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Starting On Insulin In Type 2 Diabetes

Starting On Insulin In Type 2 Diabetes

Tweet If type 2 diabetes develops, your body’s ability to produce sufficient insulin may decrease and it may be appropriate to take insulin injections to control your diabetes. Some people may be apprehensive about switching onto insulin injections. Benefits of insulin injections Insulin is a stronger medication for lowering blood glucose levels and can help with the following aspects: Decrease the effects of symptoms of high blood sugar, such as fatigue and frequent need to urinate Reduce the risk of developing diabetic complications Decrease pressure on the pancreas to produce insulin Disadvantages of being on insulin injections Raises the risk of hypoglycemia Can promote weight gain Some people may be uncomfortable about injecting Could affect employment if you drive for a living The needles used for insulin injections are very slim and many people who start injections are surprised by how painless the needles are. How many injections will I need to take each day? A number of different injection regimes are available, ranging from one injection a day to multiple injections a day. Your health team will be able to help you to choose an injection regime that best fits in with your lifestyle. Learning to inject Your health team should instruct you on injection technique to ensure insulin is delivered correctly. Watch a video on how to inject insulin Blood glucose testing People starting insulin therapy may need to regularly test their blood sugar levels to monitor the effect that insulin is having and to help prevent low glucose levels (hypoglycemia) from happening. Watch our video on how to perform a blood glucose test Insulin therapy and hypoglycemia Insulin is a powerful medication for lowering blood glucose levels and can cause blood glucose levels to go too low if Continue reading >>

Insulin Therapy In Type 2 Diabetes Mellitus: A Practical Approach For Primary Care Physicians And Other Health Care Professionals

Insulin Therapy In Type 2 Diabetes Mellitus: A Practical Approach For Primary Care Physicians And Other Health Care Professionals

The responsibility of diabetes management and insulin therapy has definitively moved to primary care physicians. Within the primary care setting, there is a growing need for clear, evidence-based guidelines related to the management of insulin therapy. Straightforward algorithms regarding insulin initiation, titration, and follow-up management can help physicians effectively treat patients with type 2 diabetes mellitus. Once 2 oral diabetic drugs have failed in a patient whose disease duration is 7 to 10 years, use of insulin therapy with a basal insulin analog should be considered. For patients who receive maximal basal insulin doses without reaching fasting blood glucose and target glycated hemoglobin levels with basal insulin analogs, a mealtime-insulin intensification approach should be considered. The authors discuss how simplified insulin initiation and titration regimens allow primary care physicians and other health care professionals to care for patients with type 2 diabetes mellitus. Diabetes affects 25.8 million people in the United States; most (90-95%) adults with a diagnosis of diabetes have type 2 diabetes mellitus (T2DM).1 Primary care physicians (PCPs) deliver approximately 90% of diabetes care in the United States.2 Type 2 diabetes mellitus is characterized by progressive β-cell failure and increasing difficulty in maintaining glycemic control.3,4 Even with multiple oral antidiabetic drugs, many patients need insulin therapy to achieve and maintain glycated hemoglobin (HbA1c) target levels.4 The intensification of diabetes treatment—that is, the transition from oral antidiabetic drugs to injectable treatments such as insulin—is often delayed in many patients, which substantially increases the risk of diabetes-related complications.5-10 In a popula Continue reading >>

Insulin Therapy For Type 2 Diabetes

Insulin Therapy For Type 2 Diabetes

A number of landmark randomized clinical trials established that insulin therapy reduces microvascular complications (1,2). In addition, recent follow-up data from the U.K. Prospective Diabetes Study (UKPDS) suggest that early insulin treatment also lowers macrovascular risk in type 2 diabetes (3). 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. In this presentation, we will give an overview of the evidence on the various insulin regimens commonly used to treat type 2 diabetes. Secondary analyses of the aforementioned landmark trials endeavored to establish a glycemic threshold value below which no complications would occur. The UKPDS found no evidence for such a threshold for A1C, but instead showed that better glycemic control was associated with reduced risks of complications over the whole glycemic range (“the lower the better”) (4). For the management of type 2 diabetes, this resulted in the recommendation to “maintain glycemic levels as close to the nondiabetic range as possible” (5). 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 (2). Moreover, the intensive glycemia treatment arm of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study, targeting A1C <6.0%, was discontinued because of higher mortality in this group compared with the standard therapy group targeting A1C from 7.0 to 7.9% (6). Therefore, the American Diabetes Association (ADA) recommendation of an A1C target <7.0% seems the most balan Continue reading >>

