Diabetes – A Mysterious Disease
History of Diabetes
More than three hundred years have passed since the discovery of the disease, which is now called diabetes.
Translated from the Greek, the word “diabetes” means “expiration” and, therefore, the expression “diabetes” literally means “losing sugar.” This reflects the main symptom of the disease – loss of sugar in the urine. Even before our era, the famous physician Arethaus wrote: “Diabetes is a mysterious disease.” This statement is relevant today, because the cause of diabetes, and especially its late complications, remains largely unsolved.
In the XVII century, the sweet taste of urine was first discovered (interesting, and under what circumstances – S.K.) in patients with diabetes. Doctors later used this symptom to diagnose the disease. In 1889, during a microscopic examination of the pancreas, characteristic clusters of cells were discovered, which they called the “islets of Langerhans” by the name of the scientist who discovered them, but they could not explain their significance for the body. Mehring and Minkowski in 1889 caused diabetes in animals by removing the pancreas. In 1921, researchers Bunting and Best managed to get insulin from pancreatic tissue, which in a dog with diabetes eliminated signs of the disease. And as early as next year, insulin was first successfully used to treat a patient with diabetes. In 1960, the chemical structure of human insulin was established, in 1976, human insulin was synthesized from pig insulin, and in 1979, the full synthesis of human insulin was carried out by genetic engineering.
Since then, insulin has been successfully used to treat diabetes. Insulin regulates blood sugar, contributing to the conversion of excess sugar into the body into glycogen. If insulin is not enough, then the amount of sugar in the blood increases and it begins to be excreted in the urine. In diabetes mellitus, insulin is administered subcutaneously. Inside, insulin cannot be taken, since digestive juices destroy it.
Symptoms of Diabetes
In some cases, diabetes for the time being does not make itself felt. The symptoms of diabetes are different for diabetes I and diabetes II. Sometimes, there may be no signs at all, and diabetes is determined, for example, by contacting an optometrist when examining the fundus. But there is a complex of symptoms characteristic of both types of diabetes. The severity of signs depends on the degree of decrease in insulin secretion, the duration of the disease and the individual characteristics of the patient:
frequent urination and a feeling of unquenchable thirst, leading to dehydration of the body;
rapid weight loss, often despite a constant feeling of hunger;
high blood sugar;
feeling weak or tired;
blurred vision (“white veil” before the eyes);
difficulties with sexual activity, which suggests;
numbness and tingling in numb limbs;
feeling of heaviness in the legs;
slow cure of infectious diseases;
slow healing of wounds;
a drop in body temperature below the average mark;
spasms of the calf muscles.
The onset of type I diabetes is characterized by a rapid deterioration in well-being and more pronounced symptoms of dehydration. Such patients need urgent administration of insulin preparations. Without appropriate treatment, a violation of all types of metabolism can lead to a life-threatening condition – a diabetic coma. The reason for this is a lack of insulin in the blood, difficulty in the penetration of glucose into the cell and, consequently, a lack of energy. The body begins to use the energy reserves found in fat depots. Since this process is too intense, a significant amount of “fat” goes into the blood. Part of it, passing through the liver, turns into ketone bodies, which enter the bloodstream and have a toxic effect on the body. A serious condition is developing that requires immediate treatment.
In order to establish a diagnosis of diabetes, it is necessary to determine two indicators:
The level of sugar in the blood
The level of sugar in the urine
|On an empty stomach||120 mg% (6.6 mmol / L)||more than 120 mg%|
|After eating||140 mg% (7.7 mmol / L)||more than 160-180 mg%|
An increase in fasting blood sugar levels of more than 120 mg% indicates the development of diabetes in a patient. Normally, sugar in the urine is not detected, since the renal filter retains all glucose. And when the blood sugar level is more than 160-180 mg% (8.8-9.9 mmol / l), the kidney filter begins to pass sugar into the urine. Therefore, a more or less significant amount of glucose is excreted in the urine. Its presence in urine can be determined using special test strips. The minimum blood sugar level at which it begins to be detected in urine is called the “renal threshold.”
