What are the side effects of insulin treatment

The main undesirable side effect of insulin therapy is hypoglycaemia. The probability of its appearance is increased with a more intensified form of treatment (see Chapter 5).

Individuals who receive insulin usually gain weight. This can be due to better glycaemic control (and the consequent reduction of glucosuria), and to the appearance of hypoglycaemias (even light ones) that lead to an increase of caloric intake. In the DCCT study (Diabetes Control and Complications Trial), individuals with Type 1 DM who received intensified insulin therapy increased their weight by 4.5 kg (9.9 lb) more than those who received conventional treatment, during the 9.5 years of follow-up. In the UKPDS study (United Kingdom Prospective Diabetes Study), individuals with Type 2 DM who received intensified insulin therapy increased their weight by 1.4-2.3 kg (3.1-5.1 lb) more than those who were treated with a sulfonylurea or metformin, respectively.

Allergic reactions following the administration of human type insulin are infrequent. They are separated into local (more frequent) and systematic (more infrequent) reactions.

Treatment with human insulin can cause the creation of small concentrations of antibodies against insulin. These create problems in the activity of the hormone only when they circulate in high concentrations in the blood, which is exceptionally infrequently.

The phenomenon of lipodystrophy used to constitute a non-infrequent problem in the past. Today, however, this is practically non-existent because of cleanliness and the type of insulin (human).

How many types of insulin therapy exist and what are they?

The answer to this question is very difficult because treatment with insulin is individualized. We could, however, first separate the treatment of insulin replacement into two main categories:

• Intensified regimens that imitate the physiologic insulin secretion from the pancreas, which are used mainly in Type 1 DM.

• Simpler regimens of insulin replacement that are administered either in cases where residual endogenous insulin secretion exists (as in Type 2 DM or during the honeymoon phase of Type 1 DM), or when the intensified regimens cannot be applied (as in cases when patients will not collaborate or cannot comprehend the treatment, or when they refuse multiple injections, self-monitoring, etc.).

How are the types of insulin therapy that imitate the physiologic secretion of insulin planned?

The physiologic secretion of insulin consists of two independent components. The first concerns the basic secretion of insulin, which occurs continually all day and is almost constant, with the exception of two peaks, one a little before waking in the morning and the second in the afternoon hours. The second component concerns the insulin that is secreted every time that the individual receives food (Figure 28.1). The

Breakfast Lunch Dinner

Figure 28.1. Secretion of insulin in a normal subject during a 24-hour period

Breakfast Lunch Dinner

Figure 28.1. Secretion of insulin in a normal subject during a 24-hour period quantity of 'prandial' insulin that is secreted depends mainly on the carbohydrate content of the meal.

In order for the treatment to imitate the physiologic secretion of insulin, it is clear that both of the above components should be taken into consideration. Therefore, two types of insulin are required; one type that imitates the basal insulin secretion and a second type, with every meal, that imitates the 'prandial' insulin. Thus, the so-called intensified basal-prandial insulin therapy regimens were created (basal-bolus regimens).

Reviewing what was previously mentioned regarding the types of insulin products, we can conclude that for the imitation of basal insulin secretion, intermediate and slow-acting insulins are to be used (in one or two injections daily), whereas before meals the rapid- and very rapid-acting insulins are to be used (an injection before each meal). Thus, various combinations result, each one of which constitutes a therapeutic regimen.

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