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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