Since the figures given in the table are interpreted differently by various medical institutions and authors, the following test is recommended to obtain an accurate result:
Fasting blood sugar levels.
Drink 75 g of grape sugar diluted in 300 ml of boiled water.
After 60 minutes, determine the blood sugar level.
After 120 minutes, determine the blood sugar level.
The test is considered negative, i.e. not confirming the diagnosis of diabetes, if the blood sugar taken on an empty stomach is below 120 mg%, and the blood taken after 120 minutes is below 140%.
If, during the first measurement, the sugar level is higher than 120 mg%, and when measured after 2 hours, it is higher than 200 mg (11.1 mmol / L), then this result confirms the presence of diabetes mellitus in the patient.
Causes of diabetes
In diabetes mellitus, the pancreas is not able to secrete the required amount of insulin or to produce insulin of the required quality. Why is this happening? What is the cause of diabetes? Unfortunately, there are no definite answers to these questions. There are separate hypotheses with varying degrees of reliability; a number of risk factors can be indicated. There is an assumption that this disease is viral in nature. It is often suggested that diabetes is caused by genetic defects. Only one thing has been firmly established: diabetes cannot be infected as it gets infected with flu or tuberculosis.
It is entirely possible that the first type of diabetes (insulin-dependent) is caused by the fact that insulin production is reduced or completely stopped due to the death of beta cells under the influence of a number of factors (for example, an autoimmune process). If such diabetes usually affects people under 40 years old, there must be reasons for it. In diabetes mellitus of the second type, which occurs four times more often than diabetes of the first type, beta cells initially produce insulin in normal and even large quantities. However, its activity is reduced (usually due to redundancy of adipose tissue, the receptors of which have a reduced sensitivity to insulin). In the future, a decrease in the formation of insulin may occur. People get sick, as a rule, age 50 years.
There are definitely a number of factors that predispose to the onset of diabetes. In the first place should indicate a hereditary predisposition. Almost all experts agree that the risk of getting diabetes increases if someone in your family has or has diabetes – one of your parents, brother or sister. However, different sources provide different numbers that determine the likelihood of the disease. There are observations that type 1 diabetes is inherited with a probability of 3-7% on the part of the mother and with a probability of 10% on the part of the father. If both parents are ill, the risk of the disease increases several times and amounts to 70%. Type 2 diabetes is inherited with a 80% probability on both the maternal and paternal side, and if both parents are ill with non-insulin-dependent diabetes mellitus, the probability of its manifestation in children approaches 100%.
According to other sources, there is no particular difference in the likelihood of developing type 1 and type 2 diabetes. It is believed that if your father or mother was ill with diabetes, then the likelihood that you will also get sick is about 30%. If both parents were sick, then the probability of your illness is about 60%.
Already this scatter in numbers shows that absolutely reliable data on this subject do not exist. But the main thing is clear: a hereditary predisposition exists, and it must be taken into account in many life situations, for example, at marriage and in family planning. If heredity is associated with diabetes, then children need to be prepared for the fact that they too can get sick. It must be clarified that they constitute a “risk group”, which means that all other factors affecting the development of diabetes mellitus should nullify by their lifestyle.
The second leading cause of diabetes is obesity. This factor, fortunately, can be neutralized if a person, aware of the entire measure of danger, will intensely fight against overweight and win this fight.
The third reason is some diseases that result in damage to beta cells. These are pancreatic diseases – pancreatitis, pancreatic cancer, diseases of other endocrine glands. A provoking factor in this case may be injury.
The fourth reason is a variety of viral infections (rubella, chickenpox, epidemic hepatitis and some other diseases, including the flu). These infections play the role of a trigger that triggers the disease. Clearly, for most people, the flu will not be the beginning of diabetes. But if this is a obese person with aggravated heredity, then the flu is a threat to him. A person in whose family there were no diabetics can repeatedly suffer the flu and other infectious diseases – and the likelihood of developing diabetes is much less than that of a person with a hereditary predisposition to diabetes. So the combination of risk factors increases the risk of the disease several times.
