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TREATMENT WITH INSULIN

Principles of Treatment

• Insulin injections are given to replace endogenous insulin in patients with absolute or relative deficiencies in insulin secretion.
• A balance must be maintained between the amount of carbohydrate consumed, insulin administered and exercise taken - all of which can affect the blood sugar.
• Self-monitoring and HbA1c measurements are advised to ensure treatment is effective and targets are met.
• Remember, prescriptions are free for all patients on oral hypoglycaemic drugs and insulin therapy.

Aims of Insulin Treatment

• Abolish hyperglycaemic symptoms
• Maintain ideal body weight
• Optimise glucose control
• Avoid hypoglycaemia
• Maintain as near normal a blood glucose as is practical and safe for the individual.

Starting insulin is best managed as an outpatient, with input from a Diabetes Specialist Nurse.

INSULIN THERAPY IN TYPE 1 DIABETES

Patients are usually seen urgently after the diagnosis is made and insulin started, preferably as an out-patient, with input from one of the Diabetes Specialist Nurses.

INSULIN THERAPY IN TYPE 2 DIABETES

The most common indication for insulin in these patients is worsening glycaemic control on oral agents. The decision to switch treatment to insulin can be difficult and the following factors should be taken into account:

• Age
• Other health problems, e.g. complications such as visual loss
• Social circumstances, e.g. patients holding HGV licence
• Patient's attitude
• Compliance with diet
• Patient's weight

In general, obese patients who are not losing weight despite hyperglycaemia do not fare better on insulin. However a trial of insulin is justified in any patient with Type 2 diabetes who is poorly controlled and has osmotic symptoms

A frequent problem encountered in treating those with Type 2 diabetes is the inevitable gain in weight after starting insulin. On average, this is around 4 kg after 6 months. Patients should be warned that this might occur particularly if they fail to reduce energy intake. Often patients continue on Metformin, where possible in an to attempt to reduce weight gain with starting insulin (see below)

Combination Therapy: Insulin & OHA's

• A combination of insulin and oral hypoglycaemic agents can be used. This is most often reserved for obese Type 2 patients.
• The most common combination regimen is with Metformin, used as an insulin-sparing agent.
• Occasionally patients can be advised to continue with daytime oral agents and are started on a single pre-bedtime insulin injection (usually an Isophane preparation).
• At present, insulin combined with a "Glitazone" is contra-indicated

The decision to use combined insulin and oral therapy is usually taken after consultation with the specialist diabetes team.

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