Manejo De Insulina

Insulin Management of Type 2
Diabetes Mellitus
Insulin therapy is recommended for patients with type 2 diabetes mellitus and an initial A1C level greater than
9 percent, or if diabetes is uncontrolled despite optimal oral glycemic therapy. Insulin therapy may be initiated as
augmentation, starting at 0.3 unit per kg, or as replacement, starting at 0.6 to 1.0 unit per kg. When usingreplacement therapy, 50 percent of the total daily insulin dose is given as
basal, and 50 percent as bolus, divided up before breakfast, lunch,
and dinner. Augmentation therapy can include basal or bolus insulin. Replacement therapy includes basal-bolus insulin and correction
or premixed insulin. Glucose control, adverse effects, cost, adherence, and quality of life need to be considered when choosingtherapy.
Metformin should be continued if possible because it is proven to
reduce all-cause mortality and cardiovascular events in overweight
patients with diabetes. In a study comparing premixed, bolus, and
basal insulin, hypoglycemia was more common with premixed and
bolus insulin, and weight gain was more common with bolus insulin.
Titration of insulin over time is critical to improvingglycemic control and preventing diabetes-related complications. (Am Fam Physician. 2011;84(2):183-190. Copyright © 2011 American Academy of
Family Physicians.)

I

nsulin is secreted continuously by beta
cells in a glucose-dependent manner
t hroughout the day. It is also secreted
in response to oral carbohydrate loads,
including a large first-phase insulin release
t hat suppresses hepaticglucose production
followed by a slower second-phase insulin
release that covers ingested carbohydrates1
(Figure 12).
Type 2 diabetes mellitus is associated with
insulin resistance and slowly progressive
beta-cell failure. By the time type 2 diabetes is diagnosed in patients, up to one-half of
t heir beta cells are not functioning properly.3
Beta-cell failure continues at a rate of about
4percent each year.4 Therefore, patients with
t ype 2 diabetes often benefit from insulin
t herapy at some point after diagnosis.
Concerns About Insulin Therapy
Pain, weight gain, and hypoglycemia may
occur with insulin therapy. Pain is associated with injection therapy and glucose
monitoring, although thinner and shorter

needles are now available to help decrease
pain. Weight gainassociated with insulin
t herapy is due to the anabolic effects of insulin, increased appetite, defensive eating from
hypoglycemia, and increased caloric retention related to decreased glycosuria. In the
U.K. Prospective Diabetes Study, patients
w ith type 2 diabetes who were taking insulin
gained an average of 8 lb, 13 oz (4 kg), which
was associated with a 0.9 percent decrease in
A1C levelcompared with patients on conventional therapy.5
Hypoglycemia may occur from a mismatch between insulin and carbohydrate
intake, exercise, or alcohol consumption.
Hypoglycemia has been associated with an
increased risk of dementia and may have
implications in cardiac arrhythmia.6,7 A ll
patients should be instructed on the symptoms and treatment of hypoglycemia. American Diabetes Association(ADA) guidelines
recommend that the blood glucose level be
checked if hypoglycemia is suspected (glucose level lower than 70 mg per dL [3.89

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American Family requests.
cial use Volume 84, Number 2

ILLUSTRATION BY SCOTT BODELL

ALLISON PETZNICK, DO, Northern Ohio Medical Specialists, Sandusky, Ohio

Insulin Management

SORT: KEY RECOMMENDATIONS FOR PRACTICE
Evidence
rating

References

Analogue insulin is as effective as human...