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!

Which Insulin?
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.

How Long Does The Insulin Work?
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).

Rapid acting

Short acting;

Intermediate-acting

Long acting;

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.

Side Effects of Insulin Therapy.
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.

Practical Points in Insulin Therapy

(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!