General principles of insulin therapy in diabetes mellitus
- David K McCulloch, MD
David K McCulloch, MD
- Washington Permanente Medical Group
Insulin is used in the treatment of patients with diabetes of all types. The need for insulin depends upon the balance between insulin secretion and insulin resistance. All patients with type 1 diabetes need insulin treatment permanently, unless they receive an islet or whole organ pancreas transplant; many patients with type 2 diabetes will require insulin as their beta-cell function declines over time.
Indications for insulin therapy, available formulations of insulin, insulin pharmacokinetics, and determinants of efficacy will be reviewed here. The specifics of insulin therapy for type 1 and type 2 diabetes and intensive insulin therapy for critically ill patients who become hyperglycemic are discussed separately. (See "Management of blood glucose in adults with type 1 diabetes mellitus" and "Insulin therapy in type 2 diabetes mellitus" and "Glycemic control and intensive insulin therapy in critical illness".)
WHICH PATIENTS NEED INSULIN
Insulin must be given to all patients with type 1 diabetes, which is due to autoimmune islet-cell injury that eventually leads to virtually complete insulin deficiency. Ideally, physiologic replacement of insulin, imitating the secretory pattern of the nondiabetic pancreas but keeping in mind that therapeutic insulin is administered subcutaneously, is desirable. (See "Pathogenesis of type 1 diabetes mellitus".)
The peak incidence of type 1 diabetes is around the time of puberty, but approximately 25 percent of cases present after 35 years of age . Insulin is also indicated for patients with secondary diabetes due to pancreatic insufficiency, as well as in many patients with type 2 diabetes to manage hyperglycemia.
Clinical features that, if present in a patient with diabetes at any age, suggest the need for insulin therapy include marked and otherwise unexplained recent weight loss (irrespective of the initial weight), a short history with severe symptoms, and the presence of moderate to heavy ketonuria. Diabetic ketoacidosis at first presentation usually indicates that the patient has type 1 diabetes and will require lifelong insulin treatment. However, some patients with type 2 diabetes, especially in the Afro-Caribbean populations (so-called "Flatbush diabetes"), may present with ketoacidosis. (See "Classification of diabetes mellitus and genetic diabetic syndromes" and "Syndromes of ketosis-prone diabetes mellitus".)
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- WHICH PATIENTS NEED INSULIN
- INSULIN PREPARATIONS
- Human versus analogs
- - Efficacy
- - Safety
- Basal versus bolus
- U-500 regular insulin
- U-300 insulin glargine
- Premixed insulins
- - ADA guidelines for mixed insulin
- Inhaled insulin
- DETERMINANTS OF INSULIN EFFICACY
- Type of insulin
- Size of subcutaneous depot
- Injection technique
- Site of injection
- Alterations in subcutaneous blood flow
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS