People with type 1 diabetes and some with type 2 diabetes will often maintain a basal-bolus injection regimen.
This schedule combines both the basal insulin and bolus insulin methods.
In particular, a basal-bolus injection regime includes an injection at each meal (bolus) and a longer-acting form of insulin (basal) once or twice a day.
In this way, the regimen emulates somewhat how a person who does not have diabetes naturally delivers insulin throughout the day.
For many people with type 1 diabetes, taking rapid-acting insulin at mealtime and a long-acting insulin once or twice a day is a good way to control their blood glucose levels.
What is the difference between long-acting peaking and long-acting peakless?
A lthough these terms seem similar, long-acting peaking is a form of insulin that does not begin to lower blood glucose levels until four to six hours after it is injected. It works mostly from eight to 30 hours after injection and continues to work for up to 24 to 36 hours. One example is ultralente insulin. The long-acting peakless is a basal type of insulin. It lowers blood glucose within one to two hours after injection and continues for 24 hours. One example is glargine insulin.
There are several advantages to this regimen, including that it simulates the natural release of insulin in the body.
It can often give a person flexibility as to when he or she can eat a meal, and even, if the insulin is adjusted correctly, how many carbohydrates a person with diabetes can consume. (Depending on the person’s condition, he or she may be able to eat more carbohydrates.) There are also some disadvantages to the regimen.
For example, it involves taking several daily insulin injections.
Hypoglycemia is often a common occurrence on a basal-bolus regimen (which is why it is recommended to keep a blood glucose testing kit and a fast-acting carbohydrate available in case of a low blood glucose level).
And depending on a person’s diabetic condition, not everyone will be able to use this regimen.
In addition, children who are on this regimen would have to be comfortable getting injections at mealtimes, either at school or other functions, and would have to understand that they need several injections each day.
What is inhalable insulin?
Inhalable insulin is a powdered form of insulin (or dry insulin) that is delivered via inhalation, sending small particles of insulin into the lungs.
From there, it is absorbed by the cells in the lungs and then into the bloodstream.
It can be used by people with type 1 or type 2 diabetes.
The delivery system may be a nebulizer, meaning a device using compressed air that allows the particles to be inhaled (a process called aerosolization), or inhalers that can be activated with the breath (the insulin is inhaled directly through the mouth and into the lungs).
The suggested advantage of inhaled insulin is that, because it enters the lungs, the dose can enter the bloodstream more quickly than injected insulin.
One form of inhaled insulin called Afrezza has been said to have “peak activity” 12 to 15 minutes after taking the dose, while insulin injections average between 30 and 90 minutes after injecting.
Insulin inhalers are not to be used all the time.
They are meant to be used mainly at the start of a meal to help with blood-sugar control.
Most research shows inhalers to be safe to use with basal insulin (for more about basal insulin, see above).
Of course, there are some warnings.
In particular, inhalers are not recommended if the person with diabetes has chronic lung problems or if the person smokes.
In addition, the most common adverse reaction with inhalable insulin (or any insulin) is hypoglycemia.
What new manmade version of insulin has recently been approved in the United States?
Research has developed a long-acting, manmade version of natural human insulin, referred to as insulin glargine.
Insulin glargine not only replaces the body’s natural insulin but also moves glucose into the tissues and prevents the liver from making extra sugar.
This type of insulin was developed by the pharmaceutical company Sanofi US (also known as Sanofi-aventis) and called by the brand name Lantus ® .
It was already on the market in 2000, but the patent expired in 2015.
This meant that other drug companies could start making their own types of insulin glargine, also referred to as “biosimilar insulin.”
Which inhalable insulin was eventually taken off the market?
I n January 2006, an inhalable insulin called Exubera, developed by Inhale Therapeutics (later Nektar Therapeutics), was commercially introduced to the public by the pharmaceutical company Pfizer. But because of poor sales, by October 2007, it had been taken off the market.
Thus, in 2016 the U.S.
Food and Drug Administration (FDA) approved the first “copycat” version of insulin glargine called Basaglar from Eli Lilly. (It was also the first company to come out with commercially available insulin in the 1920s; for more about the company and the first commercial insulin, see the chapter “Introduction to Diabetes.”) Similar to Lantus ® , the newest biosimilar insulin is administered by daily injection.
It is used mainly for children and adults with type 1 diabetes and under certain conditions in adults with type 2 diabetes.
Other biosimilar insulins will no doubt follow, as long as the pharmaceutical companies who want to develop the insulin go through a rigorous FDA approval process.
It is too early to tell whether more insulin glargines on the market will mean lower prices for many of the 10 million Americans with diabetes who use insulin.
Do people with type 2 diabetes need injectable medication that is NOT insulin?
Although some people with type 2 diabetes take oral medication and insulin, there are some who need injectable medications (along with or other than insulin) to help control their blood glucose level.
