Notes For Prescribing Insulin

There is no need to change a stabilised diabetic from animal to human insulin. Unexplained requirement of above 100 units/d is usually due to noncompliance and less often to antibodies since the withdrawal of the older insulin preparations.

Allergy still occurs to additives (protamine), to the preservative, e.g. phenol, cresol, or to insulin itself. It may take the form of local reactions (inflammatory or fat atrophy) or of insulin resistance.

Antibodies to insulin, provided they are moderate in amount, may be actually advantageous. They act as a carrier or store, binding insulin after injection and releasing it slowly as the free insulin in the plasma declines. In this way they smooth and prolong insulin action. But too high antibody concentrations cause insulin resistance.

4 An adverse effect of easy self-monitoring is that a minority of obsessional patients, told of the desirability of blood glucose concentrations being kept in the normal range to prevent diabetic complications, become obsessed with monitoring, and experience great anxiety when they find what are, in fact, normal fluctuations. They then anxiously change their insulin doses daily and as a result induce frequent hypoglycaemia, e.g. one patient had 33 episodes in 44 days, many with loss of consciousness (Beer S F et al 1989 British Medical Journal 298: 362).

Compatibility. Soluble insulin may be mixed in the syringe with insulin zinc suspensions (amorphous, crystalline) and with isophane and mixed (biphasic) insulin, and used at once: but there are insulins in which protamine is used as a carrier, and spare protamine will bind some of the short-acting neutral insulin, thus blunting its effects.

Intravenous insulin. Only Soluble (neutral, clear) Insulin Inj. should be used.

The standard strength of insulin preparations is 100 units per ml in a large and growing number of countries. Even very low doses can be accurately measured with modern special syringes. Solutions of 40 units and 80 units remain available in many countries, and healthcare providers should be aware of this.

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