Initiating Insulin In Type 2 Diabetes

Initiating Insulin In Type 2 Diabetes

Serge Jabbour, MD, and Dhiren Patel, PharmD, discuss the need for adding insulin therapy to a regimen for patients with type 2 diabetes mellitus. Serge Jabbour, MD: The question I get all the time is when to start insulin in a patient with type 2 diabetes. We typically follow the ACE guidelines. The guidelines say any patient with type 2 diabetes with an A1C level of more than 9% should be considered for insulin. Now, they say, should be considered. Its not that they must. The only time I would say its a must is if I see a patient with type 2 diabetes in a catabolic state, no matter what the A1C level is. A1C could be at 9.5%, 10%, or 12%, but they are losing weight at the same time without trying to lose weight. That means they are burning fat and muscle because if you lack insulin, that has a catabolic effect. When they are losing weight in the face of high A1C, then we have to start insulin right away if they are not in a catabolic state. It depends on every patient. It depends on how many drugs theyre on already; it depends on how high the A1C level is; it depends on if its high fasting or high postprandial, if both are high; and it depends on if we can maybe use other medications before we start insulin. Ill give you a quick example. If you have a patient whos on metformin and SU (sulfonylurea), but they have impaired kidney function, that means we cannot use SGLT2 inhibitors. They had gastroparesis. We cannot use a GLP1 receptor agonist. Their A1C level is 8.8%. Then my best choice is to add a basal insulin. So, it depends on every case. Its not a standard, and its more based on each individual. Dhiren Patel, PharmD: When it comes to insulin therapy, there are a lot of preconceived notions from the patient perspective. Many think that if Im starting insulin, my c Continue reading >>

Initiating Insulin: How To Help People With Type 2 Diabetes Start And Continue Insulin Successfully

Initiating Insulin: How To Help People With Type 2 Diabetes Start And Continue Insulin Successfully

International Journal of Clinical Practice Int J Clin Pract. 2017 Aug; 71(8): e12973. Published online 2017 Jul 23. doi: 10.1111/ijcp.12973 Initiating insulin: How to help people with type 2 diabetes start and continue insulin successfully 1 Behavioral Diabetes Institute, San Diego, CA, USA, 2 Department of Psychiatry, University of California San Diego, San Diego, CA, USA, 3 CIUSSSJewish General Hospital Endocrinology, Montreal, QC, Canada, 4 Family and Community Medicine, University of California School of Medicine, San Francisco, CA, USA, 5 Family Medicine, University of California School of Medicine, Irvine, CA, USA, 6 High Lakes Health Care, Bend, OR, USA, 7 Innovative Health Care Designs, Minneapolis, MN, USA, 8 Department of Diabetology and Internal Medicine, Warsaw Medical University, Warsaw, Poland, 9 Western Center For Public Health and Family Medicine, Western University, London, ON, Canada, 10 Research Institute of Diabetes Academy Mergentheim (FIDAM), Bad Mergentheim, Germany, 11 Diabetologische Schwerpunktpraxis, Hamburg, Germany, 12 Eli Lilly and Company, Indianapolis, IN, USA, Author information Copyright and License information Copyright 2017 The Authors International Journal of Clinical Practice Published by John Wiley & Sons Ltd This is an open access article under the terms of the Creative Commons AttributionNonCommercialNoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is noncommercial and no modifications or adaptations are made. With the growing incidence of type 2 diabetes worldwide, healthcare professionals (HCPs) find an increasing proportion of their time devoted to the management of diabetes. Because this condition is chronic and characterised by progressive decreases in Continue reading >>

Insulin Management Of Type 2 Diabetes Mellitus

Insulin Management Of Type 2 Diabetes Mellitus

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 replacement 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 insulin. Replacement therapy includes basal-bolus insulin and correction or premixed insulin. Glucose control, adverse effects, cost, adherence, 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 bolus insulin, and weight gain was more common with bolus insulin. Titration of insulin over time is critical to improving glycemic control and preventing diabetes-related complications. Insulin is secreted continuously by beta cells in a glucose-dependent manner throughout the day. It is also secreted in response to oral carbohydrate loads, including a large first-phase insulin release that suppresses hepatic glucose production followed by a slower second-phase insulin release that covers ingested carbohydrates 1 (Figure 12). Clinical recommendation Evidence rating References Analogue insulin is as effective as human insulin but is associated with less postprandial hyperglycemia and delayed hypoglycemia. A 17–19 Fasting glucose readings should be used to titrate basal insul Continue reading >>

