I Have Type 2 Diabetes: Why Should I Take Insulin

I Have Type 2 Diabetes: Why Should I Take Insulin!

Dr. S.M.Sadikot.
Hon. Endocrinologist,
Jaslok Hospital and Research Centre,
Mumbai 400026

Many people are under the false impression that because they have Type 2 diabetes, they will never need to take insulin injections.

This is far from true.

Whilst it is true that insulin treatment is vital for people with Type 1 diabetes (in fact they will die without the insulin injections!), it is also true that many of you with Type 2 diabetes may also be asked by your doctor to take insulin injections, so that your blood glucose can be well controlled.

In many of you, your pancreas can secrete some insulin but this may not be enough to meet your needs and give you good control. The tablets in this case, can only help to a certain extent. But often the deficit of insulin has to be made up by injecting insulin along with some tablets.

This especially happens in times when your body requires more insulin than usual and your pancreas is not able to increase the supply of insulin. This may happen at times of stress, both mental, or more often physical, such as infections, etc.

In such cases you may not need to take the insulin injections for a long while but only till the "stress", say infection persists in your body. Once the infections is cured you may be able to control your blood glucose by diet, exercise and tablets again.

Many patients believe that if they take insulin even for a short while, they will become "addicted' to it and will have to take it for a lifetime. This is totally wrong and one cannot get addicted to something which is found normally in one's body! Moreover, in many cases you will be able to do away with the insulin after a while.

You must also realize that the tablets which are used to treat diabetes are NOT insulin. They can only act in the presence of insulin which is secreted by your body. If the ability of your body to secrete insulin is low, then tablets will not give you good control, no matter how many tablets you take in whatever combinations!

No matter what some "quack" doctors may claim, insulin is NOT available as a tablet.

The tablets also show a lessening of their effectiveness after a few years and we can this as "secondary failure" of the tablets. They were effective initially but not now. Again you would have to take insulin injections if you want to control your blood glucose properly.

Finally there are certain conditions where we do not use tablets such as in a pregnant woman who has diabetes. You may have kidney or liver problems which also means that most of the tablets cannot be given to you.

In all these cases you will have to take insulin for varying periods of time.

So, many people with Type 2 diabetes may be asked by their doctor to take insulin injections.

This does not mean that your case has become very serious and that you have reached a terminal stage!

This is nonsense!

Some of you can be managed with diet and exercise only, some will need to add tablets whilst some if you may require insulin to get good control!

Many patients ask their doctors why he wants them to take insulin whilst he continues to treat some others with tablets. You must understand that every person is different and the capacity of secrete insulin differs in each person. The aim is to control your diabetes. The "end" point is control. The "means" will differ from person to person!

You have to think of insulin as being just one more option in trying to control your diabetes. There is nothing sinister or serious about being asked to take insulin.

In order to avoid taking insulin many patients take to herbal remedies and fall prey to various tall and false claims by many quacks about how they can not only see to it that you do not have to take the insulin injections, but that they can even "cure" your diabetes.

Please do NOT become a victim of such false claims. Some of these so-called "natural" or herbal remedies may occasionally show some lowering in your blood glucose, but this rarely lasts for more than a few days. More importantly, we know that many of these "quack" treatments are dangerous and can cause severe kidney and liver damage.

But, who would like to take injections daily?

Fortunately, the newer needles which are used to give insulin injections, and the needles used in "pens" which deliver insulin, are so small and thin needles that injections are almost painless!

The insulins available for routine clinical use are the beef, porcine and human insulin. These are the "pure" varieties and contain negligible amounts of contaminants.

Beef and porcine insulins are so called as they are extracted from the pancreas of cows and pigs respectively. "Human" insulins are made by a technique called genetic engineering which creates insulin which has the same structure as the insulin normally found in the human body. This is the reason they are called human insulins. They are NOT extracted from dead human beings! Although more and more people are using human insulins, the bovine and porcine insulins are also widely used.

The decision as to which insulin you should use is something which you and your doctor must decide.

We have seen that three major types of insulin are available for clinical use. Each of these come in various forms which have been so modified so as to alter the timings of their activity in the body after they are injected.

Thus we have insulins which have a different time of "onset" ( how soon the insulin starts working; a different "peak time" (when it shows the maximum effect) and finally the "duration" (how long it lasts in your body).

