Severe diabetics seen for the first time, as well as young patients, are usually commenced on insulin therapy from the start. Underweight patients of all ages are also given this form of therapy, since a low-calorie diet will only aggravate the loss of weight.
There are several important principles of insulin therapy that must be understood by the diabetic. Insulin therapy has the goal of helping the patient to live as normal, happy and healthy a life as possible. Ideally, the diabetic will take a keen interest in the complaint and learn as much about it as possible, for this in turn enable the patient to take an intelligent part in the prescribed therapy. Diabetics, more than any other kind of patient, become closely involved in their own therapy.
The aim is to keep free from as many adverse symptoms of the disease as possible. Small symptoms may occur, but the fewer major ones that develop, particularly hypoglycaemia, ketosis and coma the better. The diabetic must be aware of the possible complications, and be constantly on the lookout for them.
The ideal is to keep the urine as free as possible from sugar or the blood glucose levels as near to within normal levels as possible, provided this can be done without interfering with the other points cited. With time, practice and skill the average diabetic of reasonable intelligence may become expert in administering treatment.
Insulin is a potent chemical. Unfortunately it is rapidly destroyed by the acids of the gastric region, and must be given by injection, usually subcutaneously (just below the skin), although it may be given by deeper injection into the muscles, or even directly into the blood vessel if necessary.
Great changes have been made in the production of insulin since it was first isolated. The most recent have been the development of “human” insulin, and insulin coming from high-tech DNA recombinant technology. These two forms are identical. They are apt to produce fewer adverse side effects in the patient. Normal insulin supplies traditionally come from bovine (beef) or porcine (pig) sources. For this reason they contain contaminants, although in very small amounts, and in time a person may become sensitized to further injections and react unfavorably. But with human or DNA forms, this risk is entirely removed, and they can be given with safety over long periods of time. In any case, the insulins (whatever kind) used today are highly purified, and adverse effects from antigenicity are rare.
But apart from this many different forms of insulin exist. The chief difference is that while basically the same in nature, the period of time over which they exert their effect varies enormously. Soluble insulin, for example, acts rapidly, usually within half an hour, and keeps its action up for six to eight hours, or up to 12 hours with larger doses. It is now generally prescribed to initiate treatment for severe diabetics, or for those in ketosis or coma. It must he given half an hour before food is taken.
Protamine zinc insulin (PZI) is a longer-acting type, once popular, but now replaced by the newer kinds. It is absorbed over 12 – 24 hours, but hypoglycaemic attacks could occur during the day. Sometimes it was used in conjunction with the soluble forms.
Insulin Zinc Suspension (the so-called Semilente, Lente and Ultralente, or In type) is now widely used. Often one single morning dose is all that is required, hence its popularity. Local reactions are much more uncommon. Food intake is spread evenly over the day, 25 per cent at each meal and again at bedtime as a snack. Sometimes, according to patient needs and personal reactions, the Lente kind can be shortened or lengthened in effect by adding Semilente or Ultralente. Another form called Isophane insulin is longer-acting and is still used for mild diabetics requiring something more than soluble insulin.
This of course must be a very personal affair, for all patients are different, and the requirement for each person must be tailored to meet individual needs. The picture is constantly changing regarding treatment. At present many endocrinologists are finding that four injections of short-acting insulin a day (with blood tests carried out by finger pricking) is the best method. Then “topup” injections using the insulin “pen” may be given. The “pen” is a small, portable, insulin-filled device with a needle that automatically delivers a given dose of insulin as required. The patient presses a trigger with the needle firmly pressed against the skin.
Blood tests, using easy-to-use meters, have long since replaced the clumsy urine dip tests for measuring sugar levels. It is essential that patients be advised by their physician (or diabetes specialist) on the best method of treatment and dosages, which will be specifically tailor made for them.
A major report recently published indicated that the earlier and more aggressively diabetes is controlled, fewer long-term serious adverse effects develop. Diabetes, left untreated or poorly controlled, may adversely affect many organs, leading to serious illness and earlier death.
It is now believed that vast numbers of people with minimum or no obvious symptoms are in fact diabetics. Patients who are overweight, have elevated blood fats (cholesterol especially) or a family history of diabetes, should have a blood test, which is diagnostic and undergo vigorous treatment. More and more younger diabetics are being discovered on routine blood tests.
“Good control means first a state in which the patient feels well, leads a normal life and is free from symptoms. Further, the correct dose of insulin can only be determined when the patient is at home leading a normal life,” Price says. Infections (colds, bronchitis, sore throats, influenza, boils, urine infections, or any other bacterial or viral invasion) often create a situation where more insulin is needed. Mistakes may be made by the patient in measuring the insulin in the syringe or failing to take the insulin. Dietary indiscretions are a common cause. The patient simply overeats, breaking all dietetic rules.
Sometimes the pendulum may swing in the opposite direction. Too much insulin may have been taken (through error, not an uncommon occurrence, particularly in older people). This is not so likely since the introduction of the 0100 syringe. There may have been unusually heavy exertion, or missed meal(s).
Insulin pumps were invented several years ago to help to automatically stabilizes blood-sugar levels. For everyday use they are quite impractical, and are not widely used in Australia. They are difficult to use properly, and it is a full-time job for one physician to supervise 12 – 20 patients on the pumps.