Insulin for Diabetes Treatment: Facts about Side Effects

What is diabetes?

Diabetes is a set of related diseases in which the body cannot regulate the amount of sugar (specifically, glucose) in the blood.

What are the types of diabetes?

The related diseases of diabetes include:

• Type 1 diabetes
• Type 2 diabetes
• Gestational diabetes
• Prediabetes
• Metabolic syndrome (syndrome
  X)
• Insulin resistance (a condition that precedes the development of type 2 diabetes)

What are the symptoms of diabetes?

Symptoms of diabetes include

• Increased urine output
• Excessive hunger

• Urinary tract infections (UTIs)

• Unexplained weight loss

• Excessive thirst

• Excessive urination
• Excessive eating

• Poor wound healing

• Some types of infection

• Altered mental status

• Blurry vision

• Fatigue

What are examples of insulin preparations available?

Insulin preparations

Examples of rapid acting insulin

• Apidra (insulin glulisine): Supplied in a cartridge, vial, prefilled pen (Solostar)
• Novolog (insulin aspart): Supplied in a cartridge, vial, prefilled pen (FlexPen)
• Humalog: (insulin lispro): Supplied in a cartridge, vial, prefilled pen (Kwik Pen)

Examples of short acting insulin

• Novolin R, Humulin R (regular insulin): Supplied in a vial
• Velosulin (insulin with a phosphate buffer): Supplied in a pump device

Examples of intermediate acting insulin

• Humulin N, Novolin N (NPH): Supplied in a vial, pen (Humulin N pen)

Examples of long acting insulin

• Lantus (insulin glargine): Supplied in a vial, cartridge (OptiClick), prefilled pen (Solostar)
• Levemir (insulin detemir): Supplied in a vial, prefilled pen (FlexPen)
• Tresiba (deglutec injection): Supplied in a vial 

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For what type of diabetes is insulin prescribed?

Indications for insulin

• Type 1 diabetes
• Type 2 diabetes
• Insulin resistance
• Diabetic ketoacidosis (DKA)
• Gestational diabetes
• Diabetes treatment
  during pregnancy

What are the side effects of insulin?

Hypoglycemia
>40%
Severe hypoglycemia
n/a

Headache
12% to 35%
Allergic reactions
n/a

Flu-like symptoms
13%
Anaphylaxis
n/a

Weight gain
33%
Hypokalemia
n/a

Lipoatrophy
n/a

Itching
n/a

Rash
n/a

Injection site reaction
n/a

* n/a = not available

Diabetes is defined best as…
See Answer

What is the dosage and how is insulin administrated?

Dosage and Administration of insulin

• A meal should be consumed within 30 minutes after administering regular insulin
• Insulin usually is administered by subcutaneous injection into the abdominal wall, thigh, buttocks
  (gluteal region), or upper arm. Injection sites should be rotated within the same region.
• Some insulins (for example, regular insulin) also may be administered intravenously.
• The dose is individualized for each patient.
• A combination of short or rapid acting and intermediate or long acting insulin typically are used
• Some patients may develop resistance to insulin and require increasing
  doses.
• Multiple daily insulin injections or continuous subcutaneous infusions via a pump closely mimic pancreatic insulin secretion.
• Insulin sliding scales (doses of insulin that are based on the glucose
  level ) may be used for managing critically ill hospitalized patients.

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What are the contraindications, warnings, and precautions for insulin?

Contraindications

• Hypoglycemia (low blood sugar)
• Hypersensitivity to insulin or its excipients (inactive co-ingredients)

Warnings and Precautions

• Hypoglycemia may occur and is the most common side effect of insulin treatment.
• Severe, life-threatening allergic reactions, including anaphylaxis, may occur.
• Hypokalemia (low blood potassium) may occur because insulin stimulates movement of potassium from blood into cells. Combining insulin with potassium-lowering drugs may increase the risk of hypokalemia.
• Hepatic (liver) impairment may reduce the insulin requirement.
• Renal (kidney) dysfunction may reduce the insulin requirement.
• Illness, emotional disturbance, or other stress may alter the insulin requirement.
• Intravenous administration increases the risk of hypoglycemia and hypokalemia.

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Which drugs
interact with insulin?

Insulin Drug Interactions

Beta blockers (for example,
propranolol [Inderal,
Inderal LA, Innopran XL], atenolol
[Tenormin])
Beta blockers may mask symptoms of hypoglycemia or prolong hypoglycemia and alter glucose metabolism
Avoid combination if possible

repaglinide
(Prandin)
Increased risk of hypoglycemia and heart attack (myocardial infarction)
Avoid combination if possible

rosiglitazone
(Avandia) or rosiglitazone combination products
Increased incidence of hypoglycemia, fluid retention, ischemia (manifest by
angina or heart pain),
congestive heart failure
Avoid combination if possible

Thiazides and thiazide combination products
Hyperglycemia; may reduce effect of insulin
Monitor glucose levels and adjust accordingly

Corticosteroids
Hyperglycemia; may reduce effect of insulin
Monitor glucose levels and adjust accordingly

Estrogens
Hyperglycemia; may reduce effect of insulin
Monitor therapy and adjust as needed

levofloxacin
(Levaquin) and other fluoroquinolones
Increased risk of hypoglycemia or hyperglycemia
Use with caution, monitor therapy

Monoamine oxidase inhibitors (MAOIs)
MAIOs may increase insulin secretion. Combination increases risk of prolonged hypoglycemia.
Monitor glucose levels and adjust accordingly

Sulfonylureas
Increased risk of hypoglycemia and
Monitor glucose levels and adjust accordingly

Thyroid hormones
Thyroid hormones may increase insulin requirement
Monitor glucose levels and adjust accordingly

Yohimbe
Yohimbe may increase risk of hypoglycemia
Caution is advised

How well does insulin treat diabetes?

Efficacy of insulin

• In a 24 week study of patients with type 1 diabetes, regular human subcutaneous insulin (mean dose = 18.3 IU) before breakfast and dinner plus human insulin isophane suspension twice daily (mean dose = 37.1 IU) reduced
  HbA1c by 0.4% from baseline and fasting glucose by -6 mg/dl.
• In a 24 week study of patients with type 2 diabetes, regular human subcutaneous insulin (mean dose = 25.5 IU) before breakfast and dinner plus human insulin isophane suspension twice daily (mean dose = 52.3 IU) reduced HbA1c by 0.6% from baseline and fasting glucose by -6 mg/dl.

What is the mechanism of action (how it works) for insulin?

Pharmacology (mechanism of action) of insulin

Insulin is a hormone secreted by the pancreas. It regulates the movement of glucose from blood into cells. Insulin lowers blood glucose by stimulating peripheral glucose uptake primarily by skeletal muscle cells and fat, and by inhibiting glucose production
and release by the liver. Insulin inhibits lipolysis (breakdown of fat), proteolysis (breakdown of proteins), and gluconeogenesis
(manufacture of glucose). It also increases protein synthesis and conversion of
excess glucose into fat. Insulins used to treat diabetes are pharmacologically similar to the naturally produced hormone. Patients with diabetes are insensitive to insulin and do not produce enough insulin which leads to hyperglycemia and symptoms of diabetes. Exogenous insulin preparations replace insulin in diabetics, increasing the uptake of glucose
by cells and reducing the short and long term consequences of diabetes.