Treatment of type 1 diabetes is life-long. It can be challenging at times, especially in the beginning. Patients as well as the loved ones go thru an emotional roller-coaster. Its all understandable. The best thing you can do is to accept the fact and educate yourself about the treatment of type 1 diabetes in-depth. In this way, you get in the driver seat and take charge of your diabetes and prevent its complications. I have patients in their eighties, living a pretty good life without any serious complications of diabetes. One thing they did. They educated themselves about the treatment of type 1 diabetes when they were diagnosed with this disease in their young life.
Like any other illness, my comprehensive approach to treat Type 1 diabetes consists of five steps: stress management, diet, exercise, vitamins and medications. In this article I will describe the medications for the treatment of type 1 diabetes.
Though there are some experimental therapies being researched and tested today, insulin therapy is still the main treatment for Type 1 diabetic patients at present time.
The Rationale of Insulin Therapy in the Treatment of Type 1 Diabetes
In non-diabetics, the pancreas produces insulin all the time, even in a fasting state, at a rate of about 1 unit per hour. After eating a meal, the pancreas produces additional pulses of insulin to deal with the extra load of glucose in the meal. In Type 1 diabetics, of course, the pancreas does not produce insulin either in the fasting state or after a meal. With insulin therapy, you can create a continuous level of insulin by administering a long-acting insulin once a day and also regulate the glucose spike that comes with each meal by administering a short-acting insulin before each meal.
Types of Insulin
Let me first explain the various types of insulin available today:
- A long-acting insulin provides a basal—or continuous base of—insulin level in the body all the time
- A short-acting insulin before each meal provides coverage for that particular meal.
VARIOUS TYPES OF LONG-ACTING INSULIN
|Generic Name||Brand Name||Onset of Action||Peak of Action||Duration of Action|
Lantus or Toujeo
|3–4 hours||No peak||About 24 hours|
|2–3 hours||6–8 hours||12–16 hours|
Humulin N or
|2–3 hours||6–8 hours||12–16 hours|
Humulin L or Novolin L
|2–3 hours||6–8 hours||up to 24 hours|
|3–4 hours||Variable peak||Up to 28 hours|
VARIOUS TYPES OF SHORT-ACTING INSULIN
|Generic Name||Brand Name||Onset of Action||Duration of Action|
|30–90 minutes||3–4 hours|
|40–50 minutes||3–4 hours|
|40–50 minutes||3–4 hours|
Humulin R or Novolin R
|1–2 hours||5–8 hours|
Note: the time course of action of any insulin may vary considerably in different patients or at different times in the same patient. The duration of action depends on dose, site of injection, blood supply, temperature, and physical activity.
Long-Acting Insulin in the Treatment of Type 1 Diabetes
Lantus (glargine) and Humulin U (ultralente) have a slower onset and longer duration of action than Humulin N/Novolin N (NPH) or Humulin L/Novolin L (lente).
NPH, lente, ultralente, and detemir have a peak of action that is undesirable as it can cause low blood glucose unexpectedly. On the other hand, glargine doesn’t have any peak of action, making it the most desirable long-acting insulin at the present time.
Glargine insulin needs to be given only once a day and provides a good basal level. Ultralente is also given as a once-a-day injection.
Detemir, NPH or lente are also known as intermediate-acting insulin and are generally given twice a day, usually before breakfast and at bedtime (or dinner time).
MIXTURE OF INSULIN
For convenience, combination insulin—some short-acting, some long-acting—are also available.
|Brand Name||Insulin Combination||Onset of Action||Duration of Action|
Humalog Mix 75%
75% and Lispro 25%
|30 minutes||12 hours|
Novolog Mix 70%
|Aspart protamine 70% and Aspart 30%|
|30 minutes||12 hours|
|70% NPH and 30% Regular|
|1–2 hours||12–24 hours|
|50% NPH and|
|1–2 hours||12–24 hours|
Short-Acting Insulin in the Treatment of Type 1 Diabetes
Short-acting insulin, such as Humalog (lispro), Novolog (aspart), Apridia (glulisine), or Regular insulin, is used before each meal to provide premeal boluses of insulin.
