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In a non diabetic state, a background level of insulin is present in the blood stream to cope with background glucose (normal BG range is 4 – 7 mmol/l) When BG rises after glucose absorption from the gut, insulin is pulsed into the hepatic portal vein from storage in the pancreas. The amount is carefully controlled and mirrors the level of BG It may be seen from this why a fast acting and longer acting insulin is often used. The longer acting for background cover, the faster acting for a glucose challenge.

Exogenous insulin is required when no insulin is produced or is insufficient to deal with a glucose challenge

Isophane or NPH is the most commonly used intermediate insulin.

NPH stands for Neutral Protamine Hagedorn, and protamine is the retarding agent that alters the speed of absorption and action of the insulin.

Proprietary Human Mixes will always be fast acting and isophane, the name of the insulin will indicate the % mix. About 60% of patients requiring insulin are using premixed insulin, and the majority of those are using 30% mix. The benefit of premixed insulin is that the patients do not need to mix the two types of insulin thereby eliminating the risk of dosing errors.

Human insulin is the most used insulin. It is genetically engineered and is indistinguishable from the naturally occurring human insulin. Originally beef insulin was used but was found to cause problems in some patients. This is due to the body recognising the injected protein as foreign. This is less marked with porcine insulin but obviously it makes sense to use an identical insulin to that which the body would normally produce.

Cold insulin hurts and is not necessary.

Insulin cartridges in use may be kept at room temperature (max 25 C) up to 4 weeks. Insulin vials up to 6 weeks.

Insulin cartridges and vials not in use should be stored in the fridge.

Pens should not be kept in the fridge.

Most patients are using the modern insulin delivery devices. 63% of all insulin users in UK are using the insulin pens and the number is increasing rapidly (IMS data, Jan 2000). Practically all new patients today are started on insulin pens.

Insulin pumps represents an alternative for highly motivated patients. Insulin pumps are not widely used in the UK.

•HDL = “good” ; High Density Lipoprotein

•Lowers cholesterol & triglyceride

•Exercise increases # of insulin receptors

•Alternate sweet fluid with salty (broth)

Insulin Resistance: Causes and Associated Conditions

•The many features of the insulin resistance syndrome are depicted here. Genetic and environmental influences work in concert to determine an individual's insulin sensitivity at any given time. •In persons with insulin resistance, type 2 diabetes, hypertension, dyslipidemia, atherosclerosis, and PCOS are more common than in persons who are less insulin resistant.

•3 minor hemoglobins are measured in this test

•A1a, A1b, A1c---formed by glycosylation, a nearly irreversible molicular process in which glucose becomes chemically incorporated in Hemoglobin A

•

•BG is bound to hemoglobin & becomes glycosylated.

•Glycosylation occurs a constant rate during life span of a RBC (120 days or 3 - 4 mo)

•Non-compliant: proof that you hurt self in past

•Compare old Rx with New Rx

•Feeling of reward to pt with good control

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HbA1C Predicts Coronary Heart Disease in Type 2 Diabetes

•A prospective study by Kuusisto and coworkers evaluated the effect of metabolic control on coronary heart disease (CHD) events during a 3½-year period in 1,069 nondiabetic elderly patients and 229 with type 2 diabetes in Finland. •Metabolic control was determined according to HbA1C concentrations. The incidence of mortality attributed to CHD increased significantly (P<0.01) in patients with HbA1C concentrations in the highest tertile (>7.9%) compared with patients with concentrations lower than 6%. •The incidence of all CHD events was also significantly higher (P<0.05) among patients with the highest tertile HbA1C concentrations than that among patients in the lowest tertile of HbA1C. The impact of type 2 diabetes on the morbidity and mortality associated with CHD was more pronounced in women than in men. •The results of this study demonstrate that metabolic control of type 2 diabetes and the duration of diabetes are important predictors of CHD in elderly subjects, particularly women.

Kuusisto J et al. Diabetes. 1994;43:960-967.