Published Nov 3, 2014
According to the latest report from the Centers for Disease Control and Prevention, six million American adults with diabetes currently use insulin to help keep their blood sugar levels under control. A naturally occurring hormone produced by the pancreas, insulin helps to transport the sugar in food from the bloodstream into the cells, which then convert the sugar into energy.
Without insulin, sugar (also known as glucose) remains in the blood and builds up. Over time, high blood glucose levels can lead to the serious complications associated with diabetes, such as heart disease, kidney disease, poor circulation to the limbs, and amputations.
Insulin therapy can help manage blood sugar when the body can’t do it on its own. Insulin is a must for everyone with type 1 diabetes, because their bodies are not capable of even producing insulin. People who have type 2 diabetes do produce insulin, but their bodies may not produce enough or may not use the insulin properly. Consequently, they may need insulin therapy depending on their blood glucose levels, related medical conditions, and other medications they are taking.
While conventional insulin products have been very effective in helping to keep blood glucose levels under control, they do have some limitations. For example, blood sugar rises very quickly following a high-carbohydrate meal, and the insulin products we’ve had available can’t act fast enough to keep up.
It also can be challenging to know how much insulin to take, and when, to effectively manage blood sugar. Just as too little insulin leads to high blood glucose, too much insulin can cause a dangerous drop in blood glucose levels known as hypoglycemia, which can cause symptoms ranging from dizziness and weakness to lack of coordination, loss of consciousness, and, in severe cases, coma.
In addition, our bodies need a small amount of insulin working in the background at all times to prevent diabetic ketoacidosis, a buildup of toxic blood acids. To address this, people with diabetes need to have one to two injections regularly throughout the day to keep insulin in their systems. Ideally, these injections are perfectly timed, but in the real world this is not always possible. To date, none of the conventional insulin products have consistently released small amounts of basal insulin that last a full 24 hours and thereby allow a few hours leeway for the real-life variability in the timing of injections.
Faster and Longer-Acting Types of Insulin
To help resolve these issues, a number of pharmaceutical companies are now working on newer forms of insulin that work more quickly or last much longer. Faster “rapid-acting” forms, which are injected before a meal, keep up with the rise in blood sugar after eating. These newer rapid-acting products begin to act within three to five minutes of injection, peak within 30 to 90 minutes, and stay in the body for about three to five hours. One form contains a recombinant human hyaluronidase, an enzyme that temporarily breaks down hyaluronan, a structural component of the space just beneath the surface of the skin. This temporary breakdown creates a “window” for improved delivery of injectable molecules such as insulin through the skin, allowing the insulin to be absorbed more rapidly. Another agent recently approved by the U.S. Food and Drug Administration (FDA) is a rapid-acting insulin that is inhaled rather than injected.
These fast-acting types of insulin can often be used together with new-generation basal insulins that have an ultra-long duration of action of more than 42 hours. The new long-acting products consistently release insulin very slowly into the body, just as the pancreas normally would, to prevent dangerous peaks and drops in blood glucose levels. In addition, long-acting insulin allows more flexibility in the timing of the injections while still managing blood sugar levels. In fact, some long-acting products would even allow someone to inject a dose up to eight hours late and still maintain control of blood sugar the following day. One agent has already been approved and launched in the European Union, Japan, and Mexico; in the United States, the FDA has required additional data for approval, and this data is being generated.
As with most medications, the right form, dose, and frequency of insulin depends on each person’s unique needs, medical profile, and lifestyle. Changes in weight, exercise, diet, and medical condition can all affect insulin needs. If you need insulin to help manage diabetes, you and your physician can work together to determine the most appropriate insulin regimen for you.
Athena Philis-Tsimikas, M.D., is an endocrinologist and the corporate vice president for theScripps Whittier Diabetes Institute at Scripps Health in San Diego
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