Insulin

 Insulin is injected subcutaneously several times a day into the anterior abdominal
wall, upper arms, outer thighs and buttocks
 The rate of absorption of insulin may be influenced by many factors other than the
insulin formulation, including the site, depth and volume of injection, skin
temperature (warming), local massage and exercise. Absorption is delayed from
areas of lipohypertrophy at injection sites.
 Once absorbed into the blood, insulin has a half-life of just a few minutes. It is
removed mainly by the liver and also the kidneys, so plasma insulin concentrations
are elevated in patients with liver disease or renal failure.
 Insulin can be administered using a disposable plastic syringe with a fine needle
(which can be re-used several times), but this has largely been replaced by pen
injectors and insulin pumps

Types:

Type Insulin
Long-acting Glargine(Lantus), detemir(Levemir)
Intermediate-acting Isophane (NPH-Neutral Protamine Hagedorn)/(Insultarad)
Short-acting Soluble-regular (Actrapid)
Rapid-acting Lispro(Humalog), aspart(Novorapid), glulisine(Apidra)

Regimens

Basal bolus regimen (Intensive regimen)

Short-acting insulin being, taken before each meal, and intermediate- or long-acting insulin
being injected once or twice daily. This type of regimen allows greater freedom with regard
to meal timing and more variable day-today physical activity. Major risk: hypoglycemia

2/3 and 1/3 regimen

Twice-daily administration of a short-acting and intermediate-acting insulin (usually soluble

and isophane insulins), given in combination before breakfast and the evening meal, is the
simplest regimen and is still used commonly in many countries. Initially, two-thirds of the
total daily requirement of insulin is given in the morning in a ratio of short-acting to
intermediate-acting of 1:2, and the remaining third is given in the evening. Pre-mixed
formulations are available containing different proportions of soluble and isophane insulins
(e.g. 30:70 and 50:50)

• NovoMix 30
• 3/10 of novorapid
• 7/10 of insulatard
Type 2 diabetes

In type 2 diabetes, insulin is usually initiated as a once-daily long acting insulin, either alone
or in combination with oral hypoglycaemic agents. However, in time, more frequent insulin
injections are usually required.

Inpatient management of diabetic patients (sliding scale)

• An insulin sliding scale (SSI) of regular insulin doses given according to bedside
finger-stick glucose determinations is helpful in controlling blood glucose levels in
the hospital setting.
• In general, SSI should be used in addition to a regimen of intermediate-acting insulin.
If given alone, hyperglycemia usually results.
• Monitor blood glucose four times per day: before meals and at bedtime.

Complications

• Hypoglycaemia
• Weight gain
• Peripheral oedema (insulin treatment causes salt and water retention in the short
term)
• Insulin antibodies (with animal insulins)
• Local allergy (rare)
• Accidental Intramuscular injections
• Lipohypertrophy or lipoatrophy (with chronic use) at injection sites
 A common problem is fasting hyperglycaemia (‘the dawn phenomenon’), which
arises through a combination of the normal circadian rhythm and release of counter-
regulatory hormones (growth hormone and cortisol) during the latter part of the
night, as well as diminishing levels of overnight isophane insulin.