Tuesday, February 5, 2013

Insulin Omission



Insulin Omission

According to an article written by a medical doctor in the area of treatment of diabetes, one of the main principles of medical practice is “doing no harm” (Choudhary, et al. 2010). However, this is not always the case with the treatment of diabetes. This is because treatment of diabetes with the use of drugs carries a considerable risk of causing harm to the patient due to the risk of hypoglycemia. Most of the research carried out in the area of treatment of diabetes with the use of insulin suggests that treatment of diabetes would be a lot easier were it not for the risk of hypoglycemia.  The incidence and threat of hypoglycemia is the main factor affecting effectiveness in the intensive glycemic control the two types of diabetes. Hypoglycemia is common in clinical practice. Just about 90 percent of all individuals receiving insulin for the treatment of diabetes experience hypoglycemic episodes. However, the combination of the understanding of the physiological counter-regulatory responses that are induced by the condition as well as supervision of glycemic therapy play an important role in reducing the of hypoglycemia (Home et al. 2010)
Most of the treatment for diabetes entails augmenting insulin. Insulin for the treatment of diabetes is either injected directly, or used indirectly trough the means of increasing its release from the pancreatic β-cells, slowing down hepatic glucose production, or increasing insulin sensitivity. In case there is alteration of the endogenous insulin, hypoglycemia emerges as one of the possible side effects. Drews III, et al. (2012) argues that it is one of the most commonly experiences side effects of treatment for diabetes. Some of the complications which develop as a result of the treatment can be life-threatening as well as resistant to therapy.
Mayfield (2004) posits that hypoglycemia has been noted by many authors to be in many ways the Achilles’ heel of the treatment for diabetes. As a matter of fact, majority of the authors in this area have agreed with this argument. Additionally, medical authors have perceptively recognized that hypoglycemia is a major limiting factor in diabetes treatment. This is because decrease of glucose levels in people suffering from type 1 or type 2 diabetes has been revealed to lower the risks of nerve, kidney, and retinal injuries. According to Briscoe and Davis (2006) reduced levels of glucose have also been found to have a connection with reduction in cardiovascular disorder people suffering from type 1 diabetes. However, because of the possibility of developing hypoglycemia, patients of diabetes are not able to effectively control the condition with the use of insulin or oral drugs (Thomas, et al 2007).
Research carried out to find the prevalence of hypoglycemia has revealed some alarming results. Briscoe and Davis (2006) suggests a three-fold increase in serious hypoglycemia as well as coma patients with diabetes receiving intensive treatment compared to patients receiving conventional treatment. A patient with type 1 diabetes receiving intensive treatment can experience as many as ten episodes of symptomatic hypoglycemia every week as well as serious temporarily disabling hypoglycemia one time in a week. Approximately 2- to 4 percent of deaths in individuals with type 1 diabetes have been suggested to be as a result of hypoglycemia. The condition is also relatively common in patients with type 2 diabetes, with rates of prevalence of between 70 and 80 percent in clinical experiments applying insulin in the achievement of effective metabolic control.
Donnelly et al. (2005), carried out a random survey of persons (n = 267) suffering from type 1 diabetes as well as insulin-treated type 2 diabetes to document  events of hypoglycemia experienced over a four-week period. Out of the 267 participants in the survey, 155 were found to report 572 episodes of hypoglycemia. The participants suffering type 1 diabetes reported a prevalence rate of 43 episodes were individual each year. Those suffering from type 2 diabetes were shown to have a prevalence rate of 16 episodes per person every year. For individuals suffering from type 1 diabetes, the factors predicting hypoglycemia included such factors as a history of the condition. For the type 2 diabetes treated with insulin, some of the predictors included history of the condition as well as the time period of the treatment with the use of insulin.  Compared to type 1 diabetic participants, self-reports of serious hypoglycemia in type 2 diabetic participants were lower. Donnelly et al. (2005) came to the conclusion that the condition happens more frequently than was the case in the past in insulin-treated type 2 diabetes. They also noted an adequate frequency to lead to morbidity.
According to Briscoe and Davis (2006) the ineffectiveness of glucose control for people suffering from diabetes results from the concerns about the condition especially among bedridden patients as well as the patients with altered psychological status, who may not be in a position to seek help for this condition. Some of the leading reasons for hospitalization are diabetes-related cardiovascular occurrence, such as heart diseases and stroke. Most of the patients who are hospitalized for these conditions are at risk of developing hypoglycemia due to their serious health status as well as altered psychological status. Additionally, clinical intervention might put them at risk for realizing signs and symptoms of the condition. Detection and intervention for the condition requires the health care providers to be attentive in identifying the signs and symptoms, prevention of events without any compromises to the control of glucose for appropriate treatment and healing (Drews III, et al. 2012).
Some health care providers have been reluctant to use insulin in the treatment of diabetes. Wallace and Matthew (2000) have suggested that health care providers and patients have most of the time “colluded in implicit and unspoken contracts to continue oral agents for as long as possible” (p. 370). Research has suggested that use of insulin should be approached with care due to the possibility of developing hypoglycemia. Corley, et al (2011) notes that concerns regarding the condition as well as the willingness of the patient and/or capability to inject the drug are the reasons why health care providers are advised to approach the treatment with care. Together with this reluctance, is the argument that use of insulin for the treatment of diabetes is too complicated to work out in the primary care setting, especially one that is too busy. Prescription information that is given by the producers of insulin has been to some extent vague concerning the first dosage as well as titration (Home et al. 2010)