In fifth place should be called nervous stress as a predisposing factor. Especially it is necessary to avoid nervous and emotional overstrain for persons with aggravated heredity and who are overweight.
In sixth place among the risk factors is age. The older the person, the more reason to fear diabetes. It is believed that with an increase in age every ten years, the likelihood of developing diabetes doubles. A significant part of people permanently living in nursing homes suffers from various forms of diabetes. At the same time, according to some reports, a hereditary predisposition to diabetes with age ceases to be a decisive factor. Studies have shown that if one of your parents had diabetes, then the probability of your disease is 30% between the ages of 40 and 55. and after 60 years – only 10%.
Many people think (obviously, focusing on the name of the disease) that the main cause of diabetes in food is that diabetes is affected by the sweet tooth, who put five tablespoons of sugar in tea and drink this tea with sweets and cakes. There is some truth in this, if only in the sense that a person with such eating habits will necessarily be overweight. And the fact that obesity provokes diabetes has been proven absolutely accurate. We should not forget that the number of patients with diabetes is growing, and diabetes is rightly attributed to the diseases of civilization, that is, the cause of diabetes in many cases is excessive, rich in easily digestible carbohydrates, “civilized” food.
So, most likely, diabetes has several causes, in each case it may be one of them. In rare cases, some hormonal disorders lead to diabetes, sometimes diabetes is caused by damage to the pancreas that occurs after the use of certain drugs or as a result of prolonged alcohol abuse. Many experts believe that type 1 diabetes can occur with viral damage to the pancreatic beta cells producing insulin. In response, the immune system produces antibodies called insular antibodies. Even those reasons that are precisely defined are not absolute. For example, the following figures are given: every 20% of excess weight increases the risk of developing type 2 diabetes. In almost all cases, weight loss and significant physical activity can normalize blood sugar levels. At the same time, it is obvious that not everyone who is obese, even in severe form, is ill with diabetes.
Much is still unclear. It is known, for example, that insulin resistance (i.e., a condition in which tissues do not respond to blood insulin) depends on the number of receptors on the surface of the cells. Receptors are areas on the surface of the cell wall that respond to insulin circulating in the blood, and thus sugar and amino acids are able to penetrate the cell.
Insulin receptors act as a kind of “locks”, and insulin can be likened to a key that opens locks and allows glucose to enter the cell. Those who have type 2 diabetes, for some reason, have less insulin receptors or they are not effective enough.
However, it is unnecessary to think that if scientists cannot yet indicate exactly what causes diabetes, then in general all their observations on the frequency of diabetes in different groups of people are of no value. On the contrary, the identified risk groups allow us to orient people today, to warn them from a careless and thoughtless attitude to their health. Not only those whose parents are ill with diabetes should take care. After all, diabetes can be both inherited and acquired. The combination of several risk factors increases the likelihood of diabetes: for an obese patient, often suffering from viral infections – influenza, etc., this probability is approximately the same as for people with aggravated heredity. So all people at risk should be vigilant. Particular attention should be paid to your condition from November to March, because most cases of diabetes occur in this period. The situation is complicated by the fact that during this period your condition can be mistaken for a viral infection. An accurate diagnosis can be made based on an analysis of blood glucose.
Type 1 diabetes
Type I diabetes occurs with insulin deficiency in the body, when the pancreatic beta cells are not able to produce the right amount of insulin or cannot secrete it at all. The only treatment is to inject insulin from the outside, using a syringe and daily injections – plus, of course, the diet and a strictly defined diet. Why is insulin administered in such an unpleasant way? Because insulin is a protein, and if administered orally (i.e., through the mouth in the form of tablets), it decomposes in the stomach and does not enter the bloodstream. However, you can specify at least three reasons why patients should not be depressed:
Injections are not intravenous or intramuscular, but subcutaneous, that is, they are the simplest type of injection in medical practice, and almost every person (even a blind person) is able to administer insulin to himself.
