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W. M. Bortz II, “Disuse and Aging,” Journal of the American Medical 6. American College of Sports Medicine, ACSM's Guidelines for Exercise Testing and.

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The range of overall insulin requirements is very wide. No one knows if you need 30 units per day or When your doctor gives you insulin, he or she tries to give you as much as your own pancreas used to secrete before it failed. To know how much insulin you need, your doctor typically starts with a low dose and goes up gradually.

Thus, many adjustments will be required before your doctor knows how much insulin to give you. Your insulin requirements constantly change. Over time, you may need a different dosage. To make insulin therapy effective and safe, you may need a dosage adjustment about every week. Companies have developed technologies that enable insulin dosage to be as dynamic as needed to make it effective for you.

In summary, it is not your fault that you need insulin therapy. It is just another mode of therapy that you need when your pancreas fails. The main challenge is to adjust your dosage frequently. Fortunately, solutions are becoming available to facilitate this. Screen music and the question of originality - Miguel Mera — London, Islington.

References

Edition: Available editions United Kingdom. Israel Hodish , University of Michigan. Insulin syringes. From www. So, your doctor told you that you need insulin therapy for your Type 2 diabetes. Insulin therapy for Type 2 diabetes Diabetes is a condition in which your pancreas fails to secrete a sufficient amount of insulin to help you to maintain normal blood glucose, or sugar in the blood, which is transported to various parts of our bodies to supply energy. Keeping glucose levels at the therapy goal is essential Injections of insulin become necessary for many diabetics.

Frequent adjustments of insulin dosage is critical The problem is not with the patient or the doctor. Type 2 diabetes Insulin Pancreas. Exclusion criteria were 1 studies that are not published in English language and 2 studies that did not have full papers. Soon after the discovery of insulin in the early s, both patients and health workers looked at this as a step towards the cure of diabetes, despite that insulin was a replacement therapy with no curative effects on the chronic state of diabetes [ 57 ].

This desire for a cure of diabetes is still a concern for many patients with diabetes; and for many of them, insulin therapy belongs to the category of just a Band - Aid solution. This, unfortunately, impacts negatively on insulin therapy.

Insulin (medication) - Wikipedia

In spite of this, insulin therapy over the years has been revolutionized, leading to new improved formulations on the market, and devices to administer and monitor its effect [ 58 ]. Some insulin analogues are available in pharmacies in East Africa, but are not yet on the purchase lists of governments; patients have therefore to pay out-of-pocket to access them. Moreover, their use worldwide is associated with increased cost of managing diabetes and they are thus further discouraged in low-income areas like East African countries [ 59 ].

Consequently there is no subsidy on these insulins and the full cost has to be borne by the patient.

insulin therapy in diabetes

There is no published data on insurance with regards to insulin prescribing in East Africa but information obtained from dispensing pharmacies indicates that insurance companies do cover the costs when insulin analogues are prescribed. Recommendations Basal-bolus insulin therapy is a standard of care in management of diabetes in T1DM Grade A, EL I For T1DM patients with minimal metabolic decompensation minimal dehydration, fully conscious initiation starts with initial dose ranging from 0.

An algorithm showing the OADs leading to insulin is depicted in Fig. The lower incidence of major and nocturnal hypoglycemia and flexibility of administration with premix insulin analogues have made this regimen a better choice over human premix insulins when initiating insulin therapy. In both cases, continue metformin and administer premix just before meals Modified from [ 54 ]. Newer insulin co-formulations are associated with fewer hypoglycemic episodes Grade B, EL I Match the insulin dose to carbohydrate intake Grade A, EL II Counseling on scheduling regular blood glucose monitoring and awareness of hypoglycemic symptoms and their management are recommended to all patients initiating with insulin.

Titration Target for FPG level is 4. These targets can be individualized on the basis of the risk of hypoglycemia and the urgency for glycemic control Grade A, EL I Titration should be done at regular and short intervals to attain glycemic goals without causing hypoglycemia Grade A, EL I. As a result of progressively diminishing insulin secretory capacity, more patients with T2DM may require prandial insulin therapy in addition to the existing one or two doses of insulin.

Insulin analogues give better PPG control than human Regular insulin. Furthermore, an analogue-based basal-bolus regimen may be preferred over human basal-bolus regimen considering the significantly lower risk of nocturnal hypoglycemia and better outcomes in patients with T2DM [ ]. Intensification Intensification of insulin therapy should be considered when patients fail to achieve glycemic goals even after optimal dose titration Grade A, EL I Intensification with premix insulin twice daily or thrice daily, insulin co-formulation-based regimen, prandial insulin basal plus or basal bolus with the largest meal of the day, or GLP-1 RA.

Consider antihyperglycemic therapy with low risk of hypoglycemia in elderly patients who are at increased risk of hypoglycemia Grade A, EL II Consider once-daily basal insulin injection regimen over multiple daily insulin injection regimen to reduce the risk of hypoglycemia if glycemic goals can be achieved within the individualized HbA1c target Grade B, EL II.

