluctuate during the day. Morning insulin requirements is due to the same time distributed body's hormones such as Cortisol highest. At noon, the average insulin requirement is lowest, and then in the evening to rise again. Late in the evening the insulin requirement decreases again and reaches its absolute minimum, then from 3:00 clock at night to rise again.

At normal physical exercise is expected approximately at a ratio of approximately 50% basal and 50 % mahlzeitenbezogenem insulin. The average insulin requirement is calculated with about 40 E per day or by body weight for about 0.5 -1.0 units / kg body weight.

The insulin sensitivity is dependent on many factors:

Type of insulin ( in ascending order: very fast-acting insulin analogues, regular insulin, NPH insulin, long-acting insulin analogues )
Site of insulin injection (eg faster effect when injected into the abdomen, slow and delayed when injected into the thigh )
Type of insulin administration (intravenous, intramuscular, subcutaneous )
Length of the needle ( the lengths are between 6 and 12 mm, a short needle to bring the insulin is not deep enough to the blood vessels supplying, too long a needle may hit in the muscle, the insulin acts faster)
Blood flow to the injection site ( can be accelerated by sunlight, hot bath, when cold the action is slowed down )
Initial blood sugar ( at high values there is a relative insulin resistance, at low values of blood sugar is very sensitive )
Food intake ( fat-and protein-rich meals allow the blood sugar to rise slowly, rapidly absorbable carbohydrates quickly )
Exercise ( endurance sports fall faster before or after leaving the blood sugar)
Alcohol ( enjoyed the night before, the morning can lead to hypoglycaemia, as the liver - release instead of glucose - is concerned with the degradation of alcohol )
Disease ( an infection increases insulin resistance)
Stress ( both can lead to marked increases in blood sugar as well as to hypoglycaemia - depending on the type of reaction of the people )
Insulin dose ( high dose of insulin injected at a point needs to maximum effect longer than if the dose is administered in several doses. )

The correction factor indicates by how much the blood sugar drops per given unit of insulin. It provides an approximation of the number of units of insulin, the body needs to go from a higher blood sugar at a target value. The target area is in most diabetic patients between 80 and 120 mg / dl.

In adults of normal weight and lack of insulin resistance, the correction factor usually lies between 30 and 50 mg / dl per IU of insulin. For petite people and children, however, the correction factor is significantly higher (lower volume of distribution ) and with larger and thicker persons noticeably lower ( higher volume of distribution ). The dose of insulin required in each case, therefore, must always be determined individually by careful approach.

For acidification of the blood by a hyperglycaemic metabolic state in absolute insulin deficiency in type 1 diabetes ( ketoacidosis ) special rules which are taught with the training apply.

History of insulin therapy

At the start of insulin therapy, there were only animal insulins with the duration of action of regular insulin of approximately 4-7 hours. Furthermore, blood glucose self- tests were not feasible for many years, so that one had to make do in outpatient medicine for many years with urine glucose monitoring. These show only naturally very delayed and indirectly to the concentration of blood glucose. Due to the short duration of action of insulin you strove to achieve a simplification for the diabetic. Hans Christian Hagedorn, a Danish researcher, developed in 1936 from protamine and porcine insulin, the first long-acting insulin product, which is still used under the name of Neutral Protamine Hagedorn or NPH insulin today ( just not in conjunction with insulin from animal products. )

The increasing improvement of blood glucose self- testing allowed the diabetics in ever greater extent, to take their therapy on their own responsibility. In the seventies of the 20th century could be determined with the help of color changes of wetted with blood test strips relatively accurately the blood sugar level. Then the first handy electrical appliances, which indicated the value after a few minutes came. Today the times are up less than 5 seconds for the measurement process.

Accompanying the improved techniques loosened and the treatment regimen combined in the first decades hardly freedoms in the diet with little freedom of choice of the patient. Today, the patient is asked to manage his therapy, ideally with almost complete freedom in the diet independently. And from the necessary 6-8 times daily administration of insulin is often the therapy become with an insulin pump, the needle only once every 2-3 days must be changed.

An important milestone for the self-responsible therapy was the DCCT study, in addition to other studies provided evidence that the self- intensified insulin therapy benefits offered with regard to the prevention of late complications.

Regulation of therapeutic goods Gestational diabetes Chronic Somogyi rebound Angiopathy Chronic kidney disease Glycosuria protamine sulfate

413991