Side effects and side effects of insulin. Effects of Insulin - Complications of Insulin Therapy Cardiovascular Diseases

Most diabetic patients tolerate insulin treatment well if the correct doses are used. But in some cases, allergic reactions to insulin or additional components of the drug, as well as some other features, may be observed.

Local manifestations and hypersensitivity, intolerance

Local manifestations at the injection site of insulin. These reactions include pain, redness, swelling, itching, urticaria, inflammation.

Most of these symptoms are mild and usually resolve within a few days or weeks after starting therapy. In some cases, it may be necessary to replace insulin with a preparation containing other preservatives or stabilizers.

Hypersensitivity of the immediate type - such allergic reactions develop quite rarely. They can develop both on insulin itself and on auxiliary compounds, and manifest themselves in the form of generalized skin reactions:

bronchospasm,
angioedema,
drop in blood pressure, shock.

That is, all of them can pose a threat to the life of the patient. In case of generalized allergy, it is necessary to replace the drug with short-acting insulin, and it is also necessary to take anti-allergic measures.

Poor insulin tolerance due to a drop in the normal value of long-term habitual high glycemia. If such symptoms occur, then it is necessary to maintain the glucose level at a higher level for about 10 days so that the body can adapt to a normal value.

Visual impairment and sodium excretion

Side effects on the part of vision. Strong changes in the concentration of glucose in the blood due to regulation can lead to temporary visual impairment, as the turgor of tissues and the refraction of the lens change with a decrease in eye refraction (the hydration of the lens increases).

Such a reaction can be observed at the very beginning of the use of insulin. This condition does not require treatment, you only need:

reduce eye strain,
less computer use
read less,
watch less TV.

Pain nye should know that this is not dangerous and in a couple of weeks the vision will be restored.

Formation of antibodies to insulin administration. Sometimes with such a reaction it is necessary to carry out a dose adjustment to eliminate the likelihood of developing hyper- or hypoglycemia.

In rare cases, insulin delays the excretion of sodium, resulting in edema. This is especially true for those cases where intensive insulin therapy causes a sharp improvement in metabolism. Insulin swelling occurs at the beginning of the treatment process, they are not dangerous and usually disappear after 3 to 4 days, although in some cases they can last up to two weeks. That is why it is so important to know.

Lipodystrophy and drug reactions

Lipodystrophy. May manifest as lipoatrophy (loss of subcutaneous tissue) and lipohypertrophy (increased tissue formation).

If the injection of insulin enters the area of lipodystrophy, then the absorption of insulin may slow down, which will lead to a change in pharmacokinetics.

To reduce the manifestations of this reaction or prevent the occurrence of lipodystrophy, it is recommended to constantly change the injection site within the same area of the body intended for subcutaneous insulin administration.

Some medicines weaken the hypoglycemic effect of insulin. These drugs include:

glucocorticosteroids;
diuretics;
danazol;
diazoxide;
isoniazid;
glucagon;
estrogens and gestagens;
somatotropin;
phenothiazine derivatives;
thyroid hormones;
sympathomimetics (salbutamol, adrenaline).

Alcohol and clonidine can either increase or decrease the hypoglycemic action of insulin. Pentamidine can lead to hypoglycemia, which then changes to hyperglycemia, as follows.

Other side effects and actions

Somogyi syndrome is a post-hypoglycemic hyperglycemia resulting from the compensatory action of contra-insulin hormones (glucagon, cortisol, growth hormone, catecholamines) as a reaction to glucose deficiency in brain cells. Studies show that 30% of diabetic patients have undiagnosed nocturnal hypoglycemia, this is not a problem, but it should not be ignored.

The above hormones increase glycogenolysis, another side effect. Maintaining the required concentration of insulin in the blood. But these hormones, as a rule, are released in much larger quantities than necessary, which means that the response glycemia is also much more than the costs. This condition can last from several hours to several days and is especially pronounced in the morning.

The high value of morning hyperglycemia always raises the question: excessive amount or deficiency of nightly prolonged insulin? The correct answer will guarantee that carbohydrate metabolism will be well compensated, since in one situation the dose of nightly insulin should be reduced, and in another it should be increased or distributed differently.

The “Dawn Phenomenon” is a state of hyperglycemia in the morning (4 am to 9 am) due to increased glycogenolysis, in which liver glycogen is broken down due to excess secretion of contra-insulin hormones without prior hypoglycemia.