The Introduction Of Insulin In Type 2 Diabetes Mellitus

The Introduction Of Insulin In Type 2 Diabetes Mellitus

Eddy Tabet Background Conservatively, over 1 million people have been diagnosed with diabetes mellitus in Australia, the majority with type 2 diabetes mellitus (T2DM). Until the progressive decline in pancreatic beta cell function, which characterises T2DM, can be meaningfully halted, most of these patients will require insulin therapy to maintain optimal glycaemic control over time. Objective/s The aim of this article is to provide a pragmatic overview of when and how to initiate insulin therapy for T2DM in a primary care setting. Discussion Current Australian guidelines recommend initiating insulin therapy as once daily basal therapy or as premixed insulin. Com-mencement and titration of either insulin in T2DM can be conducted safely in an ambulatory care setting and it is ideal that gen-eral practitioners become familiar with this, particularly in the context of the number of people affected. For the majority with type 2 diabetes mellitus (T2DM), insulin therapy will be required to maintain optimal glycaemic control over time.1 The general practitioner (GP) plays a vital part in the care of patients with T2DM using insulin. This article provides a pragmatic overview of introducing insulin therapy in T2DM. The pathophysiology of T2DM The core pathophysiological defects leading to the development of T2DM are insulin resistance in muscle and liver cells, resulting in decreased glucose uptake and increased hepatic glucose output, coupled with failure of pancreatic beta cells to produce sufficient insulin to maintain normoglycaemia and to prevent adipose fatty acid release. This ‘glucolipotoxicity’ leads to further impairment of the beta cells, and a progressive cycle of beta cell dysfunction and metabolic decline. Although these processes are not necessarily the only Continue reading >>

10 Tips For Starting Insulin Therapy

10 Tips For Starting Insulin Therapy

Finding out that you need to start taking insulin for your type 2 diabetes may cause you to become concerned. Keeping your blood sugar levels within target range takes a bit of effort, including eating a healthy diet, exercising, and taking your medications and insulin as prescribed. But while it may sometimes seem like a hassle, insulin can help you properly manage your blood sugar, improve your diabetes management, and delay or prevent long-term complications such as kidney and eye disease. Here are 10 tips for how to make your transition to using insulin easier. 1. Meet with your healthcare team Working closely with your healthcare team is the first step to starting on insulin. They’ll discuss the importance of taking your insulin exactly as prescribed, address your concerns, and answer all of your questions. You should always be open with your doctor about all aspects of your diabetes care and overall health. 2. Put your mind at ease Starting to use insulin isn’t as challenging as you might think. Methods for taking insulin include pens, syringes, and pumps. Your doctor can help you decide what’s best for you and your lifestyle. You might need to start on long-acting insulin. Your doctor may also recommend mealtime insulin to help manage your blood sugar levels. It’s possible that you may switch to a different insulin delivery device. For example, you may start out using an insulin pen and eventually begin to use an insulin pump. When it comes to your insulin or your insulin delivery system, a one-size-fits-all plan doesn’t exist. If your current insulin regimen doesn’t work for you, discuss your concerns with your healthcare team. 3. Learn about insulin Your healthcare team can help you learn different aspects of diabetes self-care management. They can Continue reading >>

Insulin Therapy In Type 2 Diabetes Mellitus

Insulin Therapy In Type 2 Diabetes Mellitus

INTRODUCTION Type 2 diabetes is by far the most common type of diabetes in adults and is characterized by hyperglycemia and variable degrees of insulin deficiency and resistance. It is a common disorder whose prevalence rises markedly with increasing degrees of obesity. Treatment of patients with type 2 diabetes mellitus includes education, evaluation for microvascular and macrovascular complications, normalization of glycemia, minimization of cardiovascular and other long-term risk factors, and avoidance of drugs that can aggravate abnormalities of insulin or lipid metabolism. Weight reduction, diet, and oral medication (typically metformin) can all be used to improve glycemic control, although the majority of patients with type 2 diabetes fail to maintain glycemic targets after a successful initial response to therapy. The therapeutic options for such patients include adding a second or third oral agent or an injectable agent, including insulin, or switching to insulin. The role of insulin in achieving optimal glycemic control in patients with type 2 diabetes will be reviewed here. Options for initial therapy, options for the management of persistent hyperglycemia, and other therapeutic issues in diabetes management, such as the frequency of monitoring and evaluation for microvascular and macrovascular complications, are discussed separately. Continue reading >>

