Insulin Therapy For Prediabetes

  • Rukhsar Jabbar Masters in Physiotherapy, Jamia Millia Islamia, India
  • Yuna Chow BSc (Hons), Medicine, University of St Andrews

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Overview 

Insulin therapy can be a valuable tool in managing prediabetes when lifestyle changes alone aren't sufficient. It's important for you to recognize that insulin is not the first resort, but if prescribed by a healthcare professional, it can effectively regulate blood sugar levels and prevent the progression to diabetes.

Understanding the nuances of this treatment option, along with additional lifestyle strategies, will empower you to make informed decisions about your health.

Introduction

From the early 1920s, when pancreatic extracts were first employed, the groundbreaking discovery of insulin has prevented the death of many patients with diabetes mellitus.

After insulin was developed, there was a sharp decline in the overall number of deaths from diabetic coma. However, during the next few decades, diabetes became a chronic condition with faster degenerative consequences.2 

Over the next five to ten years, there is a 50% chance that someone with prediabetes may acquire diabetes. You can prevent type 2 diabetes by managing your prediabetes.

If you are fat or overweight and have one or more additional diabetes risk factors, or if any of your parents, siblings, or children have type 2 diabetes, you should get tested for prediabetes. Once you are 45, you should begin testing even if you don't have any risk factors.

You should get retested at least every three years if the findings are normal but you have additional diabetes risk factors.10

Understanding prediabetes

A condition known as prediabetes is characterised by aberrant glucose homeostasis, where blood glucose levels are higher than usual but still fall short of what is needed to be diagnosed with diabetes. 

Impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) are its defining characteristics. There is mounting evidence that indicates prediabetes is not just a risk factor for diabetes but also a hazardous state. Recent data points to the pathophysiological alterations that prediabetes is linked to in a number of tissues and organs, supporting the diagnosis of the condition as a separate pathological entity.1

Definition and diagnostic criteria

The American Diabetes Association (ADA) and the global community have different standards for diagnosing prediabetes. Furthermore, there is no similar guideline for the diagnosis of prediabetes, in contrast to the requirement that the diagnosis of diabetes be validated. This is regrettable because over half of people with impaired glucose tolerance have normal results on a second oral glucose tolerance test (OGTT) within a six-week period. When repeat testing was conducted using the internationally impaired fasting glucose criterion to identify prediabetes, 32% of the results were normal.8

A person's likelihood of receiving a prediabetes diagnosis varies significantly depending on their place of residence and the diagnostic test utilised. Using the biggest potential disparity as an example, the prevalence of prediabetes in the USA is 37.5% when diagnosed by an FPG concentration of 5.6–6.9 mmol/L, but the prevalence worldwide is 5.8% when diagnosed by a HbA1c level of 42–46 mmol/mol.8

Risk factors for prediabetes

Prediabetes is a condition that can go undiagnosed for years if there are no obvious signs, which is common until more serious health issues like type 2 diabetes manifest. It's crucial to discuss getting your blood sugar checked with your doctor if you have any of the following prediabetes risk factors:

  • Being obese
  • Being 45 years of age or older
  • Having a brother, sister, or parent who has type 2 diabetes
  • Being less than three times a week physically active
  • Have you ever been diagnosed with gestational diabetes, or have given birth to a baby weighing more than nine pounds
  • Having the syndrome of polycystic ovary.3

Insulin therapy

Insulin and its importance

Insulin, a hormone composed of 51 amino acids, plays important roles in glucose homeostasis, cell growth, and metabolism. The physiology of insulin-producing cells is fundamental to understanding the regulation of insulin secretion. The pancreatic β cells secrete the peptide hormone insulin. The human pancreas contains one to two million pancreatic islets housing different endocrine cells, primarily insulin-secreting β cells, glucagon-producing α cells, and somatostatin-secreting δ cells. Although islets compose only 1–2% of the human pancreas, they receive up to 10% of the total pancreatic blood supplies. Insulin is often released following glucose ingestion through a mechanism known as glucose-induced insulin activation. This process requires both the intracellular uptake and metabolic degradation of ingested glucose.4

Insulin's primary function is to control the body's energy supply during the fed state by maintaining the proper balance of micronutrients. For intracellular glucose to reach insulin-dependent cells and tissues, such as the liver, muscles, and adipose tissue, insulin is essential. Any imbalance in the energy sources coming from outside the body breaks down the fat that is stored in adipose tissue, which in turn speeds up the release of insulin.4

How insulin therapy works

A common and crucial component of diabetes treatment is insulin therapy. It helps avoid complications from diabetes and maintains blood sugar control. It functions similarly to the insulin hormone the body normally produces.