As a result, insulin resistance occurs and the need for insulin increases, here it can be noted that:

basal requirement is at the same level from 10 pm to midnight.
Its decrease by 50% occurs from 12 o'clock at night to 4 o'clock in the morning.
Increase by the same amount from 4 am to 9 am.

It is rather difficult to achieve stable glycemia at night, since even modern extended-release insulin preparations cannot fully mimic such physiological changes in insulin release.

During the period of a physiologically determined reduced nocturnal insulin requirement, a side effect, this is the risk of nocturnal hypoglycemia with the introduction of an extended drug before bedtime, will increase due to an increase in the activity of prolonged insulin. New long-acting (peak-free) drugs, such as glargine, may help to solve this problem.

To date, there is no etiotropic therapy for type 1 diabetes mellitus, although attempts to develop it are constantly being made.

This article contains information about the side effects and complications of insulin therapy, which in most cases develop at the very beginning of the transition to injections of this hormone, which is why many patients begin to worry and mistakenly believe that this method of treatment is not suitable for their case.

Side effects and complications of insulin therapy

1. Veil before the eyes. One of the most frequently observed complications of insulin therapy is the appearance of a veil before the eyes, which causes significant discomfort in patients, especially when trying to read something. Being uninformed in this matter, people begin to sound the alarm, and some even believe that this symptom marks the development of such as retinopathy, that is, eye damage in diabetes mellitus.

In fact, the appearance of the veil is the result of a change in the refraction of the lens, and it disappears on its own from the field of view 2 or 3 weeks after the start of insulin therapy. Therefore, there is no need to stop giving insulin injections when a veil appears before the eyes.

2. Insulin swelling of the legs. This symptom, like the veil before the eyes, is transient. The appearance of edema is associated with the retention of sodium and water in the body as a result of the start of insulin therapy. Gradually, the patient's body adapts to new conditions, and leg swelling is eliminated on its own. For the same reason, at the very beginning of insulin therapy, a transient increase in blood pressure can be observed.

3. Lipohypertrophy. This complication of insulin therapy is not as common as the first two. Lipohypertrophy is characterized by the appearance of fatty seals in the area of subcutaneous insulin injection.

The exact cause of the development of lipohypertrophy has not been established, however, there is a significant relationship between the places where fatty seals appear and areas of frequent injections of the hormone insulin. That is why you should not inject insulin constantly into the same part of the body, it is important to alternate injection sites correctly.

In general, lipohypertrophy does not lead to a deterioration in the condition of diabetic patients, unless, of course, they are of enormous size. And do not forget that these seals lead to a deterioration in the rate of absorption of the hormone from a localized area, so you should try your best to prevent their appearance.

In addition, lipohypertrophy significantly disfigures the human body, that is, leads to the appearance of a cosmetic defect. Therefore, with large sizes, they have to be removed surgically, because, unlike the complications of insulin therapy from the first two points, they will not disappear on their own.

4. Lipoatrophy, that is, the disappearance of subcutaneous fat with the formation of a hole in the area of insulin injection. This is an even rarer side effect of insulin therapy, but it is important to be informed nonetheless. The reason for the appearance of lipoatrophy is an immunological reaction in response to injections of low-quality, insufficiently purified preparations of the insulin hormone of animal origin.

To eliminate lipoatrophy, injections of small doses of highly purified insulin are used along the periphery of them. Lipoatrophy and lipohypertrophy are often collectively referred to as "lipodystrophy", despite the fact that they have different etiology and pathogenesis.

5. Red itchy spots can also occur at the injection sites of insulin. They can be observed very rarely, plus everything they tend to disappear on their own soon after the occurrence. However, in some patients with diabetes, they cause extremely unpleasant, almost unbearable itching, which is why it is necessary to take measures to eliminate them. For these purposes, hydrocortisone is first introduced into the vial with the injected insulin preparation.

6. Allergic reaction can be observed during the first 7-10 days from the start of insulin therapy. This complication resolves on its own, but it takes a certain amount of time - often from several weeks to several months.

Fortunately, today, when most doctors and patients have switched only to the use of highly purified hormone preparations, the possibility of developing allergic reactions during insulin therapy is gradually being erased from people's memory. Of the life-threatening allergic reactions, it is worth noting anaphylactic shock and generalized urticaria.