Initiating Insulin In Patients With Type 2 Diabetes

Initiating Insulin In Patients With Type 2 Diabetes

Type 2 diabetes has become a worldwide epidemic1 and is associated with multiple complications that can be prevented by modifying risk factors and optimizing glycemic control.2 The optimization of glycemic control often requires the use of multiple agents, including insulin. Insulin is an important component of anti-hyperglycemic therapy, yet there are many perceived barriers.3 Existing guidelines do not specifically address the topic of insulin initiation.4 We review and analyze the evidence from randomized controlled trials on insulin initiation and address adverse effects and barriers. We also discuss the selection of an insulin regimen, titration and delivery of care, as well as when and how to combine insulin therapy with oral antihyperglycemic agents. A summary of our systematic review and meta-analysis is available in Box 1. Box 1: We performed a systematic review of studies examining the effect of the initiation of subcutaneous insulin therapy on glycemic control, weight gain, risk of hypoglycemia, other adverse effects and diabetic complications in outpatients with type 2 diabetes. We excluded studies involving children, adolescents, or patients with type 1 diabetes or gestational diabetes, as well animal studies and trials of inhaled, intravenous, intraperitoneal or continuous subcutaneous insulin treatment. We focused on studies involving insulin-naive patients in the ambulatory care setting and excluded those comparing various insulin regimens in patients already taking insulin. Details regarding our search strategy and meta-analysis are included in Appendix 1.* We included 56 studies for quantitative review, and 39 studies and 3 systematic reviews for qualitative review (Appendix 2*). Study quality is summarized in Appendix 3.* All studies were randomized c Continue reading >>

Insulin Treatment For Type 2 Diabetes: When To Start, Which To Use

Insulin Treatment For Type 2 Diabetes: When To Start, Which To Use

Many patients with type 2 diabetes eventually need insulin, as their ability to produce their own insulin from pancreatic beta cells declines progressively.1 The questions remain as to when insulin therapy should be started, and which regimen is the most appropriate. Guidelines from professional societies differ on these points,2,3 as do individual clinicians. Moreover, antidiabetic treatment is an evolving topic. Many new drugs—oral agents as well as injectable analogues of glucagon-like peptide-1 (GLP1) and insulin formulations—have become available in the last 15 years. In this paper, I advocate an individualized approach and review the indications for insulin treatment, the available preparations, the pros and cons of each regimen, and how the properties of each type of insulin influence attempts to intensify the regimen. Coexisting physiologic and medical conditions such as pregnancy and chronic renal failure and drugs such as glucocorticoids may alter insulin requirements. I will not cover these special situations, as they deserve separate, detailed discussions. WHEN SHOULD INSULIN BE STARTED? TWO VIEWS Early on, patients can be adequately managed with lifestyle modifications and oral hypoglycemic agents or injections of a GLP1 analogue, either alone or in combination with oral medication. Later, some patients reach a point at which insulin therapy becomes the main treatment, similar to patients with type 1 diabetes. The American Diabetes Association (ADA), in a consensus statement,2 has called for using insulin early in the disease if lifestyle management and monotherapy with metformin (Glucophage) fail to control glucose or if lifestyle management is not adequate and metformin is contraindicated. The ADA’s goal hemoglobin A1c level is less than 7% for most Continue reading >>

Starting Insulin Treatment In Type 2 Diabetes

Starting Insulin Treatment In Type 2 Diabetes

Introduction The emerging epidemic of type 2 diabetes, coupled with finite health resources, requires the treatment of hyperglycaemia to be simple and efficiently managed. Type 2 diabetes is a progressive disease and eventually almost all patients will require insulin to maintain good glycaemic control. Knowing when and how to start insulin in general practice is central to the optimal management of type 2 diabetes. The need to start insulin therapy in a newly diagnosed patient with type 2 diabetes is relatively uncommon. It should be considered when there is considerable weight loss, severe symptoms of hyperglycaemia or the presence of significant ketonuria. Many of these patients can be converted back to oral drugs once glycaemic control has been established and there is some recovery of pancreatic β cell function. A more common problem is when and how to commence insulin in patients with type 2 diabetes who are in 'secondary failure'. The term secondary failure refers to the 'failure' of oral hypoglycaemic drugs to maintain glycaemic control. The United Kingdom Prospective Diabetes Study (UKPDS)1 clearly showed that most people with type 2 diabetes will experience progressive pancreatic β cell dysfunction, despite excellent control. The secondary failure rate in this study was 44% after six years of diabetes. Since the time of the UKPDS, targets for glycaemic control have become increasingly stringent so secondary failure of oral hypoglycaemic drugs now occurs much sooner and is almost invariable. The younger, the sooner, the better The key to when to start insulin is to identify the appropriate glycated haemoglobin (HbA1c) target for an individual patient. Despite the promulgation of various 'guidelines', there is no single HbA1c concentration which suits everyone Continue reading >>

