Insulin, when and how?

Control of diabetes is not always achieved with oral antidiabetic drugs (OAD), either because of metabolic imbalance despite optimal doses or because of the specific circumstances of the person with diabetes. Insulin monotherapy compared to oral antidiabetics is a potent weapon, with studies showing a reduction in HbA1c from 1.5 to 3.5%.

In long-term diabetes, the picture is dominated by a decrease in the pancreas’ ability to secrete insulin. So what are the formal indications for insulin therapy? Within the metabolic disorder, we can refer to 3 situations: fasting hyperglycemia despite optimized doses of OADs, persistent postprandial hyperglycemia, very complex drug regimens that can lead to poor adherence.

Among the other reasons for insulin institution we have:

  1. Renal failure (stage V kidney disease).
  2. Liver failure.
  3. Pregnancy (metformin already indicated in pregnancy) or planning to become pregnant.
  4. Intercurrences such as severe infections, acute myocardial infarction, or surgery.
  5. Ketoacidosis.
  6. Severe cases of weight loss.

When we do not reach HbA1c values ​​​​with optimized oral therapy, basal insulin can be started. After instituting basal insulin (which may be associated with metformin), rapid insulin can be combined with up to 3 of the main meals. Another alternative, despite being a more rigid strategy, is to associate pre-mixed insulins according to individualized schedules divided by night and morning.

In insulin therapy, it is always essential to assess hypoglycemia and teach the patient how to deal with them. In trained patients, the patient can be taught how to adjust doses without resorting to medical care. However, a closer and more personalized follow-up is often necessary, with the patient having to go to the health unit to adjust insulin doses.

People with diabetes should always try to acquire autonomy, which is impossible. The involvement of family members is essential, and the social support network (homes, day centers) must play a central role in the therapeutic management of these patients. Community resources such as CCUs should be contacted to support the patient through all stages of treatment.

In all consultations, a space should be dedicated to clarifying doubts and reviewing the administration technique. It is important to palpate the abdomen to search for lipodystrophies that may compromise insulin absorption. Units should have eye-catching and explanatory teaching materials: models for insulin injection sites and leaflets on dealing with and identifying hypoglycemia.

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