Injections are made with special insulin syringes or syringe pens with such a thin needle that the pain is almost not felt.
There is evidence that insulin in the form of tablets is already being developed, intended for oral administration and, apparently, protected from decomposition in the stomach.
Type I diabetes can be congenital (that is,
it can manifest itself in infancy) and usually occurs in young people — in children, adolescents, and people under the age of 25-30; for this reason, it is sometimes called juvenile diabetes or diabetes of the young. This name is not entirely correct, since type I diabetes can occur in both forty and seventy years of age, which is why such diabetes is currently classified as insulin-dependent. It is associated with damage to the pancreatic beta cells, as a result of which they are not able to secrete insulin. In fact, being an autoimmune disease, type 1 diabetes develops when the brain sends the wrong signals to its own antibodies and they block beta cells on the pancreatic islets.
Principles of insulin therapy in type 1 diabetics
Due to the fact that diabetes mellitus type I is insulin-dependent, the administration of insulin is the only possible treatment for this category of patients. There is no alternative to subcutaneous insulin replacement therapy, although it is only an imitation of the physiological effects of insulin.
Under normal conditions, insulin enters the portal vein system, then to the liver, where it is half inactivated, the rest is on the periphery. All this happens so quickly that the glycemia level can be maintained in a fairly narrow range even after a meal. A different path is observed for insulin injected under the skin: it is late into the bloodstream and even more so in the liver, after which the concentration of insulin in the blood remains nonphysiologically increased for a long time. This imperfection of subcutaneous insulin therapy also explains the fact that patients with diabetes are forced to conduct self-monitoring of metabolism, taking into account their nutrition, physical activity and other factors affecting the level of glycemia. But the modern strategy and tactics of insulin therapy make it possible to make the lifestyle of patients with type I diabetes very close to normal. This can only be done by educating patients with diabetes.
The need for diabetes education programs has long been recognized. As early as 1925, one of the pioneers of insulin therapy, E. Joslin, taught patients what they considered the main thing for the success of treatment: a daily triple determination of glucosuria and a change in the dose of insulin based on the data obtained. The need for inpatient treatment was rare. But with the advent of long-acting insulin preparations, the development of insulin therapy went a different way. Patients were forbidden to independently change the dose of insulin, they injected prolonged-acting insulin only 1 time per day, and for many years they had to forget about normal nutrition, put up with the increased risk of hypoglycemia and the need for frequent hospitalizations. By the beginning of the 80s, diabetologists had highly purified insulin preparations, human insulin, improved means for administering insulin (disposable insulin syringes and pen syringes), and methods for express analysis of glycemia and glucosuria using test strips. Contrary to expectations, their use alone did not lead to a decrease in the number of late complications of diabetes and a persistent improvement in the compensation of carbohydrate metabolism. According to the unanimous conclusion of the experts, a new approach was required that would allow effective management of this complex chronic disease by involving the patient himself in active control of diabetes and its treatment. Currently, the term therapeutic education is officially recognized by the World Health Organization, and it is an obligatory and integral part of the treatment of any type of diabetes. For patients with type I diabetes mellitus, this primarily means that the patient must become a competent insulin therapist. Insulin therapy is a recognized strategy for the treatment of type I diabetes patients.
A recognized strategy for the treatment of type I diabetes patients is intensified insulin therapy. Intensified insulin therapy refers to a regimen of multiple injections of insulin that mimics the physiological secretion of insulin by b-cells. As you know, under physiological conditions, basal (background) insulin secretion occurs continuously (including in the absence of food intake, and at night) and is about 1 unit of insulin per hour. During exercise, insulin secretion normally decreases markedly. To maintain glycemia within normal limits during meals, significant additional (stimulated) secretion of insulin (about 12 units per 10 g of carbohydrates) is required. This complex kinetics of insulin secretion with a relatively constant basal and varying nutritional level can be simulated as follows: before meals, the patient administers various doses of short-acting insulin, and background insulinemia is supported by prolonged-acting insulin injections. This type of insulin therapy is also called basal-bolus insulin therapy.
