Premanidhi Panda
Dr. Panda Diabetes Institute, India
Keynote: J Diabetes Metab
Usually patients with type 2 diabetes will eventually fail to respond adequately to oral hypoglycaemic drugs in term therapy and will require insulin therapy. Usally at that situation an Ultra Long Basal Insulin Like Glarigine(LANTUS) or Insulin detemir (Levemir) at bedtime before dinner with daytime oral drugs is giving good result with good control of glycemic control. It can be started safely in general practice with a good result. Insulin is a peptide hormone produced by beta cells in the pancreas. It regulates the metabolism of carbohydrates and fats by promoting the absorption of glucose from the blood to skeletal muscles and fat tissue and by causing fat to be stored rather than used for energy. Except in the presence of the metabolic disorder diabetes mellitus and metabolic syndrome. Insulin is divided as follows:- Rapid Acting Insulin:- â?¢ Regular insulin (Humulin R, Novolin R) â?¢ Insulin lispro (Humalog) â?¢ Insulin aspart (Novolog) â?¢ Insulin glulisine (Apidra) â?¢ Prompt insulin zinc (Semilente, Slightly slower acting) Examples of intermediate acting insulins include â?¢ Isophane insulin, neutral protamine Hagedorn (NPH) (Humulin N, Novolin N) â?¢ Insulin zinc (Lente) Examples of long acting insulins include â?¢ Extended insulin zinc insulin (Ultralente) â?¢ Insulin glargine (Lantus) â?¢ Insulin detemir (Levemir) Diabetes mellitus type 2 (formerly noninsulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes) is a metabolic disorder that is characterized by hyperglycaemia (high blood sugar) in the context of insulin resistance and relative lack of insulin. This is in contrast to diabetes mellitus type 1, in which there is an absolute lack of insulin due to breakdown of islet cells in the pancreas. Management:- (1)Lifestyle Interventions (2)Medication:- There are several classes of anti-diabetic medications available. Metformin is generally recommended as a first line treatment.Other medications are sulfonylurea, nonsulfonylurea secretagogues, alpha glucosidase inhibitors, thiazolidinedione, glucagon-like peptide-1 analog, and dipeptidyl peptidase-4 inhibitors.Pioglitazone, a thiazolidinedione In my view Over a period of 13years treatment to more than 25000 Patients I do not found any side effects line heart failure,Bone fracture or a single case of Bladder cancer.Its a good drug with cardiovascular saftety. Most people do not initially need insulin. But here I am writing many doctors Initially starting Insulin for business purpose. Now a dayâ??s Long acting Insulin like glarigine is best Insulin With single dose therapy at night dose rather than Twice daily dose.(GLARIGINE). When nightly insulin is insufficient, twice daily insulin may achieve better control. The long acting insulins glargine and detemire are equally safe and effective. and do not appear much better than neutral protamine Hagedorn (NPH) insulin.In pregnancy with type II diabetes Insulin is the main stay of therapy. Surgery:- Weight loss surgery in those who are obese is an effective measure to treat diabetes. Many are able to maintain normal blood sugar levels with little or no medications following surgery and long-term mortality is decreased. Insulin Therapy In Type II Diabetes:- A number of landmark randomized clinical trials established that insulin therapy reduces micro vascular complications . In addition, recent follow-up data from the U.K. Prospective Diabetes Study (UKPDS) suggest that early insulin treatment also lowers macro vascular risk in type 2 diabetes .But in my practice I did not find any difference between Insulin and Oral Antidiabetic drugs with controlling blood sugar. controversy exists on how to initiate and intensify insulin therapy.I also object to start initially with insulin thearapy to start with. My view insulin therapy in type II diabetes:- Six conditions in type II diabetes. 1. In Type II Diabetes when maximum oral hypoglycimic drug does not work. 2. You are having infection. 3. You are undergoing surgery. 4. When target organs involved(brain,heart,kidney,nerves) 5. Fulminating Conditions. 