Diabetes Management

Using Long-Acting Insulin

Diabetes is a group of diseases. In this state, the body has stopped producing insulin or is not making enough insulin.

If the body is still producing insulin, it may not be using ­­it. When any of these things happens, the body cannot get sugar from the blood into the cells. That leads to high blood sugar levels. 

Glucose is in the foods we eat that fuel our bodies cells. Insulin acts as the key to the cells to allow the glucose in. 

Diabetes mellitus encompasses 3 types: Type 1, Type 2, and Gestational. Both Type 1 diabetes and Type 2 diabetes are chronic conditions. Gestational is unique to pregnancy. Type 2 diabetes can be avoided with diet and exercise. Some may need medication and insulin. 

Type One is an autoimmune disease. Identified in the past as Juvenile diabetes, as it appeared in young people. Blood sugar is the concentration of sugar in your blood. When there is not enough insulin in the blood or the body is resistant to insulin, the body cannot use the glucose.

In this disease state, the body begins to attack the beta cells of the pancreas. The beta cells are responsible for making insulin. The damage is, unfortunately, permanent. Scientists believe the attack is environmental and has a genetic link.

Types of insulin

According to the U.S. Food and Drug Administration (FDA)Trusted Source, the five types of insulin are:

  • Rapid-acting insulin: This type starts to work just 15 minutes after you take it. It peaks within 30 to 90 minutes, and its effects last for three to five hours.

  • Short-acting insulin: This type takes about 30 to 60 minutes to become active in your bloodstream. It peaks in two to four hours, and its effects can last for five to eight hours. It is sometimes called regular-acting insulin.

  • Intermediate-acting insulin: The intermediate type takes one to three hours to start working. It peaks in eight hours and works for 12 to 16 hours.

  • Long-acting insulin: This type takes the longest amount of time to start working. The insulin can take up to 4 hours to get into your bloodstream.

  • Pre-mixed: This is a combination of two different types of insulin: one that controls blood sugar at meals and another that controls blood sugar between meals.

Long acting insulin

In Type 1, insulin is always needed to control blood sugar levels. 

Insulin falls into Short-acting insulin, Rapid-acting insulin, and Intermediate-acting insulin and Long-Acting Insulin. There are also many combinations of these 3 types called Mixed Insulins. 

Short-Acting covers mealtime blood sugar needs, 20-30 minutes before a meal.

Intermediate Insulin is usually given twice a day. This provides peak, less prolonged support of the blood glucose level.

Long-Acting can cover Insulin needs up to 24-36 hours.

Most Type 1 Diabetics use Long Acting insulin. This is an insulin analog, meaning it is like human insulin. They will mimic the body’s natural pattern of insulin release. Once absorbed, they act on cells like human insulin, absorbed from fatty tissue.

Delivery methods

Delivery of insulin is easier now than it has ever been. A decision on choice often occurs because of insurance coverage. The following are the available delivery systems:

Vial and syringe 

The Pro’s: Cost-effective and needle size are chosen. 

The Con’s: Cumbersome for transport. It must be kept at a proper temperature specific to the insulin. There is a propensity for error with the administration.

Insulin injection

Insulin injection has become simple by utilizing pre-filled insulin pens. The pre-mixed insulin pens offer ease for those that have a simple regimen or follow a sliding scale. 

The Pro’s: Many have memory storage to help you recall the insulin dosed. 

The pre-mixed pens have been helpful with these groups of people:

  • Have limited vision

  • Are older, or trouble with hand dexterity

  • Those with regular meal and activity patterns

  • Are new to insulin therapy

The con’s: The cost of refilled pens is expensive. 

Insulin Pump

The insulin pump is about the size of a pager, worn outside the body. This helps people who haven’t achieved good blood sugar control. It will deliver short-acting insulin every few minutes. The insulin administration occurs via a cannula that sits under the skin. The pump works 24 hours a day.

Pro’s: Steady insulin release mimics the body’s response to a meal. The small capacity allows young people to remain active. 

Con’s: you will still need to track your blood sugar. Also, you will need to change the needle every few days. The tubes can kink, which can cause an inaccurate dose. The startup cost can be $5000+

Injection sites

The most used injection sites include:

  • Stomach: This is the most common site used. It is important to pinch the skin before injecting.

  • Thigh: Choose an area roughly 4 inches above your knee, and pinch the skin. The inner thigh has many blood vessels, and this not an optimal area for injection.

  • Upper arm: This is the more difficult of the sites to self-administer insulin. Using the non-preferred arm tends to be easier.