No matter how close the intensified insulin therapy is to physiological conditions, one should not forget that the profile of action of simple insulin, administered subcutaneously, does not exactly correspond to the physiological kinetics of alimentary secretion of insulin. This type of insulin therapy also implies that the patient several times determines the level of blood glucose and takes these parameters into account when choosing a dose of insulin. As a rule, patients make short-acting insulin injections three times a day before meals, sometimes more often. The basal insulin requirement is most often covered by two injections of prolonged-acting insulin per day. The most common regimen of intensified insulin therapy is the following combination of injections:
in the morning (before breakfast) the introduction of insulin of short and prolonged action;
in the afternoon (before lunch) administration of short-acting insulin;
in the evening (before dinner) the introduction of short-acting insulin;
at night, the introduction of prolonged-acting insulin.
Such a scheme is basic, for each patient on certain days it may undergo changes: the number of short-acting insulin injections may be more or less depending on specific circumstances (for example, additional meals, unexpectedly high blood sugar, concomitant diseases, etc.) . Speaking about the doses of insulin, it should be emphasized that there can be no once and for all selected dose of insulin, it will often change in accordance with changes in the patient’s lifestyle. Therefore, it makes no sense to calculate the dose for a particular patient based on theoretical assumptions (daily dose per 1 kg of body weight, day and night need, ratio of basal and prandial levels of insulin, etc.), all these will be only average values. The only criterion that allows you to correctly determine the dose of insulin are the numbers of glycemia, measured by the patient himself.
When choosing a dosage of prolonged-acting insulin, one should not forget that the profile of insulin action also depends on the size of the dose: a smaller dose lasts a shorter time than a large one. This can lead to a situation where a too small morning dose of prolonged-acting insulin does not provide sufficient basal insulinemia by the time of dinner (usually in such cases they say that insulin is not enough), so the blood glucose level before dinner is markedly increased. In this case, it is necessary either to make an additional injection of short-acting insulin in the afternoon snack, or to advise the patient to administer a small additional dose of prolonged-acting insulin before dinner. Thus, sometimes there is a need for three times the introduction of insulin prolonged action per day. This type of insulin therapy is more and more common.
Currently, human insulin preparations have gained predominant distribution. At the same time, it is most convenient to use NPH-insulin preparations as prolonged-acting insulins, because unlike zinc-insulin, they can be mixed in the same syringe and administered with short-acting insulin. Speaking about the latest achievements in the field of intensified insulin therapy, it should be noted the appearance on the market of the so-called short-acting analogues of human insulin, or ultra -short-acting
insulins. The fact is that with subcutaneous injection of simple insulin, its action begins after 30–40 minutes, the concentration in the serum reaches a peak later (2–4 hours after injection) and remains elevated longer (duration of action is up to 6–8 hours) than with normal pancreatic insulin secretion. To minimize this disadvantage of treatment, subcutaneous injections of human short-acting insulin are usually recommended to be made about half an hour before meals, and additional “snacks” should be made between main meals. This can create significant inconvenience for patients, especially for those who lead an active lifestyle. By changing the structure of the molecule of human insulin, analogs with new properties can be obtained. After subcutaneous injection, this leads to faster absorption (0–15 min), faster onset of the peak of action (45–60 min) and a shorter duration of action (3–4 h) compared with regular insulin. The profile of action of such insulin provides patients with greater flexibility regarding the regimen of the day, nutrition and physical activity.