I prefer to prescribe Humalog (lispro), Novolog (aspart), or Apridia (glulisine) over Regular insulin because these newer types of insulin have a very rapid onset of action. A patient can take the injection of lispro, aspart, or glulisine just before eating their meal. However, with Regular insulin, you need to wait for about thirty to sixty minutes after the insulin shot before eating your meal. Sometimes, patients take their Regular insulin shot and then forget to eat or wait for a long time in a restaurant for their food. This places them at a high risk for low blood sugar (also known as hypoglycemia or insulin reaction).
Humalog (lispro), Novolog (aspart), and Apridia (glulisine) have another advantage in that they are out of your system in about four to five hours as compared to Regular insulin, which hangs around in the body for about eight hours. The shorter duration of action of lispro, aspart, and glulisine reduces the risk of low blood sugar before the next meal as compared to regular insulin.
Regular insulin at dinner time is usually responsible for low blood sugar in the middle of the night. All short-acting insulin should be avoided at bedtime.
You need to inject Humalog, Novolog, Apridia, or Regular insulin before each meal.
If you administer your insulin therapy via shots, it’s important to know that you can draw a short-acting insulin and a long-acting/ intermediate-acting insulin in the same syringe. For example, you can draw Humalog and NPH in the same syringe before breakfast. Draw Humalog first and then NPH.
However, Lantus is an exception to this mixing. You cannot
mix Lantus (glargine) and another insulin in the same syringe.
How to give Insulin
You can give yourself insulin in one of the following ways:
- Insulin shots
- Insulin pump
For your specific case, you’ll need to discuss the pros and cons of each option with your physician. To prepare you for a meaningful conversation with your physician, here’s what you need to know about your options:
Insulin Shots in the Treatment of Type 1 Diabetes
Insulin shots deliver insulin to the body via an injection under the skin. You can give yourself an insulin shot with a traditional insulin syringe or with the relatively new technology of an insulin pen. Insulin pens are becoming popular because of their convenience—the pens are prefilled with insulin so that you don’t have to take the time to draw insulin from a bottle. You still need to calculate the dose of insulin to be administered each time you use a pen.
If you use insulin shots, you must administer an injection before each meal. You must also check your blood glucose level before each insulin shot in order to best assess how much insulin to administer.
Advantages of Insulin Shots
- Insulin shots are a tested delivery system: we have the longest clinical experience with this form of insulin therapy
- With the help of a nurse, a diabetes educator, or a physician, it’s pretty easy to learn how to give yourself an insulin shot
- Insulin shots are relatively inexpensive compared to other forms of insulin therapy Disadvantages
- Although new needles are extra fine and much less painful than previous ones, some people still report that insulin shots are painful
- Having to give yourself multiple shots a day can be inconvenient If you and your physician determine that insulin shots are the best form of insulin treatment for you, your physician or a nurse will teach you how to draw insulin from a bottle and give yourself insulin shots under the skin. The best places for insulin shots are the stomach or a thigh. You can also inject in the buttocks or an arm, but generally the stomach or a thigh enables the best insulin absorption. To avoid bruising, scar tissue (which inhibits insulin absorption), and for best insulin absorption, it’s important to rotate your injection site each time you give yourself an insulin shot.
Insulin pens, which come prefilled, are rapidly becoming popular. They make it easier for diabetics to administer insulin, especially in situations such as at school or in a restaurant or office. Insulin pens are an especially good choice for children because they are self-contained and less cumbersome than insulin vials and syringes.
Insulin Shot/Pen Doses
Your physician will calculate the initial dose of long-acting insulin and short-acting insulin for you.