By and large, when using outdated insulin preparations, only allergic itching, swelling and redness of the skin can be observed. To reduce the likelihood of developing allergic reactions, it is necessary to avoid frequent interruptions in insulin therapy and use only human insulins.

7. Abscesses at the injection sites of insulin are practically not found today.

8. Hypoglycemia i.e. lowering blood sugar.

9. A set of extra pounds. Most often, this complication is not significant, for example, after switching to insulin injections, a person gains 3-5 kg of excess weight. This is due to the fact that when switching to a hormone, you have to completely revise your usual diet, increase the frequency and caloric content of food.

In addition, insulin therapy stimulates the process of lipogenesis (formation of fats), and also increases the feeling of appetite, which patients themselves mention a few days after switching to a new diabetes treatment regimen.

allergic reactions

Quite often, complications of insulin therapy are manifested by allergic reactions. The latter, in turn, may be associated with the formation of a local or generalized form. Local allergic reactions are an erythematous, slightly itchy or hot papule. In addition, a rather painful hardening can form in the area of insulin injection.

Generalized allergic reactions, which are complications of insulin therapy, are associated with severe cases of urticaria, itching of the skin and erosive lesions in the mouth. In addition, similar lesions may affect the nose or eyes, and the patient may also complain of nausea and vomiting, abdominal pain. No less often, allergic reactions during insulin therapy are expressed by an increase in temperature, chills. The development of anaphylactic shock is extremely rarely identified.

It should be noted that in the vast majority of cases, local allergic reactions begin due to improper insulin injection - this can be high trauma (thick or blunt needle), the introduction of a chilled component, an incorrectly chosen injection site. In this case, standard measures, namely changing the type of insulin or diluting it, will not help to cope with complications, even if it was insulin therapy for type 2 diabetes.

Hypoglycemic conditions

Incorrect calculation of the amount of insulin, namely its overestimation, insufficient amount of carbohydrates immediately or several hours after the introduction of simple insulin, provokes a sudden decrease in the concentration of glucose in the blood.

Then an extremely serious condition is identified, which can progress up to hypoglycemic coma. That is why the rules of insulin therapy must be observed in the most strict way. In the process of using insulin and its drugs with an extended action algorithm, hypoglycemia can develop within a few hours. They usually correspond to the maximum duration of the component.

In certain situations, a hypoglycemic state can form as a result of excessive physical stress or mental shock, excitement. Significant importance for the formation of hypoglycemia is assigned not so much to the level of glucose in the blood as to the speed of its decrease. With the development of hypoglycemia, an obvious feeling of hunger is formed, as well as sweating. In addition, the condition may be accompanied by a strong heartbeat, trembling not only of the hands, but of the whole body. Further inadequacy of behavior, convulsive contractions, confusion of consciousness or its complete loss can be identified.

The principles of insulin therapy must also be observed because:

hypoglycemic conditions are critical due to the possibility of a sudden death;
the highest probability of death is in elderly patients who are faced with any degree of damage to the vascular system of the heart or brain;
with often manifested hypoglycemia, irreversible changes in the psyche and memory are formed, intelligence is aggravated. In addition, the formation or aggravation of retinopathy is likely, especially in the elderly.

Based on the presented considerations, in a situation of labile diabetes - if intensified insulin therapy does not help - it is necessary to allow a minimum degree of glucosuria. In addition, we can talk about minor hyperglycemia.

insulin resistance

Insulin resistance is formed not only in the case of a decrease in the number or affinity of receptors in relation to insulin.

This can happen with the formation of antibodies to receptors or a hormonal component. In certain states, the presented process will develop due to an increase in the secretion of specific hormones. In the vast majority of cases, specialists identify this with diffuse toxic goiter, within conditions such as pheochromocytoma, acromegaly, and hypercortinism.

The medical approach, taking into account all the indications for insulin therapy, is, first of all, to identify what is the origin of insulin resistance. It is important to pay attention to the fact that the sanitation of foci of chronic infectious lesions (otitis media, sinusitis, cholecystitis and no less significant conditions) gives positive results. The same applies to the replacement of one type of insulin with another, as well as the use of one of the oral drugs that reduce the sugar ratio together with the hormonal component. No less effective should be the active treatment of already present pathological conditions of the endocrine glands.

In general, it is quite difficult to cope with insulin resistance, especially if it was formed as a result of intensified insulin therapy. However, with timely access to a specialist, this can bring positive results. In order to achieve this, it is strongly recommended that insulin regimens be kept in mind in the future.