They would take this medication either in conjunction with other diabetes medicines or singularly. (These injectable medications are not for people with type 1 diabetes.) For example, a class of injectable drugs called glucagonlike peptide-1 (GLP-1) agonists are often prescribed, along with a healthful diet and exercise. (These drugs are also associated with a low rate of developing hypoglycemia in people with diabetes.) They include such drugs as Victoza (generic name liraglutide; it is similar to the body’s naturally occurring hormone to help control blood glucose, insulin levels, and digestion), Byetta (exenatide; it helps control blood glucose levels by helping the pancreas produce insulin more efficiently), and Tanzeum (albiglutide; it improves blood glucose levels when used in conjunction with a good diet and exercise).
In general, it is thought that the GLP-1 agonists work by stimulating the pancreas’s insulin-producing beta cells in order to release insulin in response to a person’s high blood glucose levels.
Are there any experimental drugs that treat or may eventually treat diabetes?
Yes, there are many experimental drugs and medications that are, and may eventually be, used to treat diabetes or complications from the disease.
For example, a drug called Herberprot-B, developed in Cuba, has been used around the world to treat diabetic foot ulcers. (This medicine was not available in the United States because of an embargo on trade with Cuba.
In late 2016, it was reported that clinical trials on Herberprot-B were being conducted in the United States, but it is not known when the drug will become available.)
There are also experimental drugs that may or may not help people with diabetes and its complications, with one of the more controversial, and research-contrary, ones being medical marijuana.
The reason for the controversy is the profusion of opposing studies about medical marijuana and diabetes.
For example, several studies indicated that marijuana users had lower fasting insulin levels and less insulin resistance than non-users.
In a different study, it appeared that there was a 30 percent lower risk of developing diabetes for those who used marijuana.
But other studies disagreed, including one from the National Institutes of Health that warned that marijuana users had more abdominal fat, along with more insulin-resistant fat cells.
Still other studies indicated that former marijuana users had higher glucose and insulin levels in their blood than those who had never used the drug.
No one to date can actually say that marijuana can help or hinder a person with diabetes.
MONITORING FOR HYPOGLYCEMIA, HYPERGLYCEMIA, AND DIABETIC KETOACIDOSIS
Why is hypoglycemia a concern for a person with diabetes?
Hypoglycemia, or low blood sugar, is one of the most common, and often dangerous, side effects of any medication for lowering blood glucose.
The goal of a person with diabetes should be to keep blood glucose levels as close to normal as possible.
If a person with diabetes has a blood glucose level below 70 mg/dl (milligrams per deciliter), he or she can begin to experience a hypoglycemic low.
Some causes may be missing or postponing a meal or even eating less than the right amount of carbohydrates; exercising more than usual; emotional upset or stress; injecting the wrong dose of insulin; or consuming too much alcohol for that person.
Often, these lows occur for no apparent reason.
That is why many health care professionals, and sometimes people with diabetes who have had hypoglycemic episodes, recommend that a person with diabetes always carry some form of quickly absorbed glucose.
What are some symptoms of hypoglycemia?
When people with diabetes become hypoglycemic, they are often extremely confused.
At first, the brain sends out signals to raise the glucose level, and the alpha cells in the pancreas release glucagon.
This tells the liver and muscles to release the stored glycogen and then change it back to glucose to raise the blood sugar back to normal.
In the meantime, the body releases epinephrine, a hormone that increases hunger, causes a resistance to the insulin’s action, and further stimulates the breakdown of the liver’s glycogen into glucose.
Other hormones are released, including cortisol, to counteract the insulin and raise the blood glucose levels.
The result is that a person can experience dizziness, a pale or flushed face, often dilated pupils, irritability, hunger, sweating, a rapid heartbeat, weakness, nervousness or anxiousness, and shakiness.
Why is it important not to become hypoglycemic?
I t is important for a person with diabetes not to become hypoglycemic.
Not only does it cause the body to lose control, and, if a person is in the later stages of hypoglycemia, to hurt him- or herself, but it also can take a toll on the body as a whole (especially if it happens many times in a short period).
The best way to treat hypoglycemia is to recognize the first symptoms and take action right away.
For many people with diabetes, it usually means ingesting something that will get into their system quickly, such as glucose tablets, fruit juice (around 4 to 6 ounces), 2 tablespoons of raisins, or sugary candies. (Do not reach for foods containing chocolate, peanut butter, nuts, or fats unless it is the only sugary food available.
The fat can actually delay the rise in blood glucose levels.) Most of these foods will be absorbed into the system quickly and begin to raise blood glucose within five to ten minutes.
The symptoms do not stop there. Later symptoms are caused by the decreasing availability of glucose to help the brain and nervous system. These symptoms include headache, blurred vision, slurred speech, confusion, euphoria, hostility, lack of coordination, drowsiness, possible convulsions and seizures, and loss of consciousness. At this point, emergency help should be called and the person should be taken to the hospital.