Insulin Journal
VOLUME 2, NUMBER 2
Editorial
Initial therapy for patients with type 2 diabetes mellitus (DM) usually involves alterations in lifestyle—namely, diet and exercise—followed quickly by the addition of oral hypoglycemic agents. After the use of combinations of oral agents, insulin therapy
or exenatide is then considered. Because type 2 DM is inherently a progressive disorder, most patients with this disease
become candidates for insulin therapy, either in combination with oral agents, exenatide, or pramlintide, or by itself in regimens
similar to those used by patients with type 1 DM.
Numerous regimens are available for starting insulin therapy. The addition of a long-acting, once-daily insulin as basal
therapy, often with the continuance of daytime hypoglycemic agent(s), has become commonplace since the introduction of
this regimen ~5 years ago. Advancing the insulin regimen can be achieved using short-acting analogues with each meal or by
using a mixed insulin with an intermediate-acting insulin and a short-acting analogue 2 or 3 times daily.
One significant barrier to insulin use in patients with type 2 DM is the fear of injections; however, improvements
in injectable devices (eg, syringes, needles, pens) and the develpment of a noninjectable option (ie, inhaled insulin) have
helped overcome this fear in many patients. In particular, insulin pens offer several advantages for patients in terms of issues
such as social acceptability and convenience. Self-monitoring of blood glucose (SMBG) is critical to assess the results of therapy
and to avoid another major fear of patients—hypoglycemia. As these techniques improve and become less painful and
more convenient, SMBG should increase in frequency. In addition, continuous glucose monitoring is an important clinical tool
that, in conjunction with SMBG, can greatly help insulin-using patients.
Postprandial hyperglycemia is associated with worse cardiovascular outcomes, and attention to this problem has become
a major area of discussion. It can be identified by means of SMBG and should be addressed by using agents that reduce postprandial
blood glucose elevations; some oral agents, as well as exenatide and pramlintide, achieve this, as do prandial inhaled
insulins.
This issue of Insulin covers many of these aspects of treatment. Hopefully, the articles presented here will help the readers
and their patients deal with many of these difficult issues on instituting and maintaining a practical insulin regimen that is
successful over the long-term.
Physicians' Corner: Advancing Change-Perspectives on Postprandial Glycemia
Is achievement and maintenance of an A1C goal the end of our therapeutic road? It would certainly be convenient if that were all we had to do. There are clear signs on the horizon that reducing diabetic complication risk involves more than just A1C control. The way we manage DM may, once again, be in for a change.
The Rationale for Prandial Glycemic Control in Diabetes Mellitus
The objective of this article was to examine how prandial hyperglycemia-especially postprandial hyperglycemia (PPHG)-affects overall glycemic control and the complications of DM and to discuss the pharmacologic agents available to reduce PPHG.
The Role of Rapid-Acting Insulin Analogues and Inhaled Insulin in Type 2 Diabetes Mellitus
The availability of rapid-acting insulin analogues and inhaled insulin gives clinicians additional treatment options in the management of patients with diabetes mellitus (DM). Combining rapid-acting insulin analogues with basal insulin can more closely mimic physiologic insulin release to maximize glycemic control.
Insulin therapy targeting both fasting and postprandial hyperglycemia is important in achieving optimal blood glucose (BG) control in patients with type 2 DM. A practical and feasible option is the use of >=1 injection of premixed insulin analogues. Clinicians should be aware of premixed insulin analogues' advantages and limitations so that these agents can be used appropriately in the treatment of patients with type 2 DM.
Cultural Competence in Diabetes Mellitus Care: An Urgent Need
The standards of DM care apply to every individual with this disease and should continue to be the core of every clinician's practice. However, improving health care providers' cultural competence may help improve the quality of care provided to minority groups and may ultimately reduce health care disparities. Increased cultural competence may also improve patient-provider trust and communication, as well as help patients adhere to prevention and treatment plans.
Insulin Therapy: The Question This Issue
What choices do my patients have for insulin administration other than syringes and vials? What kinds of insulin pens are currently available? Why should my patients use insulin pens? If insulin pens have such advantages, why are they not used more commonly? Are there any special instructions for using pens compared with using syringes? What is the role of insulin pens in hospitals?
When Glucose Levels Are Too Low: A Major Barrier to Taking Control
When taking control of your diabetes, the goal is to keep your blood glucose levels as close to normal as possible. By doing this, many diabetes-related complications, including eye, nerve, and kidney problems, can be avoided. Unfortunately, when blood glucose levels are kept close to normal, there is the chance that they can become too low. This condition is called hypoglycemia, and it is a major barrier to taking control of your diabetes.
A 26-year-old black woman with type 2 diabetes mellitus (DM) presents to your office after being told by her primary care physician that her DM was poorly controlled. The patient has a history of peptic ulcer disease for which she takes omeprazole 40 mg daily. There is a remote history of nonspecific gastric surgery. She also has dyslipidemia, which is treated with atorvastatin 10 mg/d, and asthma, which is controlled with an albuterol metered dose inhaler. The patient has smoked 1 pack of cigarettes daily for 8 years and drinks ~6 beers a day on weekends. The patient weighed 180 pounds and was 5 feet 4 inches tall.
The patient is a 30-year-old Hispanic man who was admitted to the surgical intensive care unit (ICU) with abdominal pain, vomiting, and a blood glucose level of 426 mg/dL.
