Insulin therapy period

Secondary failure Transient loss of glycemic control may occur with fever, infection, trauma, or surgery. Insulin therapy may be needed instead of nateglinide therapy at such times. Secondary failure, or reduced effectiveness of nateglinide over a period of time, may occur. 

Occasionally, conversion to tolbutamide in the hospital may be advisable in candidates who require more than 40 units of insulin daily. During this conversion period when insulin and tolbutamide are being used, hypoglycemia rarely may occur. During insulin withdrawal, have patients test urine for glucose and acetone at least 3 times/day and report results to their physician. The appearance of persistent acetonuria with glycosuria indicates that the patient is a type 1 diabetes patient who requires insulin therapy. 

Macrovascular Complications. The connection between high insulin levels (hyperinsulinemia), insulin resistance, and cardiovascular events incorrectly leads some clinicians to believe that insulin therapy may cause macrovascular complications. The UKPDS and DCCT found no differences in macrovascular outcomes with intensive insulin therapy. One study, the Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction study " reported reductions in mortality with insulin therapy. This group assessed the effect of an insulin-glucose infusion in type 2 DM patients who had experienced an acute myocardial infarction. Those randomized to insulin infusion followed by intensive insulin therapy lowered their absolute mortality risk by 11% over a mean follow-up period of approximately 3 years. This was most evident in subjects who were insulin-naive or had a low cardiovascular risk prior to the acute myocardial infarction. " ... 

Patients with insulin-dependent diabetes receive subcutaneous insulin injections daily. The goal of insulin therapy is to provide adequate glucose control through each 24 hour period while minimizing the number of injections required to achieve that control. Repeated injections at the same site may result in atrophy or hyperplasia at the injection site. Insulin preparations of short, intermediate and long duration are available (Table 10.10). 

Metabolism Hypoglycaemia In a single-centre, double-blind, randomised, placebo-controlled crossover study, 28 type 1 diabetes patients were treated with vildagliptin 50 mg twice daily as an add-on to their insulin therapy for 4 weeks. Four patients reported mild hypoglycaemia, two with vildagliptin, one with placebo and one during the washout period. [45 ]... 

Whenever (3-blocker therapy is employed, the period of greatest danger for asthmatics or insulin-dependent diabetics is during the initial period of drug administration, since the greatest disruption of the autonomic balance will occur at this time. If marked toxicity does not occur during this period, further doses are less likely to cause problems. 

Catheter malfunction was the most frequent event (obstruction, total occlusion, and peritoneal adhesions 13,10, and 3.1 events per 100 patient-years respectively). Flushing sometimes prevented occlusion. Better tip design had a big effect. Adhesion formation decreased with daily injections of heparin. The frequency of ketoacidosis was comparable to that reported with continuous subcutaneous insulin infusion and was usually related to catheter obstruction. It diminished during the review period. Episodes of severe hypoglycemia were fewer than during intensive subcutaneous therapy. 

Since each of these disorders is caused by the lack of an enzyme, scientists are trying to design a way to replace the lost activity. Oral medication will not work because enzymes are proteins. They would simply be digested, fike any other dietary protein. Enzyme replacement therapy is one approach that is being studied. This would involve periodic injections of the enzyme into the bloodstream, a treatment just fike the injection of insulin by diabetics. Enzyme replacement therapy would require a large supply of the enzyme. Eollowing the model of insulin, the gene for the enzyme could be cloned into bacteria. The bacteria would then produce the protein, which would be purified for use by humans. 

As seen in Fig. 3, blood glucose values during triple therapy were not completely normalised during the 24-h period. This may be explained by insulin resistance, since our euglycaemic hyperin-sulinaemic clamp studies showed an improvement only in peripheral insulin sensitivity of about 60%. Therefore, to completely normalise blood glucose values, a more potent insulin synthesizer than rosiglitazone is needed. 

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