Insulin treatment maintains your blood sugar levels within the desired range. Insulin therapy is necessary for people with type 1 diabetes to maintain their health since their pancreases produce less insulin.

Insulin therapy may be a component of your treatment plan if you have type 2 diabetes. It's required when other diabetic therapies and healthy lifestyle modifications aren't enough to regulate blood sugar levels.

Pregnancy-related diabetes mellitus can also occasionally require insulin therapy. We refer to this as gestational diabetes. If you have gestational diabetes, you might need insulin therapy if healthy habits and other diabetes treatments don't help enough.5

Types of insulin used in prediabetes treatment

Insulin of any kind aids in the treatment of diabetes. The rate at which each variety lowers and maintains blood sugar differs. It is possible that you will require multiple types of insulin. What kind and how much insulin you require depends on a number of factors, including:

  • The kind of diabetes you suffer from.
  • Your blood sugar levels.
  • The amount that your blood sugar fluctuates during the day.
  • Your lifestyle habits.5

Insulins that are long-acting, ultralong-acting, or intermediate-acting are the three primary forms of insulin therapy. Your body releases glucose into the bloodstream when you are not eating, giving you energy. Insulin that is either long-, ultralong-, or intermediate-acting stops blood sugar from rising in the absence of food.

These insulins include glargine (Lantus, Basaglar), NPH (Humulin N, Novolin N), detemir (Levemir), and degludec (Tresiba). Insulin with an intermediate half-life lasts roughly 12 to 18 hours. Insulin with a long half-life lasts roughly 24 hours. Moreover, ultra-long-acting insulin has a half-life of at least 36 hours.5

Insulins with short or rapid-acting times. It is best to use these insulins prior to meals. They can assist in lowering blood sugar levels back to normal if taken with food. They also lessen the post-meal rises in blood sugar. Compared to long- or intermediate-acting insulins, they begin to function substantially more quickly. 

Rapid-acting insulins can sometimes start to function in as little as 5 to 15 minutes, yet their effectiveness is substantially reduced. Insulin that acts quickly lasts for two to three hours. Insulin that acts quickly lasts about 3 to 6 hours.
These insulins include, for example, short-acting, regular (Humulin R, Novolin R), ultrafast-acting aspart (Fiasp) and lispro (Lyumjev); rapid-acting aspart (NovoLog), glulisine (Apidra), and lispro (Humalog, Admelog).5

Insulin producers occasionally blend two forms of insulin. We refer to this as pre-mixed insulin. For those who struggle to use more than one type of insulin, it may be useful. In most cases, pre-mixed insulin begins to act in 5 to 60 minutes. It has a 10- to 16-hour battery life.

Be advised that the duration and timing of the effects of various insulin formulations can differ. Make sure you follow the directions that are included with your insulin. Moreover, adhere to any instructions given by your medical staff.5

Methods for administering insulin

Insulin is not available as a tablet. The pill would be broken down by the digestive system before it could have any effect. However, insulin can be taken in several ways, and choosing the approach that works best for you can be assisted by your healthcare team.

Options consist of:

  • Pens or shots – Using a syringe and needle, you can inject insulin subcutaneously into the fat directly beneath the skin. Or you may use a pen-like instrument to inject it. Both varieties of devices have a needle attached and can carry insulin. The type of diabetes you have will determine how frequently you need to take an insulin pen or injection. It also depends on how frequently you eat and exercise, as well as your blood sugar levels. You might have to take insulin shots or use insulin pens multiple times per day.
  • Pump for insulin – You can get modest, consistent doses of fast-acting insulin all day long using an insulin pump. This functions similarly to getting a long-acting insulin shot. Another option for an insulin pump is a quick shot, usually taken with food. It functions similarly to receiving a quick-acting insulin shot. Insulin is pushed into a little tube that is positioned beneath the skin by the pump. There are numerous varieties of insulin pumps available.5
  • Inhaled insulin (Afrezza) – Insulin of this kind acts quickly. Using an inhaler — a device that fits inside your mouth — the drug can be quickly administered. This kind of insulin is taken at the beginning of each meal. Insulin that is inhaled should not be used by smokers and by people who have lung disorders, including asthma or chronic obstructive pulmonary disease.5