It has now been irrefutably proven that to prevent late complications of diabetes, the most important thing is to constantly maintain glycemia levels close to normal. In patients with type I diabetes, this can only be achieved with the help of intensified insulin therapy. The largest study to investigate the effects of intensified insulin therapy and good diabetes control on the frequency and severity of late complications was the multicenter DCCT (Diabetes Control and Complications Trial) study. It was carried out from 1982 to 1993 in 29 diabetes centers in the USA and Canada. The study involved 1441 type I diabetes patients, patients were divided into 2 groups. The 1st group included 726 people without complications (primary prevention group), the 2nd 715 people with signs of diabetic retinopathy (secondary prevention group). In each group, one patient was prescribed traditional therapy and the other intensive. The goal of traditional therapy was to compensate clinically for the absence of symptoms of hyperglycemia, ketonuria, and frequent and severe hypoglycemia. This was achieved due to one or two injections of insulin of short and prolonged action, periodic self-monitoring of glycemia or glucosuria, training in the principles of diet. Patients, as a rule, did not conduct an independent daily correction of insulin doses, the examination was performed 1 time in 3 months. With intensive therapy, the same clinical goals were pursued, and in addition, maintaining glycemia at the level closest to that of healthy people (3.96.7 mmol / L before meals and less than 10 mmol / L after meals). Intensive therapy included a regimen of multiple injections of insulin (3 per day or more) or the use of a portable insulin dispenser, frequent (4 times a day or more) measurement of glycemia, teaching patients the principles of self-adaptation of insulin doses. Patients visited their center every month, regularly contacted a doctor by phone. In patients of both groups, the level of glycated hemoglobin (objectively indicating the degree of compensation of carbohydrate metabolism) was regularly measured, and tests were performed to evaluate retinopathy (fundus photographing), nephropathy (microalbuminuria, proteinuria, glomerular filtration) and neuropathy. The duration of observation of patients ranged from 3 to 9 years (the average was 6.5 years). Throughout the study, the level of glycated hemoglobin HbA1c in the intensive care group was maintained at a level close to 7%, whereas in the group with traditional insulin therapy it was about 9% (i.e., the same as the initial one). It was shown that the development and progression of diabetic retinopathy in the intensive care group decreased by almost 60%, its severe non-proliferative and proliferative forms requiring laser coagulation, by 50%. As a result of intensive therapy, the frequency of diabetic nephropathy decreased by 3456%, as estimated by the level of urinary protein excretion. The frequency of clinical neuropathy (60%) and macrovascular complications (41%) also decreased statistically significantly.
At first glance, intensified insulin therapy seems burdensome for patients, but ultimately, thanks to it, the quality of life of patients increases, since they freely change both the composition of food and the time of its intake. When short-acting insulin is introduced before meals, patients are trained to pre-select the required dose, depending on the amount of carbohydrates planned for this intake (including the use of a small amount of sweets), which they can arbitrarily change, and the glycemia values at this particular moment. As the basis for the treatment of type I diabetes mellitus, intensified insulin therapy cannot be considered separately from its other most important components – self-control of metabolism, a liberalized diet, physical activity accounting and training, otherwise the achieved therapeutic effect will be minimal. It would be erroneous to consider that the transfer of the patient to the regime of multiple injections by itself will automatically significantly improve compensation. Some patients today refuse to intensify insulin therapy, not only because of the need for frequent injections, but also because they do not know the benefits that it provides. From this point of view, education of patients with diabetes should play a major role in creating motivation to switch to a more complex, but also more effective way of treating this disease.
Type 2 diabetes
Obviously, type II diabetes is not a mild form of diabetes, as was previously thought, and its treatment is far from perfect.
This form of diabetes is also called non-insulin-dependent, since the introduction of insulin, as a rule, is not required at the first stages of the disease. Traditionally, they use a diet, dosed physical activity and tableted drugs that slow down the absorption of glucose in the gastrointestinal tract or increase the release of insulin by the cells of the pancreas. However, in most patients, over time, the need for additional prescription of insulin. What happens in the body of a patient with diabetes? How are exchange processes changing? Why does blood glucose rise?
