pick up the syringe with your dominant hand and "throw" the
Fig. 19-2. Thedeltoidmuscle (arrow indicates preferred sitefor intramus cularinjection). Terry Eppridge
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needle straight into the injection site as you would a dart , but, of course, don't let go of the syringe.
Do not grab any flesh, as you do for subcutaneous shots.
Do not inject at an angle,but go in perpendicular to the skin.
Befast,as a slowintramuscular shot can hurt.
Push in the plunger rapidly to inject your insulin.
Now pull out the needle.
Touch the injection site with your finger, to make sure you have not bled. 5.
If the shot hurts, you probably hit a smallblood vessel, so be pre pared for some blood.
In such a case, press the injection site firmly with a finger.
Hold it there for about a minute.
This will prevent or stop any bleeding.
If you do not press, you will de velopa slightiypainfullump wherethe blood accumulatesunder the skin.
The lump will turn yellow or black and blue after a number of hours.
If you inject through your shirt or blouse and get it bloody,apply hydrogen peroxide,as described on page 261.
Once you have given a number of intramuscular shots using your dominant hand to operate the syringe,try switching hands and arms.
This mayseemcumbersome at first, but with practice you willbe able to inject into either arm.
"MIXED" THERAPY , INSULIN PLUS ISAs
As indicated previously, if you are still making some insulin and are insulin-resistant, you maybe able to take rosiglitazone instead of reg ular insulin before certain meals.
This will depend upon your post prandial blood sugar profile.There may be no therapeutic advantage to such a substitution, but it might be more convenient.
Remember, however, that you will probably haveto wait at least 60 minutes before starting your meal.It is usuallymore convenientto take a shot of reg ular insulin, since the waiting time after injecting is generallyonly 45 minutes.
A more important use for an ISA in combination with insulin oc curs if you are overweight or have polycystic ovarian syndrome (PCOS;seeAppendix E) and your bedtime dose of long-acting insulin is more than 8-10 units.
This suggests that you may have insulin resis tance, which may respond to one of the ISAs or insulin mimetics.
Re callthat ISAs increaseyour sensitivity to insulin.Large dosesof insulin help build fat, of course,and can also cause further down-regulation,
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or desensitization, of insulin receptors.
If you're obese,the lessinsulin you have in your system storing away fat, the better.
So there may be some advantageto reducing your bedtime insulin dose.
If your physician decides to add one ofthese agents to your bedtime regimen, he or she will want you to build up the dose gradually while simultaneously reducing your dose of basal insulin.
She/he might want to beginwith the extended-release versionof metformin because it will keep working all night and is not likely to cause the digestive discomfort sometimes found with the more-rapid-acting version.
If your bedtime insulin requirements are not reduced while taking the maximum recommended doses of severaloral agents before sleeping, then the bedtime oral agents are serving no purpose and should be discontinued.
The FDA warns against using rosiglitazone or pioglita- zone for people taking insulin, as there is a small risk of congestive heart failure (due to fluid retention) in susceptible individuals who take insulin plus these medications.* This restriction does not apply to metformin or to the insulin-mimetic agents.
IS IT NECESSARY TO RECORD DAILY BLOOD GLUCOSE PROFILES AFTER INSULIN DOSES HAVE BEEN FINE-TUNED?
Type 1 diabetics, and those type 2s whose beta cellsare producing lit tle or no insulin, both tend to show significant blood sugar changes following relativelysmall changes in what they eat, their activity level, and so on.
If your blood sugarscommonlyshowchangesof more than 20 mg/dl in the course of a day, you probably should measure blood sugar profiles dailyfor the rest of your life.
Suchfrequent monitoring is necessary so that you can correct high blood sugars with lispro or low blood sugars with glucose tablets (seenext chapter).
I've seen many individuals on our regimen whose blood sugars are quite stable even though they require the 5 daily shots typical of in tensive insulin therapy.Thesepeopleusuallyrequire small doses of in sulin,typically for adults under 8 units dailyfor all dosescombined.
If
Insulinin largedosescauses fluidretention.Rosiglitazone and pioglitazone can also cause fluid retention. It is likelythat the people reported to have developed heart failure while taking both rosiglitazone or pioglitazone and insulin were taking large doses of insulin to coverthe usual high-carbohydrate diabetes diet.
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you fit into this category, your beta cells are probably still producing some insulin.
This enables your system automatically to smooth out the peaks and valleys that your blood glucose profile would otherwise show.
With such stable blood sugars (varying less than 20 mg/dl daily), there's no reason to bother taking daily blood sugar profiles.
You would, instead, prepare a full blood glucose profile (five to seven tests) for 1 day every 2 weeks.
If you spotted a change in your blood sugar ranges,you'd checkthe next few daysto see if it continued.
If it did, you would contact your physician, who might want to explore the possible reasons for such changes.