Patient selection and monitoring

Criteria for selecting patients for insulin therapy

Insulin can be administered as insulin replacement therapy or to supplement oral hypoglycemic medicines in patients with type 2 diabetes mellitus.

It is advised to aim for 80–130 mg/dL during fasting and premeal, and less than 180 mg/dL during the two hours following meals. Weight gain and hypoglycemia are linked to insulin use. Although they are far more expensive than human insulin, insulin analogues are just as good at lowering A1C levels and reducing the risk of hypoglycemia.7

Monitoring and evaluating the response to insulin therapy

A mismatch between insulin and carbohydrate intake, exercise, or alcohol use can all lead to hypoglycemia. Insulin medication can be started or intensified, although sometimes it isn't because of worries about hypoglycemia risk. Of the patients on insulin, 1% to 2% suffer severe hypoglycemia (i.e. needing help from others for treatment), and 7% to 15% have at least one episode of hypoglycemia annually. Hypoglycemia, particularly in elderly patients, has been linked to worse outcomes and increased mortality rates. Compared to those without a history of a severe hypoglycemia incident, patients with type 2 diabetes have a fatality rate that is roughly two to four times greater. Additionally, hypoglycemia has been linked to a higher risk of cardiac arrhythmias and dementia.7

All patients need to be informed about hypoglycemia's symptoms and how to manage it on their own. The following is advised by the ADAif hypoglycemia symptoms or signs are present:

  1. Check blood glucose levels; if less than 70 mg/dL (3.9 mmol/L), treat with 15 g of fast-acting carbohydrates, such as 4 oz of fruit juice or 3–4 glucose tablets; and 
  2. Check blood glucose levels again after 15 minutes to make sure they have returned to normal.7

Lifestyle modifications

Engaging in regular physical activity and losing a little weight if you are overweight can reduce your chance of developing type 2 diabetes if you have prediabetes. A small weight loss is defined as five to seven percent of your body weight, or about ten to fourteen pounds for a 200-pound person. Engaging in brisk walking or a comparable activity for at least 150 minutes per week qualifies as regular physical activity. Just thirty minutes a day, five days a week would be sufficient.3

A lifestyle modification program proposed by the CDC-led National Diabetes Prevention Program can assist you in making those adjustments and keeping them. By participating in the programme, you can reduce your risk of type 2 diabetes by up to 58% (71% if you're older than 60).

Highlights consist of:

  • Making practical, long-lasting lifestyle improvements while working with a qualified coach.
  • Learning how to incorporate more exercise and a healthy diet into your daily routine.
  • Learning techniques for stress management, maintaining motivation, and resolving issues that may impede your advancement.
  • Getting assistance from those with comparable obstacles and aspirations.3

Future directions

The long-term control of diabetes can only be partially achieved using the pharmacological approach to treating type 2 diabetes. For patients to have an effective illness management strategy, significant lifestyle changes in addition to medication therapies are essential. These consist of altered physical activity levels, nutritional adjustments, stress management or related issues, and better sleep hygiene.6

According to the American Diabetes Association's guidelines for the pharmacological therapy of diabetes, people with type 2 diabetes should be prescribed metformin as their first line of treatment. Nevertheless, the same guideline also states that vitamin B12 deficiency is a common adverse effect seen in metformin users, necessitating routine vitamin B12 testing in these individuals. Moreover, metformin is well known for producing lactic acidosis, particularly in individuals with low levels of oxygen in the blood due to kidney failure, liver damage, or other CVS problems.6

Although the negative effects of SGLT2 inhibitors remain uncertain, the combination of SGLT2 inhibitors with metformin may have been helpful in reducing hyperglycemia that cannot be controlled by metformin alone.