One of the reasons why there is an increase in blood sugar is the insufficient production of insulin by the beta cells of the pancreas. At the onset of the disease, as a rule, an excess of insulin is present in the body due to the decreased sensitivity, “immunity” of tissues to its own insulin. The pancreas begins to produce it more and more in order to absorb glucose circulating in the blood. But its possibilities are not unlimited, beta cells are depleted, and even glucose itself, which at that moment in excess in the blood, acts on them destructively. After some time, insulin production decreases.
In conditions of relative deficiency of insulin in the blood, much less glucose reaches its final destination – cells of various organs and tissues. Correspondingly, the level of glucose in the peripheral blood rises. We register this by determining elevated sugar levels in patients with type II diabetes. When it is not possible to maintain a normal level of glucose in the blood, observing the correct diet, the doctor prescribes sugar-lowering tablets to the patient. Their main function is to provide such an amount of insulin that would be enough to “process” all the carbohydrates that enter the bloodstream from food and from our own reserves. How does this happen? Tableted preparations “force” the pancreas to work in an enhanced mode, “boost” beta cells, as if “squeeze” the necessary amount of insulin from them. Obviously, the reserves of the pancreas are not unlimited, and for each patient with diabetes they are different. Ultimately, depletion of insulin-secreting cells occurs, and treatment with tablets becomes ineffective. The question is about the administration of insulin.
You have probably heard from patients with type II diabetes mellitus receiving insulin about the various periods during which they took sugar-lowering tablets.
In one, this period can last 30 years, while in someone the need for insulin arises much earlier, after 5 years or less. There is no pattern in this, it all depends on the condition of your body and how carefully you treat it, how correctly you monitor the level of sugar in the blood from the very beginning of the disease. So, despite the careful observance of all the doctor’s recommendations, tightening dietary restrictions, taking the maximum dose of sugar-lowering tablets, in patients with type II diabetes, blood sugar levels remain high, resulting in poor health, and the risk of developing diabetic complications increases significantly. This is where insulin comes to the rescue. It should be noted that a chronic increase in blood sugar for some time may not have such typical manifestations for diabetes as thirst or a significant increase in the daily amount of urine. Often, only over time, patients pay attention to general weakness, constantly bad mood, itching, frequent pustular skin lesions, progressive weight loss. Therefore, regular measurements of the amount of glucose in the blood or in individual portions of urine are very important. The most important thing is to call insulin for help on time. What amount of glucose in the blood is considered “dangerous”? At a level of more than 10 mmol / l, diabetes control should be considered unsatisfactory, with glycemia of more than 13 mmol / l, most diabetologists believe that there is no alternative to insulin.
“Fear is large” – often with these words, patients with type II diabetes mellitus, converted to insulin, characterize their state of mind before the first injection of insulin. Often, patients’ perceptions of insulin treatment are sharply negative. Often, one has to talk with the patient for a long time to convince him of the need for such treatment. In the vast majority of cases, both the patient and the doctor are rewarded for their patience and determination. The main task of the patient is to realize the need for this step and not to postpone the solution of the problem for later. It is not necessary that the injection regimen be as intense for you as for
patients with insulin-dependent diabetes mellitus who inject insulin 4-5 times a day. Sometimes it is enough for the patient to add a small dose of medium-acting insulin to sugar-lowering tablets, for example, Monotard NM, in one or two injections (in the morning and / or at night). Insulin creates a certain “basal background” in the body, on which sugar-lowering tablets act, stimulating the release of its own insulin. In some situations, the number of tablets is reduced by 50%. Often, only one administration of Monotard NM at bedtime is necessary in order to suppress the excessive release of glucose by the liver, which makes blood sugar too high in the morning.