  • Buttocks: Administration occurs below the spine and halfway up the buttocks

If you have had diabetes and inject insulin, you may start to develop scar tissue at injection sites. When you have scar tissue, it will be hard to insert the needle. Also, insulin maybe not be absorbed.

People will experience high blood glucose if they are injecting in a spot of skin with scar tissue. As a result, it is very important to rotate injection sites. You may find it helpful to track this as a reminder to rotate. 

Dosage

Your physician, diabetologist, or endocrinologist will determine your insulin regimen. What’s important to understand is that your insulin regimen will change with time.

There may be periods as you age where your needs change more. You may follow a specific insulin dose regimen or follow a sliding scale. When you use a sliding scale, you determine the amount of insulin given. You will read your pre-meal blood sugar level. Then calculate the number of carbohydrates consumed in the meal.

Depending on your need, insulin therapy may involve a combination of insulins. The dosage will be based on your metabolic needs will determine the dose. Total daily insulin requirements are generally between 0.5 to 1 unit/kg/day.

How it works

Rapid-acting insulin analogs work by absorbing into the bloodstream immediately. Insulin lispro (Humalog) begins to work within 15-20 minutes after administration. Rapid-acting insulin peaks at 1 hour and continues to work for 2 to 4 hours later.

Insulin Aspart is an insulin analog. It is a mealtime bolus to cover the carbohydrates eaten at a meal. Examples of rapid-acting include Novorapidor or Novolog. Novorapidor is a new long-acting insulin.

When injected under your skin, it has a faster onset of action than soluble human insulin. It takes effect within 10 to 20 minutes. The greatest effect will occur between 1-3 hours after injection, and the effect may last for up to 5 hours. 

Bolus insulin (mealtime insulin) is given many times per day. This imitates what a healthy pancreas would do. The person must eat to avoid hypoglycemia. These are both administered at mealtime and act fast.

Basal insulin is a type of long-acting insulin that provides a base cover of insulin. This background insulin helps give you coverage all day. It will give you slow and steady coverage. This mimics what a normal pancreas would do with a slow release of insulin. This helps prevent lows in-between meals and overnight.

Pre-mixed insulin is a combination of intermediate-acting insulin and short-acting insulin. It is cloudy-colored insulin. It is available in the names Humulin 70/30, Novolin 70/30, and ReliOn 70/30. It is useful as it requires only one injection.

Types of long-lasting insulin

Long-acting insulins have a slow peak less effect. Here will explore the ones available:

There are currently four different long-acting insulin products available:

  • Glargine Insulin is reputable insulin to choose from, sold as Lantus and Basaglar. It is a long-acting insulin used in both Type 1 and Type 2 diabetes. Glargine is the first insulin recommended by physicians in the U.K. and U.S.A. Preferred for ease of use, it is injected one time daily. It will increase the sugar uptake in muscles and fat cells and reduce the amount of sugar produced in the liver. 

    Pro’s: Reduction in severe hypoglycemia.

    Cons: Potential for mild hypoglycemia, weight gain, itching, or skin rash.
  • Nph insulin (Humulin) – This is an intermediate-acting insulin. It peaks within 2 hours and lasts for 24 hours. Out of the insulins, this appears different. It will have a cloudy or mild appearance. This needs to be shaken before administration. Regular insulin (Novolin) becomes active at 30 minutes and peaks between 2-4.

    Pros: Fewer shots, very inexpensive (the only generic insulin on the market). Reduced risk of Diabetic ketoacidosis when the NPH is active. 

    Cons: There is an unpredictable second peak time. This can cause hypoglycemia if you aren’t prepared. Nocturnal hypoglycemia is common among Type 1 diabetics, occurring while they sleep. It will often disrupt sleep but comes without warning. An Observational study completed with 82 patients transferred from once or twice daily NPH to insulin glargine once daily was shown to reduce nocturnal hypoglycemia and to improve fasting glucose. The first effect was a reduction in HbA1c of about 0.3% 2
  • Inhaled insulin (Afrezza) is new to the market. This has sold under the name Farixga and Exubera. The insulin molecule is a fast-acting insulin that is quickly absorbed into the lung. It starts to work about 15 minutes after inhalation. It will peak in approximately 1 hour and keeps working for 2 to 4 hours. 

    Pros: Works rapidly and is an alternative to injection. It also can be as a combination with other oral medications.

    Cons: Those who smoke, have COPD or other lung disorders are not good candidates. Those that have kidney or liver disease should not use inhaled insulin.