Consider using insulin analogues in renal impaired patients with diabetes for improved glycemic control with low risk of hypoglycemia Grade B, EL II Frequent blood glucose monitoring and dose adjustments are recommended in chronic renal failure CRF diabetic patients when they are treated with insulin Grade B, EL II. Choice of insulin regimen and preparation should be based upon cost, severity of hyperglycemia, risk of hypoglycemia, and likelihood of interventional procedure in near future Grade B, EL II Patients with T2DM on combination therapy of premixed insulin analogues and OADs should be carefully monitored for signs and symptoms of heart failure HF , weight gain and edema, and a prompt clinical action is recommended if any deterioration in cardiac symptoms occurs Grade B, EL II.

This poses a risk of hypoglycemia, hyperglycemia, ketoacidosis, dehydration, and thrombosis [ ]. Insulin therapy in religious fasting requires that the patient is educated on the risks posed by fasting, is familiar with SMBG, adheres to appropriate nutrition intake, proper exercise, and dose adjustment to minimize complications [ ]. East Africa is lacking in studies to describe the characteristics and multiple approaches to the management of people with diabetes who fast during Ramadan and other religious fasts.

Insulin Therapy

Premix insulin analogues have proven efficacy and safety profile with lower rates of hypoglycemia and hence are preferred over premix human insulins in patients with insulin therapy during religious fasting periods [ , , , ]. Insulin glargine has been safely used in fasting Muslim T2DM patients [ ]. If a patient is taking NPH or premix insulin at suhoor , it is important to check blood glucose at noon before up-titration of the pre- suhoor dose.

For those on insulin and SU, a decision on the need to reduce doses of both agents or to start with insulin only is required on the basis of individual assessment. Use of insulin lispro and insulin pumps was reported to be safe in fasting T1DM [ , ]. Malaria and other acute febrile illnesses AFI are frequent causes of fever in patients with diabetes who reside in East Africa.

Hyperglycemia may follow any AFI but equally hypoglycemia has been encountered in malaria and sepsis [ , ].

EDITOR DISCLOSURES AT TIME OF PUBLICATION

In addition, hyperglycemia in patients with AFI may be secondary to medications administered e. Quinine administration has been associated with hypoglycemia [ ]. The overall goal is to avoid hypoglycemia [ ] and to minimize glycemic variability. An increased prevalence of hyperglycemia, insulin resistance, diabetic dyslipidemia, and lipodystrophy has been reported in diabetes patients with HIV infection [ ].

Majority of patients presenting with comorbid diabetes and hyperglycemic may be managed as T2DM, taking into consideration comorbidity of infections [ ]. Thiazolidinediones and DPP-4 inhibitors are also used in patients with HIV Use incretin mimetics if weight loss is desired Insulin Initiate basal-bolus regimen or premixed insulin 1. Hypoglycemia Medications that are associated with the highest risk of injury when used in error are known as high-alert medications.

Weight Gain Insulin therapy is associated with increase in body weight [ ]. Psychosocial Aspects Psychosocial barriers to successful insulin therapy in East Africa include lack of physician—patient interaction, understanding of diabetes and its treatments by both physicians and patients, and proper provision of testing and follow-up of patients [ ]. Mental Illness Evidence on the association between poor glycemic control and comorbid depression among T2DM patients in East Africa has shown that most T2DM patients with poor glycemic control witnessed further worsening of glycemic control with increasing depression.

Treatment for Non-critically Ill Patients Insulin is the preferred treatment for glycemic control in critically ill patients [ ]. Recommendations Consider using basal plus bolus correction insulin regimen, with the addition of meal-related insulin in patients who have good nutritional intake, in non-critically ill patients Grade A, EL I Avoid sliding scale insulin in the inpatient hospital setting Grade A, EL I.

What is an intensive insulin regimen?

Correctional insulin coverage should be added as needed before each feeding. Correctional insulin should be administered SC. Insulin Delivery Devices Insulin can be administered via various methods such as vial and syringe, insulin pen, jet injectors, and continuous subcutaneous insulin infusion CSII using insulin pumps.

Lack of refrigeration facilities at home may force patients to use improvised cooling systems such as storing insulin vials submerged in water or keeping insulin in a pot with sand [ ]. These should be used with caution as they may result in contamination of insulin and subsequent injection abscesses. The patient also overslanted the needle.

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Insulin therapy in type 2 diabetes

This is necessary to prevent medication leakage so as to get the full dose Grade A, LE I Many patients in East Africa reuse syringes for various reasons, including financial. Pens and syringes with needles used in this setting should have protective mechanisms for all sharp ends of the delivery device Grade A, LE II The health care worker should be involved in the training of the patient and safe disposal of sharps Grade A, LE I.

Recommendation In switching from one insulin to another similar insulin original to biosimilar it is advised to carry out a dose titration always starting with a reduced dose and to up-titrate to avoid hypoglycemia. Economic Consideration The high negative impact of diabetes on the economy of individuals, families, societies, and countries has been well established [ 2 ]. Acknowledgements Funding No funding or sponsorship was received for this study or publication of this article.


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