Thus We Have

Insulin Begins Working Peaks At Ends Working Lows Occur At
Lyspro 15-20 minutes 30-90 min 3-4 hours 2 to 4 hr
Insulin- aspart 15-20 minutes 40-50 min 3-4 hours 2 to 4 hr
Regular 30-60 minutes 80-120 min 4-6 hours 3 to 7 hr
NPH 2-4 hours 6-10 hours 14-16 hours 6 to 12 hr
Lente 3-4 hours 6-12 hours 16-18 hours 7 to 14 hr
Ultralente 4-6 hours 10-16 hours 18-20 hours 12 to 24 hr
Insulin Glargine 2-3 hours almost no peak 18-26 hours 4 to 24 hr

Rapid acting

Rapid acting

This is seen in "special" types of insulin which are called insulin analogs. Human insulin has been further modified to alter the time of its activity. Presently only Lyspro is available in India, although insulin aspart should soon be available for clinical use.

Short acting

Short acting

Short-acting (regular) insulin usually reaches the blood within 30 minutes after injection. It peaks 2 to 4 hours later and stays in the blood for about 4 to 8 hours.Intermediate acting;

Intermediate-acting

Intermediate-acting

(NPH and lente) insulins reach the blood 2 to 6 hours after injection. They peak 4 to 14 hours later and stay in the blood for about 14 to 20 hours.Intermediate-acting insulins include lente and NPH. Insulin preparations with a predetermined proportion of NPH mixed with regular, such as 70% NPH to 30% regular, or a 50/50 mix are called intermediate acting for purposes of classification, although their activity characteristics would be different from either only NPH/Lente or only Regular insulins.

Long acting

Long acting

Long-acting (ultralente) insulin takes 6 to 14 hours to start working. It has no peak or a very small peak 10 to 16 hours after injection. It stays in the blood between 20 and 24 hours.

However, each person responds to insulin in his or her own way. That is why onset, peak time, and duration are given as ranges.

If you are using insulin, it may be worthwhile to have some understanding of the timings of the insulins which you are using. When blood glucose levels are not well controlled at certain times during the day, or if hypoglycemic reactions are occurring, the knowledge of the action and characteristics of each insulin being taken will help to determine where changes need to be made.

The main side effect is a hypoglycemic (low blood glucose) reaction which we have discussed in a separate section.

The antibodies seen in the older "impure" insulins could give rise to antibodies in the blood which would not allow insulin to be effective or lead to an allergic reaction. These problems are rarely seen with the "pure" insulins available now.

Edema; insulin has salt retaining properties and may cause fluid retention; in some patients it may be necessary to adjust the dose of diuretics and/or salt intake.

"Bumps" or "hollows" seen at the site where the insulin is injected was common with the older impure insulins and is called lipodystrophy; rarely seen nowadays.

(A) Insulins are presently available in strengths of U-40, and U-100; one must ensure that the syringes used by the patient are compatible with the strength of insulin used.

In other words, make sure that if you are using an insulin which has a strength of U-40 ( which means that 1c.c. contains 40 units of insulin), you MUST use a syringe where 1c.c. is divided into 40 parts. Similarly, if you are using a U-100 insulin ( in which 1c.c contains 100 units of insulin) make sure that you use a syringe in which 1 c.c. is divided into 100 parts.

This is very important and using the wrong strength syringe and insulin can lead to serious problems.

This problem would not arise in people using insulin "pens".

(B) Insulin vials should be preferably stored at 4-8 C. If possible they should be kept in the refrigerator, but NOT in the freezer section. The insulin vial should be brought down to body temperature by gently rubbing it between the palms before withdrawing the insulin into the syringes.

If refrigeration facilities are unavailable, then the currently used vial can be stored at room temperature away from heat and direct sunlight.

If vials have to be stored for longer periods, a simple method is for the unopened vials to be stored in the earthen pots which contain drinking water and are found in most homes where a refrigerator is not present.

(C) It is advisable to use disposable syringes.

You can re-use the same disposable syringe and needle for around 6-8 injections, or less if the needle feels blunt.

You should never use a syringe which has been used by someone else!

Preparing The Insulin Injection

Follow these steps when preparing a single type of insulin for an injection.

1. Roll the bottle (vial) gently between your hands. This will warm the insulin if you have been keeping the bottle in the refrigerator. Roll a bottle of cloudy insulin until the white powder has dissolved.

