Diabetis and New Insulins

 

What are the different types of insulin?
There are several types of insulin. They are classified by how fast they work and how long they continue to work in the body. They include:

Mealtime (or “bolus”) insulin: Short-acting insulins given before meals to control the rise of blood sugar levels after eating. They are usually given in combination with basal (long-acting) insulin:
1. Short-acting: Regular insulin
2. Rapid-acting: Lispro, aspart, glulisine

Basal insulin: Controls blood sugar levels between meals and throughout the night. This is usually given once daily and can be used alone or in combination with oral anti-diabetic medications or rapid-acting insulins:
1. Intermediate acting: NPH
2. Long acting: Glargine and detemir

Pre-mixed—Combination of bolus and basal insulins. Controls blood sugar levels after and between meals. These are usually given twice daily before breakfast and dinner. They can be used alone or in combination with oral medications.

The type of insulin your doctor prescribes will depend on the type of diabetes you have, your lifestyle (e.g., foods you eat, how much you exercise), your age, your body’s response to insulin, and how often you are able or willing to check your blood sugar and give yourself injections.

What are the “new” insulins?

In recent years, scientists have developed new products called insulin analogues or “designer” insulins. These have been genetically engineered to better match the insulin produced by your body (or pancreas).

Insulin analogs have been shown to make it easier to control blood glucose. By controlling and preventing blood sugar swings, namely hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose) they may reduce the risk of diabetic complications and improve quality of life for people with diabetes.

Same as traditional insulins, the new insulin analogs are taken by injections with a syringe, an insulin pen or an insulin pump. Injectable products include long-acting, basal insulins (e.g., glargine and determir) and rapid acting, bolus insulins (e.g., lispro, aspart, and glulisine).

Some of the new insulins have not yet been approved for use during pregnancy. If you have gestational diabetes, talk with your doctor to see what may be the best insulin for you.

Choosing an insulin delivery device

If your diabetes treatment plan includes insulin therapy, you can choose between various insulin delivery devices.

Syringe and needle

Many people choose to inject insulin with disposable syringes and needles. You withdraw insulin from a bottle into a syringe, and then inject the medication in the layer of fat under your skin — often in the abdomen. Insulin syringes come in various sizes to match insulin dosage. Needles also come in varying lengths.

• Pros: Disposable syringes and needles are inexpensive. Injections are quick, once you get the hang of it. Syringes with large print are available if needed.
• Cons: Withdrawing insulin from a bottle may not be discreet, and it's challenging if you don't see well or your fingers are numb, stiff or shaky.

Refillable insulin pen
Refillable insulin pens have the same features as disposable pens. But instead of discarding the pen when it's out of insulin, you replace the insulin cartridge yourself. When you're not using the pen, you protect the insulin cartridge with a cover that looks like the top of an ink pen.

• Pros: Refillable insulin pens are convenient, discreet and easier to use than a syringe and needle. They're especially useful for people who use very low doses of insulin.
• Cons: Refillable insulin pens cost about the same as disposable insulin pens, but more than syringes and needles. You may need to give yourself two injections if you use more than one type of insulin.

 

Disposable insulin pen

A disposable insulin pen resembles an ink pen. The cartridge is pre-filled with insulin, and the tip is a needle. You turn a dial to mark the amount of insulin you need and press a plunger to inject the insulin. You attach a new needle for each injection. When the insulin is gone, you discard the entire pen.

• Pros: Disposable insulin pens are convenient, discreet and easier to use than a syringe and needle.
• Cons: Disposable insulin pens cost more than syringes and needles. You may need to give yourself two injections if you use more than one type of insulin.

Insulin pump

An insulin pump can help you manage your diabetes. By using an insulin pump, you can match your insulin to your lifestyle, rather than getting an insulin injection and matching your life to how the insulin is working. When you work closely with your diabetes care team, insulin pumps can help you keep your blood glucose levels within your target ranges. People of all ages with type 1 diabetes use insulin pumps and people with type 2 diabetes have started to use them as well.

How do insulin pumps work?

 

An insulin pump delivers infusions of insulin through a catheter placed in the layer of fat under the skin.

Insulin pumps deliver rapid- or short-acting insulin 24 hours a day through a catheter placed under the skin. Your insulin doses are separated into:

Basal insulin, which is delivered continuously over 24 hours, and keeps your blood glucose levels in range between meals and overnight. Often, you program different amounts of insulin at different times of the day and night.
Bolus doses to cover carbohydrate in meals, when you eat, you use buttons on the insulin pump to give additional insulin called a bolus. You take a bolus to cover the carbohydrate in each meal or snack. If you eat more than you planned, you can simply program a larger bolus of insulin to cover it.
Correction or supplemental doses, you also take a bolus to treat high blood glucose levels. If you have high blood glucose levels before you eat, you give a correction or supplemental bolus of insulin to bring it back to your target range.

Where to put the insulin pump?

Insulin pumps come in different types, shapes, colors, and features. They are approved for use in children, adults and pregnant women.