Thereafter, you will need to be educated on how to adjust the dose of short-acting insulin according to the type of meal you are about to eat, your level of blood glucose before the meal, and your level of activity after the meal. As a general rule, 1 unit of short-acting insulin will cover 10–15 g of carbohydrates. I tell my patients to decrease the dose if a high level of exercise such as jogging is planned after the meal. I also provide my patients with a detailed sliding scale as a guide to further adjust the dose of short-acting insulin before each meal. Ask your physician about providing you with something similar.
On each office visit, your blood glucose values should be reviewed and insulin doses should be further fine-tuned by your physician.
Insulin Pump in the Treatment of Type 1 Diabetes
Via a needle inserted under the skin and attached to a beeper shaped pump that can hook to a belt loop, an insulin pump delivers insulin under the skin continuously. You program the pump to automatically administer an individualized basal rate of insulin throughout the day and night. After checking your blood glucose, you must also manually prompt the pump to administer a bolus of insulin before each meal.
You can program more than one basal rate, depending upon your individual needs. For example, most patients need to have two basal rates: one from 9 a.m. to 3 a.m. and then another higher basal rate from 3 a.m. to 9 a.m. to provide coverage for the dawn phenomenon.
What is Dawn Phenomenon?
At dawn, many diabetics have an increase in blood glucose due to a surge of three hormones in the body: growth hormone, cortisol, and catecholamines. All three of these hormones cause an increase in blood glucose. This is known as the dawn phenomenon.
Some patients prefer to have 3-4 basal rates.
Only short-acting insulin such as Lispro or Aspart is used in an insulin pump to provide both a continuous, basal rate as well as premeal boluses.
Advantages of Insulin Pump
- The biggest advantage of an insulin pump is that it provides greater flexibility in timing of meals. You don’t have to eat at a particular time as is the case with insulin injection therapy. You can even skip a meal without the fear of low blood sugar because, in an insulin pump, you don’t use any long acting insulin and only a small dose of short-acting insulin is being administered at a continuous, basal rate. You give a large dose of short-acting insulin in the form of a bolus only when you eat a meal. If you skip a meal, you don’t give yourself a bolus and therefore don’t run the risk of low blood sugar.
- Patients who have wide swings in their blood glucose values on insulin shots generally do much better by switching to an insulin pump. Second-generation sensor-augmented pump, with built-in continuous glucose monitoring(CGM), offers round-the-clock glucose monitoring. The pump also delivers early notification of oncoming lows and highs so the patient can react quickly to the changes in the sugar level.
- Pregnant patients also are good candidates for an insulin pump
Disadvantages of Insulin Pump
- The learning curve: an insulin pump requires a certain level of learning skills on the part of the patient. The pump is like any technical gadget—you need to learn its various prompts thoroughly. For example, you must learn how to set the basal rate/rates, how to give boluses, and how to load the insulin reservoir in the pump. You must be able to take good care of your insulin pump and its accessories.
- The pump needle must be changed every three days—you will still need to insert a needle under your skin each time
- You must be motivated and vigilant in order to avoid and recognize complications that can occur with the use of the insulin pump, such as skin infections and mechanical failures
- Insulin pumps come with an increased risk of skin infection at the needle site. If not treated promptly, an infection at the needle site can lead to a rapid rise in blood glucose levels and even a life-threatening medical emergency, such as diabetic ketoacidosis (DKA).
- Pump mechanical failure can lead to cessation of insulin delivery and your blood glucose can rise rapidly. This situation can potentially throw you into a life-threatening medical emergency, diabetic ketoacidosis (DKA). Therefore, you need to keep a supply of insulin shots on hand for emergency situations, such as when your insulin pump or its tubing is not functioning properly.
- The insulin pump is much more expensive than insulin shots
- Some patients don’t like having the pump attached to them—the pump might appear lumpy under clothing, creating cosmetic problems for some patients
Getting Started on an Insulin Pump
Once you decide to use an insulin pump, your physician will arrange for a nurse to spend time with you to educate you about your insulin pump. The nurse will familiarize you with the insulin pump and its accessories.
