Intensive insulin therapy

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Intensive insulin therapy or flexible insulin therapy is a therapeutic regimen for diabetes mellitus treatment. This newer approach contrasts with conventional insulin therapy. Rather than minimize the number of insulin injections per day (a technique which demands a rigid schedule for food and activities), the intensive approach favors flexible meal times with variable carbohydrate as well as flexible physical activities. The trade-off is the increase from 2 or 3 injections per day to 4 or more injections per day, which was considered "intensive" relative to the older approach. In North America in 2004, many endocrinologists prefer the term "flexible insulin therapy" (FIT) to "intensive therapy" and use it to refer to any method of replacing insulin that attempts to mimic the pattern of small continuous basal insulin secretion of a working pancreas combined with larger insulin secretions at mealtimes. The semantic distinction reflects changing treatment.

Contents

Rationale

Long-term studies like the UK Prospective Diabetes Study (UKPDS) and the Diabetes control and complications trial (DCCT) showed that intensive insulin therapy achieved blood glucose levels closer to non-diabetic people and that this was associated with reduced frequency and severity of blood vessel damage. Damage to large and small blood vessels (macro- and microvascular disease) is central to the development of complications of diabetes.

This evidence convinced most physicians who specialize in diabetes care that an important goal of treatment is to make the biochemical profile of the diabetic patient (blood lipids, HbA1c, etc.) as close to the values of non-diabetic people as possible. This is especially true for young patients with many decades of life ahead.

General description

A working pancreas continually secretes small amounts of insulin into the blood to maintain normal glucose levels, which would otherwise rise from glucose release by the liver, especially during the early morning dawn phenomenon. This insulin is referred to as basal insulin secretion, and constitutes almost half [1] the insulin produced by the normal pancreas.

Bolus insulin is produced during the digestion of meals. Insulin levels rise immediately as we begin to eat, remaining higher than the basal rate for 1 to 4 hours. This meal-associated (prandial) insulin production is roughly proportional to the amount of carbohydrate in the meal.

Intensive or flexible therapy involves supplying a continual supply of insulin to serve as the basal insulin, supplying meal insulin in doses proportional to nutritional load of the meals, and supplying extra insulin when needed to correct high glucose levels. These three components of the insulin regimen are commonly referred to as basal insulin, bolus insulin, and high glucose correction insulin.

Two common regimens: pens, injection ports, and pumps

One method of intensive insulinotherapy is based on multiple daily injections (sometimes referred to in medical literature as MDI). Meal insulin is supplied by injection of rapid-acting insulin before each meal in an amount proportional to the meal. Basal insulin is provided as a once or twice daily injection of dose of a long-acting insulin.

In an MDI regimen, long-acting insulins are preferred for basal use. An older insulin used for this purpose is ultralente, and beef ultralente in particular was considered for decades to be the gold standard of basal insulin. Long-acting insulin analogs such as insulin glargine (brand name Lantus, made by Sanofi-Aventis) and insulin detemir (brand name Levemir, made by Novo Nordisk) are also used, with insulin glargine used more than insulin detemir.[ citation needed ] Rapid-acting insulin analogs such as lispro (brand name Humalog, made by Eli Lilly and Company) and aspart (brand name Novolog/Novorapid, made by Novo Nordisk and Apidra made by Sanofi Aventis) are preferred by many clinicians over older regular insulin for meal coverage and high correction. Many people on MDI regimens carry insulin pens to inject their rapid-acting insulins instead of traditional syringes. Some people on an MDI regimen also use injection ports such as the I-port to minimize the number of daily skin punctures.

The other method of intensive/flexible insulin therapy is an insulin pump. It is a small mechanical device about the size of a deck of cards. It contains a syringe-like reservoir with about three days' insulin supply. This is connected by thin, disposable, plastic tubing to a needle-like cannula inserted into the patient's skin and held in place by an adhesive patch. The infusion tubing and cannula must be removed and replaced every few days.

An insulin pump can be programmed to infuse a steady amount of rapid-acting insulin under the skin. This steady infusion is termed the basal rate and is designed to supply the background insulin needs. Each time the patient eats, he or she must press a button on the pump to deliver a specified dose of insulin to cover that meal. Extra insulin is also given the same way to correct a high glucose reading. Although current pumps can include a glucose sensor, they cannot automatically respond to meals or to rising or falling glucose levels.