In some patients with type II diabetes who take sugar-lowering tablets, it becomes necessary to administer insulin just before meals. This happens in cases when the insulin secretory reserves of the pancreas are not enough for the absorption of carbohydrates taken with food. In these cases, short-acting insulin is prescribed, for example Actrapid NM, three times a day before main meals (before breakfast, lunch and dinner). This allows you to quickly reduce blood glucose levels and breaks the “vicious cycle of toxic hyperglycemia.” At the same time, the secretion of own insulin by the pancreas improves, insulin resistance to muscle tissue and liver decreases, the possibility of lowering the dose of insulin, and in some cases its cancellation, becomes real. In patients with a long duration of type II diabetes mellitus, insulin secretion deficiency can be significant. In cases where there is almost no native insulin, and the reserves of its stimulated secretion are exhausted, insulin remains the only choice. The modes of administration of insulin may be different. Sometimes two injections of prolonged-acting insulin are sufficient to maintain an acceptable level of metabolic compensation. More often there is a need for additional administration of short-acting “food” insulin before main meals. This regimen of insulin therapy requires frequent measurements of glucose in the blood and good skills of the patient in self-monitoring of diabetes.
To avoid multiple injections, specialists at the largest Danish pharmaceutical company, Novo Nordisk, developed the mixed preparation Mikstard, which consists of short and prolonged insulins. Their proportions are different: 10, 20, 30, 40, 50. This means that, for example, Mikstard 10 contains 10% short-acting insulin and 90% long-acting insulin. Thus, in 10 units of this combined preparation contains 1 unit of short and 9 units of prolonged insulin. Your doctor will help you choose the best insulin for you. The use of mixed insulin is most justified in patients with type II diabetes, when two injections per day are enough – before breakfast and before dinner. In the same patient, the type of Mikstard insulin used may vary.
In addition to the typical situation described above, when there is a need for insulin injections, there are a number of points when this can not be avoided. These are cases when taking sugar-lowering tablets is not recommended or can be harmful: severe liver or kidney disease, allergic reactions when taking antidiabetic drugs. In the presence of severe diabetic complications (proliferative retinopathy, severe peripheral neuropathy, especially its painful form, progressive nephropathy with impaired renal excretory function), insulin treatment is also recommended. Timely prescribed insulin will improve the course of the disease and affect the progression of complications.
Insulin is prescribed to patients with type II diabetes mellitus taking sugar-lowering tablets if surgery is to be performed with general anesthesia. This temporary measure helps maintain normal blood glucose levels before, during, and after surgery. Subsequently, patients return to their usual treatment regimen.
The need for insulin may occur in conditions of an infectious disease with an increased body temperature or with prolonged stress. At this time, the patient with diabetes has a greater than usual need for insulin, and its relative deficiency is manifested by an increase in glucose in the blood. To avoid the development of diabetic coma, it is necessary to inject insulin.
In our clinic, a patient from the Krasnodar Territory, 72 years old, in whom type II diabetes mellitus was detected at the age of 43, was observed. Diabetes experience was quite large – almost 30 years. The patient was worried about weakness, thirst, gradual weight loss, frequent urination, severe pain in the arms and legs. Despite the fact that the patient complied with the nutrition plan, took sugar-lowering tablets at the maximum dose, the blood sugar level was high – 13-17 mmol / l during the day, glucose was also detected in the urine.
The patient was prescribed Mikstard 20 at a dose of 20 units before breakfast and 15 units before dinner. Sugar-lowering tablets were canceled. After 5 days, the state of health improved, thirst disappeared, pain in the arms and legs decreased. The blood glucose level dropped to normal values: 5-8 mmol / l during the day, sugar was not detected in urine. After 2 months, the patient returned to her previous treatment – she started taking sugar-lowering tablets.
There may be doubt: can patients with type II diabetes mellitus inject insulin on their own, because these are usually elderly people, often with low vision and sore hands? Now this has ceased to be a problem, thanks to the use of simple and accurate insulin syringes or NovoPen3 syringe pens. Visually impaired patients can be guided by characteristic clicks when typing a dose in a syringe pen. The injection itself is almost painless.
Thus, insulin for a patient with type II diabetes mellitus is not a “lifelong cross”, however, if it is necessary, it is better to start injections immediately. No need to be afraid of insulin, because it is the main assistant in the fight against poor health and complications of diabetes.