Page 27 - The SA Journal Diabetes & Vascular Disease Volume 9 No 4 (November 2012)

VOLUME 9 NUMBER 4 • NOVEMBER 2012 169
SA JOURNAL OF DIABETES & VASCULAR DISEASE HANDS ON
Tony needs to be given information on:
The type and dose of insulin being prescribed •
The method of injecting insulin •
How to recognise and deal with hypos •
How to do home blood glucose testing •
How to dispose of sharps •
How to adjust his insulin dose according to his •
individual needs •
How to adjust his treatment if he is unwell •
How insulin therapy might affect his job and insurance •
Travelling when on insulin •
Driving when on insulin •
How to minimise the side-effects of insulin therapy •
Where to get ongoing information and support. •
UNDERSTANDING THE DIFFERENT TYPES OF INSULIN
Most insulin these days is human insulin, which is not actually obtained
from humans but is either human insulin produced by other cells (e.g.
yeast cells) in laboratories or a synthetic adaptation of human insulin (an
analogue), which has been modified to determine its duration of action –
either long-acting or rapid-acting insulin. The Diabetes UK website www.
diabetes.org.uk has a clear explanation of the different types of insulin
currently available. These include:
Rapid-acting insulin analogues, which can be injected just before, •
with, or after food because they only last long enough to work on the
meal at which they are taken. These insulins tend to last between
two and five hours, with a peak action of anywhere from immediately
after administration to three hours.
Short-acting insulins, which are injected up to 30 minutes before a •
meal to cover the rise in blood glucose levels that occurs with that
meal. They have a peak action of two to six hours but can last for up
to eight hours.
Medium- and long-acting insulins, which are taken once or twice a day •
to provide background insulin. These are often used in combination
with short-acting insulins or rapid acting analogues Their peak activity
is between four and 12 hours but they can last up to 30 hours.
Mixed insulin, which consists of a combination of medium- and •
short-acting insulin.
Mixed analogue, which consists of a combination of medium-acting •
insulin and rapid-acting analogue.
Long-acting analogues, which are usually injected once a day to pro- •
vide a constant supply of insulin over 24 hours. They don’t need to
be timed to coincide with meals because they act slowly, without a
peak, throughout the day.
There are lots of important considerations when choosing an insulin regi-
men for an individual patient. Optimising glucose control is clearly impor-
tant, but quality of life is also an issue. These factors will influence the
decision to put Tony on:
• a once-a-day injection of long acting insulin to minimise the number
of injections needed and to reduce the risk of hypoglycaemic epi-
sodes (hypos)
• a once, twice- or three-times-a-day premixed insulin injection regi-
men, or
• a basal bolus regimen with one injection of a longer-acting insulin to
provide a continuous stream of insulin into the blood, which is backed
up with extra injections of short-acting insulin to cope with meal-time
blood glucose peaks.
DECIDING ON THE APPROPRIATE INSULIN DOSE
In line with other drugs, such as ACE inhibitors, the plan is to start low and
Tony has had type 2 diabetes for
15 years and, despite optimal
treatment with oral hypoglycaemic
agents and careful attention to
diet and activity levels, his HbA1c
is 9.4%. After careful discussion
regarding the pros and cons of
insulin therapy, Tony has agreed that it is the best way forward for
managing his diabetes.
How would you proceed with insulin initiation for Tony?
Equipment needed for starting a patient on insulin
• Pen device, with cartridge where
appropriate
• Needles
• Sharps box
• Leaflets about the injection
device, insulin type and dose
• Calibrated blood glucose meter
and test strips
• Lancet and finger-pricking device
• Diary to record readings if meter
does not do this
• Contact numbers.
Key steps in insulin initiation