Both MDI and pumping can achieve similarly excellent glycemic control. Some people prefer injections because they are less expensive than pumps and do not require the wearing of a continually attached device. However, the clinical literature is very clear that patients whose basal insulin requirements tend not to vary throughout the day or do not require dosage precision smaller than 0.5 IU, are much less likely to realize much significant advantage of pump therapy. Another perceived advantage of pumps is the freedom from syringes and injections, however, infusion sets still require less frequent injections to guide infusion sets into the subcutaneous tissue.

Intensive/flexible insulin therapy requires frequent blood glucose checking. To achieve the best balance of blood sugar with either intensive/flexible method, a patient must check his or her glucose level with a meter monitoring of blood glucose several times a day. This allows optimization of the basal insulin and meal coverage as well as correction of high glucose episodes.

Advantages and disadvantages

The two primary advantages of intensive/flexible therapy over more traditional two or three injection regimens are:

  1. greater flexibility of meal times, carbohydrate quantities, and physical activities, and
  2. better glycemic control to reduce the incidence and severity of the complications of diabetes.

Major disadvantages of intensive/flexible therapy are that it requires greater amounts of education and effort to achieve the goals, and it increases the daily cost for glucose monitoring four or more times a day. This cost can substantially increase when the therapy is implemented with an insulin pump and/or continuous glucose monitor.

It is a common notion that more frequent hypoglycemia is a disadvantage of intensive/flexible regimens. [2] The frequency of hypoglycemia increases with increasing effort to achieve normal blood glucoses with most insulin regimens, but hypoglycemia can be minimized with appropriate glucose targets and control strategies. The difficulties lie in remembering to test, estimating meal size, taking the meal bolus and eating within the prescribed time, and being aware of snacks and meals that are not the expected size. When implemented correctly, flexible regimens offer greater ability to achieve good glycemic control with easier accommodation to variations of eating and physical activity.

A 2020 Cochrane systematic review did not find enough evidence of reduction of cardiovascular mortality, non-fatal myocardial infarction or non-fatal stroke when comparing insulin to metformin monotherapy. [3]

Semantics of changing care: why "flexible" is replacing "intensive" therapy

Over the last two decades, the evidence that better glycemic control (i.e., keeping blood glucose and HbA1c levels as close to normal as possible) reduces the rates of many complications of diabetes has become overwhelming. As a result, diabetes specialists have expended increasing effort to help most people with diabetes achieve blood glucose levels as close to normal as achievable. It takes about the same amount of effort to achieve good glycemic control with a traditional two or three injection regimen as it does with flexible therapy: frequent glucose monitoring, attention to timing and amounts of meals. Many diabetes specialists no longer think of flexible insulin therapy as "intensive" or "special" treatment for a select group of patients but simply as standard care for most patients with type 1 diabetes.

Treatment devices used

The insulin pump is one device used in intensive insulinotherapy. The insulin pump is about the size of a beeper. It can be programmed to send a steady stream of insulin as basal insulin. It contains a reservoir or cartridge holding several days' worth of insulin, the tiny battery-operated pump, and the computer chip that regulates how much insulin is pumped. The infusion set is a thin plastic tube with a fine needle at the end. There are also newer "pods" which do not require tubing. It carries the insulin from the pump to the infusion site beneath the skin. It sends a larger amount before eating meals as "bolus" doses.

The insulin pump replaces insulin injections. This device is useful for people who regularly forget to inject themselves or for people who don't like injections. This machine does the injecting by replacing the slow-acting insulin for basal needs with an ongoing infusion of rapid-acting insulin.

Basal insulin: the insulin that controls blood glucose levels between meals and overnight. It controls glucose in the fasting state.

Boluses: the insulin that is released when food is eaten or to correct a high reading.

Another device used in intensive insulinotherapy is the injection port. An injection port is a small disposable device, similar to the infusion set used with an insulin pump, configured to accept a syringe. Standard insulin injections are administered through the injection port. When using an injection port, the syringe needle always stays above the surface of the skin, thus reducing the number of skin punctures associated with intensive insulinotheraphy.

Related Research Articles

Conventional insulin therapy is a therapeutic regimen for treatment of diabetes mellitus which contrasts with the newer intensive insulin therapy.

<span class="mw-page-title-main">Hypoglycemia</span> Health condition

Hypoglycemia, also called low blood sugar, is a fall in blood sugar to levels below normal, typically below 70 mg/dL (3.9 mmol/L). Whipple's triad is used to properly identify hypoglycemic episodes. It is defined as blood glucose below 70 mg/dL (3.9 mmol/L), symptoms associated with hypoglycemia, and resolution of symptoms when blood sugar returns to normal. Hypoglycemia may result in headache, tiredness, clumsiness, trouble talking, confusion, fast heart rate, sweating, shakiness, nervousness, hunger, loss of consciousness, seizures, or death. Symptoms typically come on quickly.