6. Gestational Diabetes With Previous History of Type II diabetes. The team says their findings apply to type 2 diabetes patients with hemoglobin A1c levels below 8.5%. But they note that patients with levels above 8.5% may be likely to see greater benefits from insulin therapy, as they are at greater risk of diabetes complications.But here I observe with Oral tablet there is no difference between Insulin and Oral Antidiabetic Drugs. Still then more than 75years old If HBA1C more than 8.5 Insulin can be given along with Oral Drugs. Currently, we are failing our patients by not recognizing that their preferences and views of treatment burden are the most important factors in helping them make glycemic treatment decisions that are best for them. With age group 30-70years:- In younger diabeteics with high oral drugs with HBA1C more than 7 Insulin can be started early with life style modification to minimize Macrovascular and Microvascular Complication when fails with oral drugs.In old person more than 75years when HBA1C >8.5 Insulin should be started as soon as possible. Oral drugs with insulin:- After coming of newer oral drugs particularly (1)Glimiperide (2)Pioglitazone a Wonderful drug in my opinion (3)Voglibose I never got any uncontrolled blood sugar Patient. Out of 47000 Patients 80% are within this regimen. I have add Insulin when any younger patient having HBA1C >7 after the oral drugs and Older patient >8.5.I used to prefer Ultra long Basal Insulin once before dinner . In my study I have taken in my convenient dose in sliding scale not 0.5units/Kg body weight. <150 Nil, 150-170 2Units, 170-190 4Units, 190-210 6Units In my study i have never found any hypoglycemia except one who has taken small diet than Usual diet. There was tremendous result in with blood sugar, HBA1C,Lipid Profile. Conclusion: In my study I have conclusion do not start Insulin Initially. Start with Oral drugs. After 2-3months if Blood sugar will not be controlled. Add Ultralong Basal Insulin in sliding dose rather than Usal 0.5Units/Kg body weight. Used in sliding scale.<150 Nil,150-170 2Units,170-190 4Units and so on. Use of insulin glargine(LANTUS) by giving subcutaneously compared with Without Lantus with three drugs to be continued as before is associated with less nocturnal hypoglycemia and lower post-dinner glucose levels. These data are consistent with peak less and longer duration of action of insulin glargine compared without Lantos. Achievement of acceptable average glucose control requires titration of the insulin dose to an FBG target 110mg/dl. These data support use of insulin glargine (LANTUS)in insulin combination regimens in type 2 diabetes Who those are not controlled with Thee drug Regimen. Patients with shorter duration T2DM better achieved target A1C levels. A single subcutaneous injection of glargine at a dose as per my sliding scale can acutely reduce glucose, HBA1C, and Lipid profile levels for 24 h in obese insulin-resistant type 2 diabetic individuals. Glargine lowers blood glucose by mainly inhibiting EGP with limited effects on stimulating glucose disposal. Large doses of glargine have minimal effects on glucose flux and retain a relatively hepatospecific action in type 2 diabetes. Numerous studies have investigated the clinical efficacy of insulin glargine in both type 1 and type 2 diabetes. Glargine has been found to lower A1C, provide effective basal insulin replacement, and reduce the risk of hypoglycemia.
Premanidhi Panda completed his MBBS from Berhampur University, India and Post-doctoral studies, MD (MED) from Utkal University School of Medicine. He is the Director of Dr. Panda Diabetes Institute, India, a premier Diabetes Hospital and Research Centre in India. He worked in Tisco Hospital (India), Benghazi Medical (Libya), and Medwin Hospital. He was awarded with India’s Best Doctor Award-2013 (diabetes) by Medgate Today Survey. He was awarded MRCP, FRCP by Royal College of Physician and Surgeon. He published more than 20 papers in reputed journals and received several national and international awards for his contribution in Diabetes
Email: pandadrpremanidhi@gmail.com
