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(11) Diabetes

Insulin Timing

My doctor is considering changing me from one to two insulin injections per day. Will the second interfere with my social life – eating out, and so on?

No, instead the second injection should make your life more flexible. Most people on one injection a day find that they need a meal in the late afternoon, around 6.00 to 7.00pm. With a second injection, this meal can be delayed for several hours with the insulin given shortly beforehand. With an insulin pen, it is also more convenient to give yourself an insulin injection even when eating out.

I have heard that there is new fast-acting insulin which is even faster acting than Actrapid. Does it have any advantages?

You are quite right, there are now three new synthetic ‘designer’ insulins: two rapid-acting insulins – lispro (Humalog) from Lilly, and aspart (NovoRapid) from Novo Nordisk – and two longer- acting versions – glargine (Lantus) from Aventis and detemir  (Levemir) from Novo Nordisk. They are the first of what will be a series of new insulins (known as insulin analogues), which will be produced in the years to come. They are designed not to aggregate when injected under the skin (a process that occurs to a varying extent with other insulins), thus facilitating their absorption and action.

Their big potential advantage is – at least for Humalog and Novo-Rapid – that they don’t need to be injected until immediately before the meal, and their action more closely matches the digestion of the meal than that of conventional clear insulin’s. This results in better control of the rise in blood glucose following meal digestion and absorption with lowering of the peak glucose concentration. They have another advantage stemming from their short action: when injected before breakfast, they are less likely to cause hypos before lunch as their effects wear off more quickly.

They are ideally suited for the popular ‘basal + bolus’ regimens (i.e. long acting ‘basal’ insulin at night with a ‘bolus’ of short-acting insulin before each meal) and are available in vials, cartridges and disposable pens.

What should I do if I suddenly realize I have missed an injection?

It is quite easy to forget to give yourself an injection or – even worse – to be unable to remember whether or not you have had your injection. If this happens you should measure your blood glucose level to help you decide what to do next.

If your blood glucose is high (more than 10 mmol/litre) you probably did forget your injection and you should have some short-acting insulin as soon as possible. The dose depends on how close you are to the next injection time.

If your blood glucose is normal or low (7 mmol/litre or less) you probably did have your injection even if you have forgotten doing it. It would be safest to check your blood glucose again before your next meal and, if it is high, to have an extra dose of short-acting insulin. Novo Nordisk have recently introduced an insulin doser called Innovo, which has a built-in memory that recalls the amount of dose injected and the number of hours that have elapsed since the last injection.

Does the timing of the injections matter? Can a person who is on two injections a day take them at 10.00am and 4.00pm?

Unless you are taking Humalog or NovoRapid, which are very quick-acting insulins and should be taken just before a meal, it is best to have your insulin about 30 minutes before a meal, and we discuss this further in the next section on Diet and insulin. If you have your main meals in the middle of the morning and in the afternoon, then you could try giving insulin at the times you suggest. You may find that an afternoon injection may not last the 18 hours until the next morning – that is why most people try to keep their two injections approximately 12 hours apart.

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