<span class="mw-page-title-main">Insulin pump</span> Medical device to administer insulin

An insulin pump is a medical device used for the administration of insulin in the treatment of diabetes mellitus, also known as continuous subcutaneous insulin therapy. The device configuration may vary depending on design. A traditional pump includes:

The following is a glossary of diabetes which explains terms connected with diabetes.

<span class="mw-page-title-main">Diabetic ketoacidosis</span> Medical condition

Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes mellitus. Signs and symptoms may include vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion and occasionally loss of consciousness. A person's breath may develop a specific "fruity" smell. Onset of symptoms is usually rapid. People without a previous diagnosis of diabetes may develop DKA as the first obvious symptom.

<span class="mw-page-title-main">Blood glucose monitoring</span> Use of a glucose monitor for testing the concentration of glucose in the blood

Blood glucose monitoring is the use of a glucose meter for testing the concentration of glucose in the blood (glycemia). Particularly important in diabetes management, a blood glucose test is typically performed by piercing the skin to draw blood, then applying the blood to a chemically active disposable 'test-strip'. The other main option is continuous glucose monitoring (CGM). Different manufacturers use different technology, but most systems measure an electrical characteristic and use this to determine the glucose level in the blood. Skin-prick methods measure capillary blood glucose, whereas CGM correlates interstitial fluid glucose level to blood glucose level. Measurements may occur after fasting or at random nonfasting intervals, each of which informs diagnosis or monitoring in different ways.

Basal rate, in biology, is the rate of continuous supply of some chemical or process. In the case of diabetes mellitus, it is a low rate of continuous insulin supply needed for such purposes as controlling cellular glucose and amino acid uptake.

<span class="mw-page-title-main">Subcutaneous administration</span> Insertion of medication under the skin

Subcutaneous administration is the insertion of medications beneath the skin either by injection or infusion.

<span class="mw-page-title-main">Infusion pump</span>

An infusion pump infuses fluids, medication or nutrients into a patient's circulatory system. It is generally used intravenously, although subcutaneous, arterial and epidural infusions are occasionally used.

The term diabetes includes several different metabolic disorders that all, if left untreated, result in abnormally high concentration of a sugar called glucose in the blood. Diabetes mellitus type 1 results when the pancreas no longer produces significant amounts of the hormone insulin, usually owing to the autoimmune destruction of the insulin-producing beta cells of the pancreas. Diabetes mellitus type 2, in contrast, is now thought to result from autoimmune attacks on the pancreas and/or insulin resistance. The pancreas of a person with type 2 diabetes may be producing normal or even abnormally large amounts of insulin. Other forms of diabetes mellitus, such as the various forms of maturity onset diabetes of the young, may represent some combination of insufficient insulin production and insulin resistance. Some degree of insulin resistance may also be present in a person with type 1 diabetes.

An insulin analog is any of several types of medical insulin that are altered forms of the hormone insulin, different from any occurring in nature, but still available to the human body for performing the same action as human insulin in terms of controlling blood glucose levels in diabetes. Through genetic engineering of the underlying DNA, the amino acid sequence of insulin can be changed to alter its ADME characteristics. Officially, the U.S. Food and Drug Administration (FDA) refers to these agents as insulin receptor ligands, although they are usually just referred to as insulin analogs or even just insulin.

Pulsatile intravenous insulin therapy, sometimes called metabolic activation therapy or cellular activation therapy, describes in a literal sense the intravenous injection of insulin in pulses versus continuous infusions. Injection of insulin in pulses mimics the physiological secretions of insulin by the pancreas into the portal vein which then drains into the liver. In healthy, non-diabetic individuals, pancreatic secretions of insulin correspond to the intake of food. The pancreas will secrete variable amounts of insulin based upon the amount of food consumed among other factors. Continuous exposure to insulin and glucagon is known to decrease the hormones' metabolic effectiveness on glucose production in humans due to the body developing an increased tolerance to the hormones. Down-regulation at the cellular level may partially explain the decreased action of steady-state levels of insulin, while pulsatile hormone secretion may allow recovery of receptor affinity and numbers for insulin. Intermittent intravenous insulin administration with peaks of insulin concentrations may enhance suppression of gluconeogenesis and reduce hepatic glucose production.