Starting Your Patients On Insulin

Starting Your Patients On Insulin

The insulin pen start checklist and help sheet will guide you through the essential elements of an insulin start consultation, including such areas as cognitive assessment, insulin delivery, types of insulin, hypoglycemia, monitoring, driving and instructions for oral medications. Resources for patients Developed to complement the resources for health-care professionals, we have also prepared two easy-follow-guides for your patients, providing them with basic information to address common questions and concerns about starting on insulin. Thinking of starting insulin will help your patients as they learn about the opportunity to include insulin to help them manage their diabetes. Getting started with Insulin is a tool that will help diabetes health-care providers work together with their patients to start insulin, and build insulin therapy into their lives. Continue reading >>

Initiating Insulin For People With Type 2 Diabetes

Initiating Insulin For People With Type 2 Diabetes

Due to its progressive nature, many people with type 2 diabetes will eventually require insulin treatment. Insulin initiation is frequently managed in secondary care. However, New Zealand guidelines now recommend that insulin initiation for people with type 2 diabetes be managed in primary care where possible, with additional support as required. View / Download pdf version of this article Insulin depletion is probable over time Type 2 diabetes is a progressive disease characterised by insulin resistance and a decreasing ability of pancreatic β-cells to produce insulin. Both of these factors contribute to hyperglycaemia. Following lifestyle modifications, most patients with diabetes begin treatment with oral hypoglycaemic medicines. Over time, the efficacy of oral medication frequently diminishes. Treatment with insulin is eventually required, either alone, or more commonly in conjunction with oral medicines such as metformin. It is possible for people with insulin resistance to delay or, in some cases, even avoid the need for insulin treatment through exercise and significant weight loss, however, patients with type 2 diabetes should be made aware at an early stage of treatment, of the probability that they may require insulin in the future. Insulin initiation is often delayed Evidence is accumulating that in all developed countries, many people with diabetes are failing to meet glycaemic targets.1,2 As insulin has a greater blood glucose lowering ability than any other hypoglycaemic medicine, it is important that initiation of insulin treatment is considered in all patients with poor glycaemic control, following appropriate lifestyle changes and the use of oral hypoglycaemic medicines. In the United Kingdom, a large ten year population-based study of treatment practi Continue reading >>

Type 2 Diabetes: How To Start Insulin

Type 2 Diabetes: How To Start Insulin

Once-Daily Insulin May Be a Starting Point, Study Suggests Oct. 24, 2007 -- Do you have type 2 diabetes and need to start taking insulin ? Scientists have new insights on how you should do so. Taking insulin once daily at bedtime may be a first step, with fewer risks than other insulin -dosing strategies, a new study shows. Those findings are preliminary, so patients should ask their doctors what they recommend. But diabetes experts are certain of this: Get your hemoglobin A1c below 7% to cut your risk of heart attack , stroke , and other diabetes complications -- and if that means taking insulin, so be it. Your hemoglobin A1c number shows how well your blood sugar has been controlled for the past two to three months. The goal for hemoglobin A1c should be less than 7%. If type 2 diabetes patients can't reach that goal with a healthy lifestyle and oral medications , they may need to start giving themselves insulin shots. The new study included some 700 type 2 diabetes patients in the U.K. and Ireland. The patients were taking the maximum dose of the oral drug metformin (sold generically and as Glucophage ) and a class of diabetes pills called sulfonylureas, which include Glucotrol , Glucotrol XL, DiaBeta , Micronase , Glynase PresTab, Amaryl , Dymelor, Diabinese , Orinase , and Tolinase , But despite taking those diabetes drugs, the patients' hemoglobin A1c levels were still too high, measuring 7% to 10%. All of the patients started taking insulin, but they took it in one of three different ways: After taking insulin for a year, some of the patients met their hemoglobin A1c goal. That goal was met by 17% of the patients taking insulin twice daily, nearly a quarter of those taking insulin with meals, and 8% of those taking insulin once daily at bedtime . There was a fine Continue reading >>

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