While the use of insulin for the treatment of diabetes has been associated with the risk of developing hypoglycemia, the solution would seem to be stopping the use of insulin. However, regardless of the prevalence of the condition, there seems to be inadequate research detailing the solution. Most of the available research does not support stopping of the use of insulin. Due to these factors, health care providers have at times tended to holdup making the required transition from oral drugs to insulin. As a matter of fact, evidence from research reveals that the hemoglobin A1c (A1C) results that trigger glucose-lowering activity is ≥ 9%.  Home et al. (2010) argues that this regrettable given the fact that various studies have revealed that outstanding glycemic control is achievable with the use of insulin treatment, especially with type 2 diabetes. Additionally, there is more and more body of research revealing that timely and efficient intervention with the use of insulin is more significant than was earlier believed.
Management of hypoglycemia has been proven possible without necessarily having to stop the use of insulin as the survival of the patient depends on this therapy. Concerns regarding the condition are normally revealed in physical orders. Regardless the fact that endocrinologists have warned against its utilization for a long time, the rapid-acting or regular analog insulin sliding scale with no basal insulin replacement is still a commonly used method of trying to control hyperglycemia in the clinical setting. According to Corley, et al (2011) normally, due to the concern for the condition, basal insulin is not provided, and there is administration of prandial insulin only when there is elevation of pre-meal blood glucose (Fowler 2008).
However, unsurprisingly, the approach fails to work. This is because in case insulin is not given prior to a meal, the level of blood glucose increases considerably and will remain high at the time of the following meal (Fowler, 2008). This necessitates a large dose of normal aspart or lispro insulin. This can result in hypoglycemia, par especially in case it is given at bedtime with no a meal. Therefore, it is noted that normal insulin sliding scales are unsuccessful, cause the risk of developing hyperglycemia and hypoglycemia, and should therefore be completely avoided (Quilliam, et al. 2011).
On the contrary, bolus and basal insulin offers a more physiological replacement of insulin. One of the recent ADA technical reviews on diabetes among inpatients utilized the term “scheduled insulin requirement” or “programmed insulin requirement” in reference to the dose required for hospitalized patients that is required to cover for both nutritional and basal needs. When those suffering from diabetes eat their meals on schedule, there is requirement for basal and separate prandial insulin. These provide viable options. Hirsch (2004) suggests switching of treatment to more basal-bolus insulin therapy rather than discontinuing the use of insulin as this can prove fatal. According to Fowler (2008) switching from conventional regimens that make use of normal and NPH insulins to more physiological basal and bolus insulin treatment with insulin analogs has been shown to lower the risk of hypoglycemia. However, it is important to note that not all researches have found out this connection, and, additionally, the risk of major hypoglycemia has not changed a lot in different researches carrying out comparisons between new insulin analogs and regular insulin regimens. There is also the cost factor in that insulin analogs are much more costly compared to the use of regular and NPH insulin (Schopman, Geddes and Frier 2011).
Use of insulin pump therapy has been revealed in studies to possess the benefit of conveying both minor doses of insulin as well as variable basal doses. Anderbro, et al. (2010) argues that this might offer lower chances of developing hypoglycemia for individuals receiving insulin treatment for type 1 diabetes. Various studies have provided evidence to show that the use of insulin pump therapy lowers the risk of developing hypoglycemia. However, it is important to note that insulin pumps can be relatively labor-intensive and also may not be appropriate for all persons with diabetes. The insulin pump therapy is also costly, with the pump only costing several thousand dollars, plus the monthly changes of supply (Hirsch, et al. 2005).
The primary objective of diabetes therapy is normalizing the levels of glucose, without causing them to go down excessively. However, almost all diabetes treatments are capable of causing the risk of hypoglycemia (Johannesen, et al. 2011). This condition is a possibly life threatening complication of treatment of diabetes and is also a considerable cause of mortality and morbidity, particularly for patients receiving insulin treatment. This is a cause for caution for health care providers in the use of insulin for treatment of diabetes. Risk of the condition ought to be weighed strongly in the adjustment or initiation phase of diabetes treatment regimens. Stopping the use of insulin might also result fatal for patients with diabetes. Thus, care should be taken to watch out for the signs of hypoglycemia and reverse it (Tomky 2005). It is important to teach patients the signs and symptoms as well as the good treatment for the condition. It is also important to teach them how to prevent it. These kinds of precautions should make it possible for health care providers to optimize diabetes control while at the same time minimizing the risk of harm for the patients as a result of hypoglycemia (Castaldo et al. 2011).
The risk and incidence of hypoglycemia is a main limiting factor in the management of diabetes. However, it is possible under careful supervision for health care practitioners to minimize or control hypoglycemic risks through the understanding of the physiological counterregulatory responses as well as aggressively monitoring insulin therapy (Sarkar, et al. 2010). Hypoglycemia is more problematic in type 1 diabetes in the event of aggressive glycemic treatment as well as in advanced type 2 diabetes due to compromised glucose counterregulatory system. However, this does not mean that use of insulin therapy should be stopped in the event of hypoglycemia. There is need for education relating to aspects such as self-monitoring of the level of glucose, physiological insulin replacement, diet, lifestyle and medication. These aspects are important in the maintenance o proper glycemic control, avoiding hypoglycemia, and preventing long-term complications (Salem, et al. 2011).


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