Pastipsulip lipodystrophy

With a tendency to the formation of lipodystrophy, it is necessary to observe the norms for the introduction of insulin with particular pedantry. It is strongly recommended to alternate the areas of its daily injections with maximum correctness. The exclusion of the formation of a pathological condition can be facilitated by the introduction of insulin mixed in one syringe with a similar ratio of 0.5% of the composition of novocaine.

When using monocomponent formulations of porcine and human insulin, the incidence of lipodystrophy is significantly reduced.

There is no doubt that a certain value is assigned to the incorrect introduction of insulin. We are talking about frequent injections into the same parts of the body, the introduction of a cold hormonal component and the subsequent cooling of this place. In addition, it is necessary to pay attention to insufficient massaging after the introduction of the agent. In some situations, the most aggravated, lipodystrophy is accompanied by more or less obvious insulin resistance - which even a child can complain about.

Additional Complications

In some cases, basus bolus insulin therapy or other types of intervention may be associated with the formation of complications, which I would like to talk about further. In particular, insulin edema of the lower extremities, which are transient. They are associated with a delay in the body of a component such as sodium or water. This happens, in the vast majority of cases, at the initial stage of insulin therapy.

A similar consequence of treatment may be an increase in blood pressure. Further, experts draw attention to the fact that insulin therapy sessions for type 1 or type 2 diabetes are associated with:

It is very important that none of the presented cases remain without medical attention. In some cases, diabetics tend to self-medicate or, even worse, use folk remedies. In such a situation, even intensive insulin therapy will be associated with the development of pathological consequences. It is also necessary to exclude such a possibility in the future, because there are frequent cases when a particular complication forms again and is significantly aggravated.

Thus, insulin therapy in children, as well as in adults, may be associated with the development of a whole list of complications. These can be various allergic reactions, the formation of insulin resistance and other equally serious conditions. This can be excluded only if all the norms of therapy are observed and the instructions of a specialist are followed. Otherwise, there is a need for an additional recovery course.

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Insulin therapy is the leading way to treat type 1 diabetes, in which there is a failure in carbohydrate metabolism. But sometimes such treatment is used for the second type of disease, in which the cells of the body do not perceive insulin (a hormone that helps convert glucose into energy).

This is necessary when the disease is severe with decompensation.

Also, the introduction of insulin is indicated in a number of other cases:

diabetic coma;
contraindications to the use of sugar-lowering drugs;
lack of a positive effect after taking antiglycemic agents;
severe diabetic complications.

Insulin is a protein that is always injected into the body. In origin, it can be animal and human. In addition, there are different types of hormone (heterological, homologous, combined) with different periods of action.

Treatment of diabetes through hormone therapy requires compliance with certain rules and proper dosage calculation. Otherwise, various complications of insulin therapy may develop, which every diabetic should be aware of.

hypoglycemia

In case of an overdose, a lack of carbohydrate food, or some time after the injection, the blood sugar level may drop significantly. As a result, a hypoglycemic state develops.

If a prolonged action agent is used, then a similar complication occurs when the concentration of the substance becomes maximum. Also, a decrease in sugar levels is noted after strong physical activity or emotional shock.

It is noteworthy that in the development of hypoglycemia, the leading place is occupied not by the concentration of glucose, but by the rate of its decrease. Therefore, the first symptoms of a decrease may occur at rates of 5.5 mmol / l against the background of a rapid drop in sugar levels. With a slow decrease in glycemia, the patient may feel relatively normal, while glucose levels are 2.78 mmol / l and below.

The hypoglycemic state is accompanied by a number of symptoms:

severe hunger;
frequent heartbeat;
increased sweating;
tremor of the limbs.

With the progression of the complication, convulsions appear, the patient becomes inadequate and may lose consciousness.

If the sugar level has not fallen very low, then this condition is eliminated in a simple way, which consists in eating carbohydrate foods (100 g of muffin, 3-4 pieces of sugar, sweet tea). If there is no improvement over time, the patient should eat the same amount of sweets.

With the development of hypoglycemic coma, intravenous administration of 60 ml of glucose solution (40%) is indicated. In most cases, after this, the condition of the diabetic stabilizes. If this does not happen, then after 10 minutes. he is again injected with glucose or glucagon (1 ml subcutaneously).