You then start a test period. For about three or four days, you wear an insulin pump, but instead of insulin, saline (salt water) runs through the system.
Once you feel comfortable with the operation of the pump, you go back to your physician to initiate your insulin therapy.
Insulin Pump Doses
The total daily dose of insulin for an insulin pump is about seventy five percent of the total daily dose that you take in the form of injections. Fifty percent of this dose is provided as the basal rate for the twenty-four-hour period and the other fifty percent is divided into three doses, one before each meal. In the first week, you need to check your blood glucose before each meal, as well as at bedtime and at 3 a.m. Thereafter—if you have your pump and your blood glucose levels under control—you will likely only have to check your blood glucose before each meal.
Adjusting Pump Doses
As mentioned above, there is a certain learning curve when you use an insulin pump. You can’t assume that your diabetes is now on autopilot! Depending on your blood glucose values, your physician may make further adjustments to your basal rate as well as boluses before meals. For example, in my patients, if early morning blood glucose values are high, I add another higher basal rate for the hours between 3 a.m. and 9 a.m. to cover the dawn phenomenon.
I also recommend further adjustments in the dose of boluses according to a patient’s blood glucose level before a meal, the amount of carbohydrates in the meal, and the level of activity planned after the meal. I tell my patients to decrease the dose of bolus if a high level of exercise such as jogging is planned after the meal. When using an insulin pump, it’s especially important to learn carbohydrate counting so that you can accurately administer a bolus before each meal. A dietitian can help you in this regard. As a general rule, 1 unit of insulin is needed to cover 10–15 g of carbohydrates. But you will need to figure out how many grams of carbohydrates get covered by 1 unit of insulin, in your case.
Symlin (generic: pramlintide) in the Treatment of Type 1 Diabetes
Symlin is not insulin. It is a synthetic analogue of amylin, a hormone that is normally secreted along with insulin by the beta cells of the pancreas. Amylin decreases glucose production by the liver, decreases the rate at which food passes from the stomach to the intestines, and also reduces appetite. Through these actions, amylin prevents a sharp increase in blood glucose after a meal. In Type 1 diabetics, amylin is no longer present. Symlin has the same actions as amylin.
However, Symlin is not a replacement for insulin. It is used in addition to insulin to further control blood glucose levels after a meal.
Symlin must be taken before meals, in addition to short-acting insulin such as Humalog, Novolog, apridia, or regular insulin. Like insulin, Symlin needs to given by injection. However, insulin and Symlin cannot be mixed in the same syringe. Insulin and Symlin need to be given by separate injections. Symlin has not been tested in children.
Caution about Symlin
Symlin, in combination with insulin, can cause severe hypoglycemia.
Therefore, you should not use Symlin if:
- You frequently experience hypoglycemia
- You cannot tell when your blood sugar is low (hypoglycemia unawareness)
- You do not check your blood glucose before and after every meal and at bedtime
- You do not see your doctor at least every two months
Side Effects of Symlin
Symlin often causes nausea. If you already suffer from slow stomach emptying (a diabetic complication known as gastroparesis), you should not be on Symlin. Other side effects include vomiting, headache, weakness, dizziness, and allergic reaction. At this time, we have very limited experience with Symlin at the Jamila Diabetes & Endocrine Medical Center. Therefore, I can’t give you my complete opinion about this new drug. Insulin Resistance Syndrome in Type 1 Diabetics Some Type 1 diabetics slowly develop Insulin Resistance Syndrome as they get older, gain weight, and adopt a sedentary lifestyle. A typical young, thin, Type 1 diabetic patient requires about 30 to 40 units of insulin per twenty-four hours. If you use more than 40 units of insulin per each twenty-four-hour period, you probably have insulin resistance. Insulin resistance places you at high risk for cardiovascular events such as heart attacks and strokes.
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