In addition to potentially improving health outcomes for T2DM patients, the use of multidrug combination therapy for diabetes can cause other problems that should be carefully considered. Furthermore, the comorbidities that emerge with diabetes need to be given more consideration.6

Conclusion

Glycemic values that are above normal but below the diabetes threshold characterise prediabetes, an intermediate stage of hyperglycemia. Although there is variation in the diagnostic criteria for prediabetes among worldwide professional organisations, the condition is nevertheless associated with a significant risk of acquiring diabetes, with an annual conversion rate of 5% to 10%.9

To sum it up, even though insulin therapy isn't usually the first thing for prediabetes, it becomes really important when lifestyle changes aren't enough. With the help of healthcare professionals, insulin therapy can help control blood sugar levels, stopping prediabetes from turning into diabetes. The important thing is to have a plan that's personalized and covers everything – using insulin and making lifestyle changes – so people can manage their health and lower the risks of prediabetes.

References 

  1. Lawal Y, Bello F, Kaoje YS. Prediabetes deserves more attention: a review. Clinical Diabetes [Internet]. 2020 Oct 1 [cited 2024 Jan 15];38(4):328–38. Available from: https://diabetesjournals.org/clinical/article/38/4/328/35402/Prediabetes-Deserves-More-Attention-A-Review.
  2. Owens DR. Clinical evidence for the earlier initiation of insulin therapy in type 2 diabetes. Diabetes Technology & Therapeutics [Internet]. 2013 Sep [cited 2024 Jan 16];15(9):776–85. Available from: http://www.liebertpub.com/doi/10.1089/dia.2013.0081
  3. CDC. Centers for Disease Control and Prevention. 2021 [cited 2024 Jan 17]. Prediabetes - your chance to prevent type 2 diabetes. Available from: http://bit.ly/2hMpYrt
  4. Rahman MS, Hossain KS, Das S, Kundu S, Adegoke EO, Rahman MdA, et al. Role of insulin in health and disease: an update. Int J Mol Sci [Internet]. 2021 Jun 15 [cited 2024 Jan 18];22(12):6403. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8232639/
  5. Mayo Clinic [Internet]. [cited 2024 Jan 18]. Diabetes treatment: Using insulin to manage blood sugar. Available from: https://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/diabetes-treatment/art-20044084
  6. Management of Type 2 Diabetes: Current Strategies, Unfocussed Aspects, Challenges, and Alternatives[cited 2024 Jan 18]. Available from: https://karger.com/mpp/article/30/2/109/204772
  7. Howard-Thompson A, Khan M, Jones M, George CM. Type 2 diabetes mellitus: outpatient insulin management. [Internet]. 2018 Jan 1 [cited 2024 Jan 18];97(1):29–37. Available from: https://www.aafp.org/pubs/afp/issues/2018/0101/p29.html.
  8. Davidson MB. Should prediabetes be treated pharmacologically? Diabetes Ther [Internet]. 2023 Oct 1 [cited 2024 Jan 18];14(10):1585–93. Available from: https://doi.org/10.1007/s13300-023-01449-7
  9. Bansal, Nidhi. “Prediabetes Diagnosis and Treatment: A Review.” World Journal of Diabetes, vol. 6, no. 2, Mar. 2015, pp. 296–303. PubMed Central, https://doi.org/10.4239/wjd.v6.i2.296.
  10. Insulin Resistance & Prediabetes - NIDDK.” National Institute of Diabetes and Digestive and Kidney Diseases,https://www.niddk.nih.gov/health-information/diabetes/overview/what-is-diabetes/prediabetes-insulin-resistance

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Rukhsar Jabbar

Masters in Physiotherapy, Jamia Millia Islamia, India

Rukhsar Jabbar is a physiotherapist specializing in neurology, having attained her master's degree in the field. She is particularly passionate about research-based medical content writing, demonstrating a commitment to promoting health awareness. Her dedication lies in bridging the gap between evidence-based scientific information to accessible content, catering to individuals of diverse backgrounds. Looking ahead, Rukhsar aspires to make significant contributions to the field of research, further enhancing the understanding and application of evidence-based information in healthcare.

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