Hypoglycemia is an extremely dangerous diabetic complication, because it can cause death. At risk are elderly patients with lesions of the heart, brain and blood vessels.

A constant decrease in sugar can lead to the appearance of irreversible mental disorders.

Also, the patient's intellect and memory worsen, and the course of retinopathy develops or worsens.

insulin resistance

Sugar level

Often with diabetes, the sensitivity of cells to insulin decreases. To compensate for carbohydrate metabolism, 100-200 units of the hormone are needed.

However, this condition occurs not only due to a decrease in the content or affinity of receptors for a protein, but also when antibodies to receptors or a hormone appear. Insulin resistance also develops against the background of protein destruction by certain enzymes or its binding by immune complexes.

In addition, the lack of sensitivity appears in the case of increased secretion of contra-insulin hormones. This occurs against the background of hypercortinism, diffuse toxic goiter, acromegaly and pheochromocytoma.

The basis of treatment is to identify the nature of the condition. To this end, eliminate the signs of chronic infectious diseases (cholecystitis, sinusitis), diseases of the endocrine glands. The type of insulin is also being replaced or insulin therapy is supplemented by the intake of sugar-lowering tablets.

In some cases, glucocorticoids are indicated. To do this, increase the daily dosage of the hormone and prescribe a ten-day treatment with Prednisolone (1 mg / kg).

Sulfated insulin can also be used for insulin resistance. Its advantage is that it does not react with antibodies, has good biological activity and practically does not cause allergic reactions. But when switching to such therapy, patients should be aware that the dose of a sulfated agent, in comparison with a simple type, is reduced to ¼ of the initial amount of a conventional drug.

Allergy

When insulin is administered, complications can vary. So, in some patients there is an allergy, which manifests itself in two forms:

Local. The appearance of a fatty, inflamed, itchy papule or hardening at the injection site.
Generalized, in which there is urticaria (neck, face), nausea, pruritus, erosion on the mucous membranes of the mouth, eyes, nose, nausea, abdominal pain, vomiting, chills, fever. Sometimes anaphylactic shock develops.

To prevent the progression of allergies, insulin replacement is often performed. For this purpose, the animal hormone is replaced by a human hormone or the manufacturer of the product is changed.

It is worth noting that the allergy mainly develops not to the hormone itself, but to the preservative used to stabilize it. In this case, pharmaceutical companies can use different chemical compounds.

If it is not possible to replace the drug, then insulin is combined with the introduction of minimal doses (up to 1 mg) of Hydrocortisone. For severe allergic reactions, the following drugs are used:

Calcium chloride;
Hydrocortisone;
Diphenhydramine;
Suprastin and others.

It is noteworthy that local manifestations of allergies often appear when the injection is not done correctly.

For example, in case of an incorrect choice of injection site, skin damage (blunt, thick needle), injection of a too cold agent.

Pastipsulip lipodystrophy

There are 2 types of lipodystrophy - atrophic and hypertrophic. The atrophic form of the pathology develops against the background of a prolonged course of the hypertrophic type.

Exactly how such post-injection manifestations occur has not been established. However, many doctors suggest that they appear due to persistent injury to the peripheral nerves with further local neurotrophic disorders. Also, defects can occur due to the use of insufficiently pure insulin.

But after the use of monocomponent agents, the number of manifestations of lipodystrophy is significantly reduced. Incorrect administration of the hormone is also of no small importance, for example, hypothermia of the injection site, the use of a cold preparation, and so on.

In some cases, against the background of lipodystrophy, insulin resistance of varying severity occurs.

If diabetes has a predisposition to the appearance of lipodystrophy, it is extremely important to adhere to the rules of insulin therapy, changing injection sites daily. Also, to prevent the occurrence of lipodystrophy, the hormone is diluted with an equal volume of Novocain (0.5%).

In addition, lipoatrophies have been found to disappear after injection with human insulin.

Other effects of insulin therapy

Often, insulin-dependent diabetics have a veil before their eyes. This phenomenon causes severe discomfort to a person, so he cannot write and read normally.

Many patients mistake this symptom for. But the veil before the eyes is the result of changes in the refraction of the lens.

This consequence disappears on its own after 14-30 days from the start of treatment. Therefore, there is no need to interrupt therapy.

Other complications of insulin therapy are swelling of the lower extremities. But such a manifestation, like vision problems, goes away on its own.

Swelling of the legs occurs due to water and salt retention, which develops after insulin injections. However, over time, the body adapts to the treatment, so it stops accumulating fluid.