Roll the bottle

2. Wipe the rubber lid of the insulin bottle with an alcohol wipe or a cotton ball dipped in alcohol. If you are using a bottle for the first time, remove the protective cover over the rubber lid.

3. Remove the plastic cap covering the needle on your insulin syringe (without touching the needle).

Pull the plunger of the syringe
Illustration of step 4

4. Pull the plunger of the syringe back and draw air into the syringe equal to the number of units of insulin to be given.

5. Insert the needle of the syringe into the rubber lid of the insulin bottle. Push the plunger of the syringe to force the air into the bottle. This equalizes the pressure in the bottle when you remove the dose of insulin. Leave the needle in the bottle.

Insert the needle of the syringe into the rubber lid
Illustration of step 5
Turn the bottle and syringe upside down
Illustration of step 6

6. Turn the bottle and syringe upside down and hold them in one hand. Position the tip of the needle so that it is below the surface of insulin in the bottle. Pull back the plunger to fill the syringe with slightly more than the correct number of units of insulin to be given.

7. Tap the outside (barrel) of the syringe so that trapped air bubbles move into the needle area. Push the air bubbles back into the bottle. Make sure you now have the correct number of units of insulin in your syringe.

Tap the outside (barrel) of the syringe
Illustration of step 7
Remove the needle from the bottle

8. Remove the needle from the bottle. Now you are ready to give the injection.

1. Roll the insulin bottles (vials) gently between your hands. This will warm the insulin if you have been keeping the bottle in the refrigerator. Roll the cloudy insulin bottle until all the white powder has dissolved.

2. Wipe the rubber lid of both insulin bottle with an alcohol wipe or a cotton ball dipped in alcohol. If you are using a bottle for the first time, remove the protective cover over the rubber lid.

3. Remove the plastic cap covering the needle on your insulin syringe (without touching the needle).

Pull the plunger
Illustration of step 4

4. Pull the plunger back on your insulin syringe and draw air into the syringe equal to the number of units of cloudy insulin to be given.

5. Push the needle of the syringe into the rubber lid of the cloudy insulin bottle. Push the plunger of the syringe to force the air into the bottle. This equalizes the pressure in the bottle when you later remove the dose of insulin. Remove the needle from the bottle.

Push the needle of the syringe into the rubber lid
Illustration of step 5

6. Pull the plunger of the syringe back and draw air into the syringe equal to the number of units of clear insulin to be given.

7. Push the needle of the syringe into the rubber lid of the clear insulin bottle. Push the plunger to force the air into the bottle. Leave the needle in place.

Turn the bottle and syringe upside down
Illustration of step 8

8. Turn the bottle and syringe upside down and hold them in one hand. Position the tip of the needle so that it is below the surface of insulin in the bottle. Pull back the plunger to fill the syringe with slightly more than the correct number of units of clear insulin to be given.

9. Tap the outside (barrel) of the syringe so that trapped air bubbles move into the needle area. Push the air bubbles back into the bottle. Make sure that you have the correct number of units of insulin in your syringe. Remove the needle from the clear insulin bottle.

Tap the outside (barrel) of the syringe
Illustration of step 9

10. Insert the needle into the rubber lid of the cloudy insulin bottle. Do not push the plunger because this would force clear insulin into your cloudy insulin bottle. If clear insulin is mixed in the bottle of cloudy, it will alter the action of your other doses from that bottle.

Turn the bottle and syringe upside down
Illustration of step 11

11. Turn the bottle and syringe upside down and hold them in one hand. Position the tip of the needle so that it is below the surface of insulin in the bottle. Slowly pull back the plunger of the syringe to fill the syringe with the correct number of units of cloudy insulin to be given. This will prevent air bubbles entering the syringe. Remove the needle from the bottle.

12. You should now have the total number of units for the clear and cloudy insulin in your syringe. For example, if 10 units of clear and 15 units of cloudy are needed, you should have 25 units in your syringe. Now you are ready to give the injection.

Injection sites include the abdomen, outer upper arms, the thighs, buttocks, or hip areas. Do not inject insulin near bony places or joints. Do not give injections closer than 1 inch apart. Insulin absorption can vary from site to site. The best absorption site is the abdomen. Try and rotate the injection site

Giving The Injection

Your doctor will help you learn to inject insulin. This is an illustration of giving an insulin injection in your thigh.

Push needle straight in
Push plunger in

Remove the needle, replace the cap and store it safely if you are going to re-use it.