If you become ill,or if,say, you have a school-age child who brings home a cold, you might want to check your blood sugar profiles everyday.
If your physician has prescribed oral or injected steroids for other disorders such as asthma or bursitis, you should be checking and recording blood sugars, as they will cer tainly increase.
SOME FINAL CONSIDERATIONS REGARDING LISPRO, ASPART, AND GLULISINE INSULINS
Perhaps as a result of reading one of my prior books, you may already be covering elevated blood sugars with regular insulin.
If this is the case, be very careful when using lispro, glulisine, or aspart for this purpose.
I and many of my patients have found them to be more ef fective than regular , that is, a given dose is likely to lower blood sugar more than the same dose of regular.
For example, I find that while 1 unit R will lowermy blood sugar 40 mg/dl, 1 unit H will lower it 60 mg/dl.
I advise, therefore, that you initially take two-thirds as much lispro (H) as your prior regular (R) for this purpose.
Based upon the initial effecton your blood sugar,you can then adjust subse quent doses of these analog insulins.The same consideration applies if you eat out and use H to covera meal.
We have also observed that when lispro is used to cover meals, blood sugars are lesspredictablethan with regular.This result was not mentioned in reports of clinical trials of lispro, probably because the trial population followed a high-carbohydrate diet and had such wide blood sugar fluctuation that this effect was not apparent.
In spite of this consideration, I believe that lispro greatiybenefits those who use it properly.I am most grateful for its availability.
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It's certainly worth mentioning that lispro is available in small (3 cc) cartridges.
These can becarried inajacket pocket or small purse without creating an unsightly bulge or the need for refrigeration.
When using cartridges, insert a needle andpull back ontheplunger of the syringe very slowly.
Do not inject airinto these cartridges.
If you draw out too much insulin, do not inject it back into the cartridge.
Squirt the excess into a plant or wastebasket, et cetera.
Aspart and glulisine function on a par with lispro, although some what less rapidly.
INSULIN PUMPS
Mucheffortand expense arebeing devoted to promoteand marketin sulin pumps. These devices were designed to make multiple daily in jections easier. They also do awaywiththeneed forlong-acting insufins. The instruments consist of two basic elements:
• A pump unit about the size of a small pocket calculator, which you can hang from a belt, keep ina pocket, or pinto yourclothing. • Large-bore plastic tubing that stays in your skin, typically just above your waist.
The plastic tubing, which is inserted into the skin through a large, retractable needle, usually should be changed every 2-3 days.
The pump unitcan beloaded with a supply of lispro or other very rapid acting insulin that lasts a number of days before refilling is nec essary.
It delivers a tinybasal flow of insulin all daylong, giving an ef fect similar to that of 2 daily injections of long-acting insulin.
This basal rate canbe preset bythe user andcan even besetto change auto matically at various timesof the day.
Premeal bolusor corrective doses arereadily produced bysetting thedose andthenpushing a button.
Insulin pumps offer the following advantages over multiple daily injections
• There is no need to carry a number of insulin syringes when away from home, but catheters and other supplies must accom pany you. • Correctiveinjections are elegantiy simple. • Pumps canbesetto automatically increase thebasal delivery rate shortly before arising in the morning, thereby circumventing
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problems associated with the dawn phenomenon. They thus ren der it unnecessary for you to arise earlyon weekends to take your long-acting insulin.
On the other hand, insulin pumps can pose some problems
• Pump failure, tubing coming out ofthe skin, insulin coagulation, tubing blockage, or kinking can occur in spite of sophisticated alarms and safeguards.
As a result, ketoacidosis has occurred overnight in many type 1 users. • There is a moderate incidence of infections at injection sites.
Manyofthesehaveformedabscesses requiring surgical drainage. • Severe hypoglycemia is more common among pump users, pos siblybecause of mechanical problems. • Insulin pumps cannot be used to give intramuscular injections for more rapidlowering of elevated blood sugars. • All of the long-term (seven-plus years) pump users that I have seen had fibrosis (scar tissue formation) at the injection site.This had impaired their insulin absorption so much that even high doses failed to control their blood sugars.
In addition, blood sugar effects of pump boluses appeared to be inconsistent in these individuals. • Until recendy, pump delivery rates could not be set for less than 0.1 units per hour.This makes it necessary for basal dosing to be in multiples of 2.4 units per day, thereby preventing fine adjust ments of basal insulin.
For example, I require 3 units of glargine twice daily formybasal insulin.With a pump I would have to take either too little , 4.8 units (2 x 2.4) , or too much , 7.2 units (3 x 2.4).Some pump manufacturers now maketheir product ad justable to 0.01 units perhour,which overcomesthis problem. • Many people are turned off by the idea of constandy having large-bore tubing sticking in their abdomens. • Usersexperience at leastsome inconvenience with the four S's , sleep, showers,swimming, and sex.