For similar reasons, at the initial stage of therapy, patients may periodically increase blood pressure.

Also, against the background of insulin therapy, some diabetics gain weight. On average, patients recover by 3-5 kilograms. After all, hormonal treatment activates lipogenesis (the process of fat formation) and increases appetite. In this case, the patient needs to change the diet, in particular, its calorie content and frequency of meals.

In addition, the constant administration of insulin lowers the amount of potassium in the blood. You can solve this problem with a special diet.

To this end, the daily menu of a diabetic should be replete with citrus fruits, berries (currants, strawberries), herbs (parsley) and vegetables (cabbage, radishes, onions).

Prevention of the development of complications

To minimize the risk of the consequences of insulin therapy, every diabetic should learn self-control methods. This concept includes compliance with the following rules:

Constant monitoring of blood glucose concentration, especially after meals.
Comparison of indicators with atypical conditions (physical, emotional stress, sudden illness, etc.).
timely correction of the dose of insulin, antidiabetic drugs and diet.

Test strips or a glucometer are used to measure glucose. Level determination using test strips is carried out as follows: a piece of paper is immersed in urine, and then they look at the test field, the color of which changes depending on the concentration of sugar.

The most accurate results can be obtained using double field strips. However, a blood test is a more effective method for determining sugar levels.

Therefore, most diabetics use a glucometer. This device is used as follows: a drop of blood is applied to the indicator plate. Then, after a couple of seconds, the result appears on the digital display. But it should be borne in mind that glycemia for different devices can be different.

Also, in order not to contribute to the development of complications, a diabetic must carefully monitor his own body weight. You can find out if you are overweight by determining the Kegle index or body weight.

Side effects of insulin therapy are discussed in the video in this article.

1. The most frequent, formidable and dangerous is the development of HYPOGLYCEMIA. This is facilitated by:

- overdose;

- discrepancy between the administered dose and the food taken;

- diseases of the liver and kidneys;

- other (alcohol).

The first clinical symptoms of hypoglycemia (vegetotropic effects of "fast" insulins): irritability, anxiety, muscle weakness, depression, visual acuity change, tachycardia, sweating, tremor, pallor of the skin, "goose bumps", a feeling of fear. The decrease in body temperature in hypoglycemic coma has diagnostic value.

Long-acting drugs usually cause hypoglycemia at night (nightmares, sweating, anxiety, headache on waking - cerebral symptoms).

When using insulin preparations, the patient always needs to have a small amount of sugar, a piece of bread with him, which, if there are symptoms of hypoglycemia, must be eaten quickly. If the patient is in a coma, then glucose should be injected into the vein. Usually 20-40 ml of a 40% solution is sufficient. You can also inject 0.5 ml of epinephrine under the skin or 1 mg of glucagon (in solution) into the muscle.

Recently, in order to avoid this complication, new achievements in the field of technique and technology of insulin therapy have appeared and put into practice in the West. This is due to the creation and use of technical devices that provide continuous administration of insulin using a closed-type apparatus that regulates the rate of insulin infusion in accordance with the level of glycemia, or facilitates the administration of insulin according to a given program using dispensers or micropumps. The introduction of these technologies makes it possible to carry out intensive insulin therapy with the approximation, to some extent, of the level of insulin during the day to the physiological one. This contributes to the achievement of diabetes compensation in a short time and maintaining it at a stable level, normalization of other metabolic indicators.

The simplest, most affordable and safest way to implement intensive insulin therapy is the introduction of insulin in the form of subcutaneous injections using special devices such as a "syringe-pen" ("Novopen" - Czechoslovakia, "Novo" - Denmark, etc.). With the help of these devices, you can easily dose and carry out almost painless injections. Thanks to the automatic adjustment, it is very easy to use the pen syringe, even for patients with reduced vision.

2. Allergic reactions in the form of itching, hyperemia, pain at the injection site; urticaria, lymphadenopathy.

An allergy can be not only to insulin, but also to protamine, since the latter is also a protein. Therefore, it is better to use preparations that do not contain protein, for example, insulin tape. If you are allergic to bovine insulin, it is replaced with porcine insulin, the antigenic properties of which are less pronounced (since this insulin differs from human insulin by one amino acid). Currently, in connection with this complication of insulin therapy, highly purified insulin preparations have been created: monopeak and monocomponent insulins. The high purity of monocomponent preparations ensures a decrease in the production of antibodies to insulin, and therefore the transfer of a patient to monocomponent insulin helps to reduce the concentration of antibodies to insulin in the blood, increase the concentration of free insulin, and therefore helps to reduce the dose of insulin.