A diabetic diet is a diet that is used by people with diabetes mellitus or high blood sugar to minimize symptoms and dangerous complications of long-term elevations in blood sugar.

The untethered regimen is a technique combining the use of an insulin pump with a slow-acting insulin analog such as Lantus or Levemir. This allows an insulin dependent person to disconnect the pump when desired while maintaining the flexible benefits that the insulin pump can provide.

<span class="mw-page-title-main">Diabetes management software</span>

Diabetes Management Software refers to software tools that run on personal computers and personal digital assistants to help persons with Type 1 and Type 2 diabetes manage the data associated with:

In medicine, a bolus is the administration of a discrete amount of medication, drug, or other compound within a specific time, generally 1–30 minutes, to raise its concentration in blood to an effective level. The administration can be given by injection: intravenously, intramuscularly, intrathecally, subcutaneously, or by inhalation. The article on routes of administration provides more information, as the preceding list of ROAs is not exhaustive.

<span class="mw-page-title-main">Insulin (medication)</span> Use of insulin protein and analogs as medical treatment

As a medication, insulin is any pharmaceutical preparation of the protein hormone insulin that is used to treat high blood glucose. Such conditions include type 1 diabetes, type 2 diabetes, gestational diabetes, and complications of diabetes such as diabetic ketoacidosis and hyperosmolar hyperglycemic states. Insulin is also used along with glucose to treat hyperkalemia. Typically it is given by injection under the skin, but some forms may also be used by injection into a vein or muscle. There are various types of insulin, suitable for various time spans. The types are often all called insulin in the broad sense, although in a more precise sense, insulin is identical to the naturally occurring molecule whereas insulin analogues have slightly different molecules that allow for modified time of action. It is on the World Health Organization's List of Essential Medicines. In 2020, regular human insulin was the 307th most commonly prescribed medication in the United States, with more than 1 million prescriptions.

<span class="mw-page-title-main">Minimed Paradigm</span> Insulin pumps

MiniMed Paradigm is a series of insulin pumps manufactured by Medtronic for patients with diabetes mellitus. The pump operates with a single AA battery and uses a piston-plunger pump to infuse a programmed amount of insulin into the patient through a length of tubing. The Paradigm uses a one-way wireless radio frequency link to receive blood sugar measurements from select glucose meters. The Paradigm RT series adds the ability to receive data from a mated continuous blood-glucose monitor. Although the pump can use these measurements to assist in calculating a dose of insulin, no actual change in insulin delivery occurs without manual user-intervention.

<span class="mw-page-title-main">Insulin degludec</span> Ultralong-acting basal insulin analogue

Insulin degludec (INN/USAN) is an ultralong-acting basal insulin analogue that was developed by Novo Nordisk under the brand name Tresiba. It is administered via subcutaneous injection once daily to help control the blood sugar level of those with diabetes. It has a duration of action that lasts up to 42 hours, making it a once-daily basal insulin, that is one that provides a base insulin level, as opposed to the fast- and short-acting bolus insulins.

Carbohydrate counting or “carb” counting is a meal planning tool used in diabetes management to help optimize blood sugar control. It can be used with or without the use of insulin therapy. Carbohydrate counting involves determining whether a food item has carbohydrate followed by the subsequent determination of how much carbohydrate the food item has in it.

References

  1. ↑ Davidson PC, Hebblewhite HR, Steed RD, Bode BW (December 2008). "Analysis of guidelines for basal-bolus insulin dosing: basal insulin, correction factor, and carbohydrate-to-insulin ratio". Endocrine Practice. 14 (9): 1095–1101. doi:10.4158/EP.14.9.1095. PMID   19158048. S2CID   39503937.
  2. ↑ Nathan DM, Genuth S, Lachin J, Cleary P, Crofford O, Davis M, et al. (September 1993). "The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus". The New England Journal of Medicine. 329 (14): 977–986. doi: 10.1056/NEJM199309303291401 . PMID   8366922. S2CID   21528496.
  3. ↑ Gnesin F, Thuesen AC, Kähler LK, Madsbad S, Hemmingsen B (June 2020). Cochrane Metabolic and Endocrine Disorders Group (ed.). "Metformin monotherapy for adults with type 2 diabetes mellitus". The Cochrane Database of Systematic Reviews. 2020 (6): CD012906. doi:10.1002/14651858.CD012906.pub2. PMC   7386876 . PMID   32501595.
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