Insulin Therapy: Current Concepts Ambrish Mithal, Ganesh Jevalikar, Pankaj Shah
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1INSULIN THERAPY: Current Concepts2
3INSULIN THERAPY: Current Concepts
Editors Ambrish Mithal MD DM Chairman and Head, Division of Endocrinology and Diabetes Medanta - The Medicity Gurgaon 122 001, Haryana, India Ganesh Jevalikar MD Consultant, Pediatric Endocrinology Division of Endocrinology and Diabetes Medanta - The Medicity Gurgaon 122 001, Haryana, India Pankaj Shah DM Division of Endocrinology, Metabolism, and Diabetes Mayo Clinic Rochester, MN 55905, USA Foreword Robert Rizza
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Insulin Therapy: Current Concepts
First Edition: 2014
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This book is dedicated to our patients who continue to have faith in us despite the imperfections of our treatment
Contributing Authors
Robert A Rizza md
Professor of Medicine
Mayo Clinic
Rochester, MN 55905, USA
We have come a long way from the exciting discovery of insulin in 1921. Diabetes mellitus in children has evolved as a result from a lethal acute to subacute disease to a chronic condition. Newer discoveries of insulin therapy are making management of diabetes less inconvenient for the patients. Education of the people with diabetes, their nurses, and physicians is making insulin use more effective. Together these measures seem to be reducing the incidence of diabetic complications. There are still several unresolved problems with insulin use: improved rapidity of rapid-acting insulin, stability of basal insulin concentrations, provision of more than one basal rate through a 24-hour period, administration of insulin without puncturing the skin, and consistency of insulin action from dose to dose.
Improvements in the technologies for continuous subcutaneous insulin (CSII) delivery have further simplified management of type 1 diabetes. Use of continuous glucose monitoring (CGM) can predict hypoglycemia before it becomes life-threatening. Introduction of CGM augmented CSII is now able to suspend insulin delivery with hypoglycemia or anticipated hypoglycemia. Further research of the closed loop system will possibly need the appropriate use of both insulin and anti-insulin hormone like glucagon. It will probably also need the input from lifestyle factors: food, activity, mood, etc.
History of discovery of insulin and the modification of the native insulin molecule is a reflection of how meticulous perseverant science leads to improves health of individual patients leading to healthier and longer life of the multitude of people with diabetes. Understanding of the physiology of insulin and glucagon secretion and action has led to a more rational effective clinical utilization of these hormones in the intensive insulin regimen used widely and the possible development of a dual-hormone pump in the future. Without doubt the newer insulin analogs have made the so-called intensive insulin therapy a little less inconvenient especially for the people with type 1 diabetes mellitus: reduced time the person has to wait between the meal dose and the food, and reduced fear of hypoglycemia when not eating. This convenience has been further enhanced by the availability of the newer insulin 12delivery systems: pens and pumps. Subcutaneous continuous insulin infusion can provide just the right amount of basal insulin (e.g., more than one basal insulin rate), reducing the theoretical risk of hypoglycemia when insulin needs are the lowest (middle of the night) and when not eating.
Acute glycemic complications like ketoacidosis and hypoglycemia can often be effectively self-managed by the patient. Further understanding of pathophysiology and good clinical studies have improved treatment enhancing survival while reducing utilization of useless therapeutic interventions in severe hospitalized cases. Most hospitalizations of people with diabetes mellitus are for other co-morbid conditions. Systemic standardized approach for a good glycemic control with meticulous attention to prevention and prompt treatment of hypoglycemia is likely to improve outcomes in our patients with hyperglycemia during the hospitalizations. Management of hyperglycemia in complex clinical situations require modification of goal, targets, and means to achieve the glycemic targets while attempting to minimize the additional burden of management.
Insulin therapy carries substantial risks. Allergies are rare. Hypoglycemia often limits the ability of our patients to reach the targets of glycemic control. Physiologic use of insulin, anticipation and prompt recognition of hypoglycemia, and appropriate therapy of hypoglycemic episodes is an ongoing goal of insulin therapy.
These issues have been extensively reviewed in a reader friendly format in this book.
I am pleased to write this foreword for this book on insulin. In the true spirit of collaboration, the book reflects the opinion of competent authorities from India and abroad, and, public and private sector. This book has been compiled and edited with expertise from Dr Mithal, Dr Shah, and Dr Jevalikar. Authors, both from India and the United States, include people with extensive clinical experience in insulin use and are leaders in clinical research.
Diabetes mellitus is one of the commonest chronic disorders worldwide. The number of diabetics in the world was estimated to be 366 million in 2011 and is expected to rise to 552 million by 2030. In India alone, more than 60 million are estimated to be affected by this condition. Optimum management of diabetes, however, remains an elusive goal. Although major advances have taken place in the therapies available for both type 1 and type 2 diabetes, treatment continues to fall far short of ideal.
Insulin was the first agent used for treating diabetes more than 90 years ago and is the only, life saving, treatment for type 1diabetes. It is also an important treatment modality for type 2 diabetes. Since its discovery in 1921, incremental improvements in insulin therapy have taken place resulting in insulins with superior kinetics, greater ease of administration and convenient dosing schedules. Increasing use of genetic engineering has opened up numerous possibilities of developing new and ingenious “designer” insulin analogs. Recent years have witnessed rapid progress in this area, with a range of short-, long-, and ultra-long acting insulins now available, and several more innovative molecules under development.
There is a need for physicians to have a thorough understanding of practical aspects of newer insulins to ensure best use and practice. It is important to simplify apparently complex regimens and choose the best suited insulin for a particular patient. This book is an attempt to provide practical guidance for using insulin, at the same time explaining the theory and logic behind choices and decisions. It provides information in an easy and comprehensible manner to practicing physicians and medical students.
Chapters have been authored by renowned experts in the field from academia, corporate hospitals, and industry from India and the United States of America. They have drawn on their stores of knowledge and wisdom to contribute wholeheartedly to this project. The book has 11 chapters which cover history, physiology, pharmacokinetics, insulin analogs, newer delivery devices, insulin pump therapy, emergencies and practical use in type 1 and type 2 diabetes, as well as in special situations.
We would like to thank our colleagues at the Division of Endocrinology and Diabetes, Medanta the Medicity for ideas, suggestions, and constructive criticism throughout the writing of this volume. We would also like to express our gratitude to Jaypee Brothers Medical Publishers for tolerating our tardiness and numerous idiosyncrasies!
Ambrish Mithal
Ganesh Jevalikar
Pankaj Shah