Even more advantageous is the species-specific human insulin, obtained by DNA recombinant method, that is, by the method of genetic engineering. This insulin has even less antigenic properties, although it has not been completely freed from this. Therefore, recombinant monocomponent insulin is used for insulin allergy, insulin resistance, as well as in patients with newly diagnosed diabetes mellitus, especially in young people and children.

3. Development of insulin resistance. This fact is associated with the production of antibodies to insulin. In this case, the dose must be increased, and human or porcine monocomponent insulin should be used.

4. Lipodystrophy at the injection site. In this case, the injection site should be changed.

5. Decrease in the concentration of potassium in the blood, which must be regulated by diet.

Despite the presence in the world of well-developed technologies for producing highly purified insulins (monocomponent and human, obtained using DNA recombinant technology), a dramatic situation has developed with domestic insulins in our country. After a serious analysis of their quality, including international expertise, production was stopped. Technology is currently being upgraded. This is a forced measure and the resulting deficit is compensated by purchases abroad, mainly from Novo, Pliva, Eli Lilly and Hoechst.

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1. Allergic reactions

They appear:

a) in the local form - an erythematous, slightly itchy and hot to the touch papule or limited moderately painful induration at the injection site;

b) in a generalized form, characterized in severe cases by urticaria (appearing earlier and more pronounced on the skin of the face and neck), itching of the skin, erosive lesions of the mucous membranes of the mouth, nose, eyes, nausea, vomiting and abdominal pain, as well as fever and chills. In rare cases, the development of anaphylactic shock is observed.

To prevent further progression of both local and generalized allergic manifestations, in the overwhelming majority of cases, it is enough to replace the used insulin with another type (replace monocomponent pig insulin with human insulin) or replace insulin preparations from one company with similar preparations, but manufactured by another company. Our experience shows that allergic reactions in patients often occur not to insulin, but to a preservative (manufacturers use various chemical compounds for this purpose) used to stabilize insulin preparations.

If this is not possible, then prior to obtaining another insulin preparation, it is advisable to administer insulin with microdoses (less than 1 mg) of hydrocortisone mixed in a syringe. Severe forms of allergy require special therapeutic intervention (prescription of hydrocortisone, suprastin, diphenhydramine, calcium chloride).

However, it should be borne in mind that allergic reactions, especially local ones, often occur as a result of improper administration of insulin: excessive trauma (too thick or blunt needle), the introduction of a very cold drug, the wrong choice of injection site, etc.

2. Hypoglycemic conditions

With an incorrect calculation of the dose of insulin (its overestimation), insufficient intake of carbohydrates, soon or 2-3 hours after the injection of simple insulin, the concentration of glucose in the blood decreases sharply and a serious condition occurs, up to hypoglycemic coma. When using long-acting insulin preparations, hypoglycemia develops during the hours corresponding to the maximum action of the drug. In some cases, hypoglycemic conditions can occur with excessive physical stress or mental shock, excitement.

Of decisive importance for the development of hypoglycemia is not so much the level of glucose in the blood as the speed of its decrease. Thus, the first signs of hypoglycemia may appear already at a glucose level of 5.55 mmol / l (100 mg / 100 ml), if its decrease was very rapid; in other cases, with a slow decrease in glycemia, the patient may feel relatively well with a blood sugar content of about 2.78 mmol / l (50 mg / 100 ml) or even lower.

During the period of hypoglycemia, a pronounced feeling of hunger, sweating, palpitations, trembling of the hands and the whole body appear. In the future, there is inadequacy of behavior, convulsions, confusion or complete loss of consciousness. At the initial signs of hypoglycemia, the patient should eat 100 g of rolls, 3-4 pieces of sugar or drink a glass of sweet tea.

If the condition does not improve or even worsens, then after 4-5 minutes you should eat the same amount of sugar. In the case of a hypoglycemic coma, the patient must immediately inject 60 ml of a 40% glucose solution into a vein. As a rule, after the first administration of glucose, consciousness is restored, but in exceptional cases, if there is no effect, after 5 minutes, the same amount of glucose is injected into the vein of the other hand. A rapid effect occurs after subcutaneous administration of 1 mg of glucagon to the patient.