Knowing how an insulin pump works is one thing. But you may be wondering where you are supposed to put it. You can buy a pump case or it can be attached to a waistband, pocket, bra, garter belt, sock, or underwear. You can also tuck any excess tubing into the waistband of your underwear or pants.

When you sleep, you could try laying the pump next to you on the bed. You could even try wearing it on a waistband, armband, legband, or clip it to the blanket, sheet, pajamas, stuffed toy, or pillow with a belt clip.

Showering and bathing are other instances when you should know where to put your insulin pump. Although insulin pumps are water resistant, they should not be set directly in the water. Instead, you can disconnect it. All insulin pumps have a disconnect port for activities, such as swimming, bathing, or showering. Some pumps can be placed on the side of the tub, in a shower caddy, or in a soap tray. There are also special cases you can buy. You can hang these cases from your neck or from a shower curtain hook.

No matter what you may think, you can still have fun when you are using an insulin pump. When you exercise or play sports, you can wear a strong elastic waist band with a pump case. You can also wear it on an armband where it is visible. Women can tape the insulin pump to the front of their sports bra. Some coaches do not allow any devices to be worn because getting the pump knocked into you or falling on it can be painful. In this case, you may just need to take the insulin pump off.

When you disconnect your pump, you are stopping all delivery (basal and bolus) by the pump. Here are some important tips to remember when disconnecting your pump.

It is important for you to remember that if you stop your pump while it is in the middle of delivering any bolus -- it will NOT be resumed. You may need to program a new one.
Be sure to bolus to cover the basal rate you will miss. If your blood glucose level is under 150, you can wait an hour to bolus.
Do not go longer than one to two hours without any insulin.
Monitor your blood glucose every three to four hours.

Now that you know how the insulin pump works and how to wear it, take a look at some of the facts to see if this is right for you.

Advantages of Using an Insulin Pump
Some advantages of using an insulin pump instead of insulin injections are:

• Eliminates multiple daily insulin injections
• Delivers insulin more accurately than injections
• Insulin pumps often improve A1C
• Usually results in fewer large swings in your blood glucose levels
• Makes diabetes management easier – if your glucose level is high or you feel like eating, figure out how much insulin you need and push the little button on the pump
• Allows you to be flexible about when and what you eatCan improve your quality of life
• Reduces severe low blood glucose episodes
• Eliminates unpredictable effects of intermediate- or long-acting insulin
• Allows you to exercise without having to eat large amounts of carbohydrate

Although there are many good reasons as to why using an insulin pump can be an advantage, there are some disadvantages.

Disadvantages of Using an Insulin Pump
The disadvantages of using a pump are that it:

• Can cause weight gain
• Can cause diabetic ketoacidosis (DKA) if your catheter comes out and you don’t get insulin for hours
• Can be expensive
• Can be bothersome since you are attached to the pump most of the time
• Can require a hospital stay or maybe a full day in the outpatient center to be trained

There are pluses and minuses to using a pump. Even though using an insulin pump has disadvantages, most pump users agree the advantages outweigh the disadvantages.

Getting Started
Once you have talked with your diabetes care team and have become comfortable with all of the options on your insulin pump, you and your team will need to determine how much insulin to use in the insulin pump (basal rates, boluses, and corrections) by using certain formulas and calculations.

It may take several months to get comfortable with the pump. During those first months is the time to adopt some good habits. Here are some tips to help you adjust:

Take your insulin at a specific time, such as five minutes before you eat, so you don't forget boluses.
When traveling anywhere, bring extra supplies or at least an insulin pen, in case you are unable to use your pump for some reason.
With an insulin pump, when you eat, what you eat, and how much you eat is up to you. You can eat more carbohydrate and still manage your blood glucose, but weight gain can happen. Talk to a dietitian about this when you start on the pump. It's a lot easier to not to gain weight, than it is to lose it after you have already gained it.
When you take the insulin pump off or turn it off, figure out a system to remember to turn it back on. Listen to the alarms on the pump or set a timer!
Make a habit of recording blood glucose checks, carbohydrate amounts, carbohydrate doses, correction doses, and exercise when you do them. It really helps to sit down and look over your blood glucose record at the end of every week (or even every day) to see if you have any problem areas. Reviewing your records is the key to improving blood glucose control.

Your diabetes care team has record forms, or you can make your own. Just be sure that you have enough room to record everything you need. Keeping daily records is best, but some people find keeping records for two weekdays and one weekend day gives enough information to see the patterns.

This is a lot of information. Fortunately, you don't need to be an expert on insulin pumps overnight. If you are uncertain about anything, you can go to your diabetes care team for help. Everyone learns at a different pace and it is okay if it takes you a while to get the hang of it.

Resources

• American Diabetes Association: www.diabetes.org
• National Diabetes Education Program (NIH): http://ndep.nih.gov
• National Diabetes Information Clearinghouse (NIDDK): http://diabetes.niddk.nih.gov/