September 18, 2013

What You Need to Know About Insulin

Insulin is the medication people with type 2 diabetes seem to want to avoid. From doctors to patients this aversion seems to be very common. I am happy that so many of our group is the other way and using insulin to an advantage in managing our diabetes. All of us are using multiple daily injections (MDI) and not regretting it. One has investigated switching to an insulin pump, but the cost ended this when his insurance company rejected his request.

I have looked at different images indicating the proper place to inject insulin and in general, they all indicate the same areas, but not the same for the outer edges. Part of the reason could be that some people make different recommendations based on the type of insulin being injected. There are four primary areas for injecting insulin and all are supposed to be injected into fatty tissue. This does not mean that every area with fatty tissue is acceptable. The acceptable areas are the abdomen, the back of the arms, the upper side of the thigh, and the upper part of the buttocks as shown in the following image indicate.

There are some suggestions laid out by Joslin that I consider valid considerations and a few others that may work. For best absorption, the abdomen is the first area, followed by the back of the upper arms, buttocks, and thighs. Do not inject into any area in these places that have scars, hardened or lumpy feeling tissue. 

Warning: Do not inject any fast acting insulin (such as Novolog) within four (4) inches of long-acting insulin (such as Lantus). Doing this will cause the long-acting insulin to become faster acting insulin and bring about an episode of hypoglycemia.

The newer insulins (analogues) work the same from all four of the injection sites. This is true of both the long-acting analogues (e.g. Levemir or Lantus) as well as the rapid-acting ones (e.g. Humalog). This is true of the newer premixed insulins made up of two analogues. If you are using a GLP-1 agent (e.g. Byetta or Victoza), you can also inject it at any of the injection sites.

The older insulins (e.g. rapid-acting human insulins like NovoRapid or NPH) you should use the ‘waist rule’. Injections above the waist (abdomen and arm) are absorbed faster than injections below the waist (thigh and buttocks). Use the abdomen when injecting the faster-acting insulins since absorption is fastest there and this insulin is usually given just before meals. Use the thigh or buttocks when you’re using NPH as the basal insulin since absorption is slowest there and you want it to last as long as possible.

When you’re using older premixed insulins (e.g. Mixtard), they should be given in the abdomen in the morning to increase the speed of absorption of the short-acting insulin (to cover breakfast). Any mix containing NPH and given in the evening should be injected in the thigh or buttocks. This leads to slower absorption and decreases the risk of nighttime hypoglycemia.

Many people (patients and surprisingly many doctors) believe the myth that by taking insulin, their pancreas will stop producing insulin. Often these same doctors push oral medications until people become glucose toxic. Then the doctors are forced to prescribe insulin because blood glucose is so high that it inhibits normal insulin function and by adding insulin therapy, this helps the pancreas work more efficiently.

Because most in the medical community view type 2 diabetes as being progressive, they continue to push oral medications long beyond when insulin therapy would have created more success. Yes, even over time, our beta cell in our pancreas will stop working and insulin therapy then becomes a necessity. If insulin therapy had been initiated earlier, more beta cells might have been preserved and would have continued producing insulin for a much longer time. This is one reason I will continue to ask doctors and patients why insulin is always considered the medication of last resort.


Anonymous said...

It is very difficult to get a prescription for insulin especially in Ontario Canada where it was first invented.

Bob Fenton said...

Is this because doctors want you to stay on oral medications, or is this a problem in Ontario with the health care system?