No pre-mixed insulins are using Lantus and detemir. This is because insulin glargine and detemir cannot mix. When combined with other insulin, action is disrupted.

With insulin use, there are many favorable results. Generally, there is a reduction in the risks of diabetes complications. Contradictory, some research has shown contradictions with long-term insulin use. Those with heart failure and diabetes do not have favorable outcomes.4

Hyperglycemia

Hyperglycemia occurs when blood glucose is high and consistent monitoring is needed. A diabetic coma can occur if blood sugar levels are too high or too low. This is a life-threatening situation. If you are unable to respond to stimuli and left untreated, it could be deadly.

Elevated blood sugar levels should be closely monitored. A diabetic coma can occur if blood sugar levels are too high or too low.

Type 1 diabetes can cause these symptoms and a situation called Diabetic Ketoacidosis. High blood sugars lead to the buildup of an acid called ketones. Ketones are present in your blood when you don’t have enough insulin to respond to the glucose.

If your blood sugar level is too high, you may experience:

  • Increased thirst

  • Fatigue

  • Frequent urination 

  • A rapid heartbeat

  • Shortness of breath

  • Nausea and vomiting

  • A very dry mouth

  • Stomach pain

  • Fruity breath odor (caused by ketone bodies breaking down)

Hypoglycemia

Hypoglycemia can occur if you take the wrong insulin dosage. Many mistakes are avoidable. When an insulin overdose occurs, it is due to one of the following:

  • Taking the insulin but then skipping a meal

  • Taking the wrong insulin. This could occur if you interchange long-acting for short-acting insulin or vice versa.

  • Misreading the vial. If your vision is low, you may have difficulty seeing. This can also occur if you begin you use new insulin in unfamiliar packaging

Most insulin overdoses can be treated at home. Your physician will help you plan. These are some general suggestions on how to manage an insulin overdose: 

  • Check your blood sugar. You will want to identify how low it is. If you are extremely low, it is safer to have an item that you are not required to chew. 
  • If you skipped a meal, and have overdosed insulin, eat something. Also, eat a rapid-acting carb.

  • Most important Rest. Get off your feet and take a break. When you move, your blood sugar will go lower.

  • Recheck your blood sugar after 15 or 20 minutes. If it’s still low, repeat the process. Take another 15 to 20 grams of a quick-acting sugar, and eat something if you can. Continue to rest.

  • Continue to monitor yourself over the next few hours. You will be prone to having another low blood sugar. Continue to snack if you need to raise your blood sugar. If it stays low after 2 hours, seek out medical attention. If you are experiencing confusion, please let a friend or family member know of the situation. If it worsens, those alerted will be able to help you.

Give your family and friends these instructions:

  • If you lose consciousness, they should call 911 immediately.

  • They may need to inject you with something called glucagon. This is an insulin antidote. If you’re prone to low blood sugar, ask your doctor if you should have glucagon on hand at home.

  • If you’re alert enough to follow instructions, they should give you one of the 15 g carbs mentioned before.

  • If your symptoms don’t improve during the next hour, they should call 911.

The best way to prepare for an occurrence is to understand that you may have complications at one point. It is important to wear some identification or medical alert tags. Be sure to inform your friends and family members of your signs and symptoms of low blood sugar.

Conclusion 

Glycemic control is assessed with the HbA1C test. Patient self-monitoring of blood glucose may help. Practitioners will use this information to make a medication adjustment and insulin changes.1 Making sure you get an HbA1C test 2-4 times a year will help prompt insulin dose changes. When you take control of your diabetes, you are likely to delay or prevent any related challenges.

Sources

  1. American Diabetes Association (2020). Glycemic Targets: Standards of Medical Care in Diabetes. United States: American Diabetes Association. Chapter 6.
  2. Insulin glargine, Editor(s): J.K. Aronson, Meyler’s Side Effects of Drugs (Sixteenth Edition), Elsevier, 2016, Pages 149-151, ISBN 9780444537164,
  3. (http://www.sciencedirect.com/science/article/pii/B9780444537171008970)
  4. CHRISTEL OERUM. (2018). Insulin Types: Their Peak Times and Durations. Available: https://diabetesstrong.com/insulin-types/. Last accessed December 4, 2020.
  5. Franco Cosmi. (2018 Feb 28). Treatment with insulin is associated with worse outcomes in patients with chronic heart failure and diabetes. European Journal of Heart Failure. 2018 May;20(5 (10.1002), 888-895

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