Hypoglycemic conditions are dangerous because of the possibility of sudden death (especially in elderly patients with varying degrees of damage to the vessels of the heart or brain). With frequently recurring hypoglycemia, irreversible disorders of the psyche and memory develop, intelligence decreases, existing retinopathy appears or worsens, especially in the elderly. Based on these considerations, in cases of labile diabetes, it is necessary to allow minimal glucosuria and slight hyperglycemia.

3. Insulin resistance

In some cases, diabetes is accompanied by conditions in which there is a decrease in tissue sensitivity to insulin, and 100-200 units of insulin or more are required to compensate for carbohydrate metabolism. Insulin resistance develops not only as a result of a decrease in the number or affinity of insulin receptors, but also with the appearance of antibodies to receptors or insulin (immune type of resistance), as well as due to the destruction of insulin by protosolytic enzymes or binding by immune complexes. In some cases, insulin resistance develops due to increased secretion of contra-insulin hormones, which is observed with diffuse toxic goiter, pheochromocytoma, acromegaly, and hypercortinism.

Medical tactics consists primarily in determining the nature of insulin resistance. Sanitation of foci of chronic infection (otitis media, sinusitis, cholecystitis, etc.), replacement of one type of insulin with another or the combined use of one of the oral hypoglycemic drugs with insulin, active treatment of existing diseases of the endocrine glands give good results. Sometimes they resort to the use of glucocorticoids: slightly increasing the daily dose of insulin, combine its administration with taking prednisolone at a dose of about 1 mg per 1 kg of the patient's body weight per day for at least 10 days. In the future, in accordance with the existing glycemia and glucosuria, the doses of prednisolone and insulin are gradually reduced. In some cases, there is a need for a longer (up to a month or more) use of small (10-15 mg per day) doses of prednisolone.

Recently, sulfated insulin has been used for insulin resistance, which is less allergenic, does not react with insulin antibodies, but has 4 times higher biological activity than regular insulin. When transferring a patient to treatment with sulphated insulin, it must be borne in mind that such insulin requires only 1/4 of the dose of simple insulin administered.

4. Pastipsulip lipodystrophy

From a clinical point of view, hypertrophic and atrophic lipodystrophy are distinguished. In some cases, atrophic lipodystrophy develops after a more or less long-term existence of hypertrophic lipodystrophy. The mechanism of occurrence of these post-injection defects, capturing the subcutaneous tissue and having a diameter of several centimeters, has not yet been fully elucidated. It is assumed that they are based on long-term traumatization of small branches of peripheral nerves with subsequent local neurotrophic disorders or the use of insufficiently purified insulin for injections. With the use of monocomponent preparations of porcine and human insulin, the frequency of lipodystrophy decreased sharply. Undoubtedly, incorrect administration of insulin is of some importance (frequent injections in the same areas, administration of cold insulin and subsequent cooling of the injection area, insufficient massaging after injection, etc.). Sometimes lipodystrophy is accompanied by more or less pronounced insulin resistance.

With a tendency to form lipodystrophy, one should follow the rules for administering insulin with particular pedantry, correctly alternating the places of its daily injections. The introduction of insulin mixed in one syringe with an equal amount of 0.5% novocaine solution can also help prevent the occurrence of lipodystrophy. The use of novocaine is also recommended for the treatment of lipodystrophy that has already occurred. Successful treatment of lipoatrophies by injection with human insulin has been reported.

As noted above, the autoimmune mechanism of IDD has now been established and confirmed. The insulin therapy we have considered is only a substitution therapy. Therefore, there is a constant search for means and methods of treating and curing IDD. In this direction, several groups of drugs and various effects have been proposed that are aimed at restoring a normal immune response. Therefore, this direction was called immunotherapy IDD.

General immunosuppression is aimed at suppressing humoral immunity, i.e. the formation of autoantibodies, which include cytoplasmic, cell-surface antibodies, antibodies to glutamate decarboxylase, insulin, proinsulin, etc. glands. According to most researchers, this direction of the attraction of diabetes mellitus has no prospects, because. the listed drugs affect only the final phase of the immune response, and not the primary pathogenetic mechanisms leading to the destruction of pancreatic b-cells.

Endocrinology…

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If you do not follow certain safety measures and rules, then insulin treatment, like any other type of treatment, can cause various complications. The complexity of insulin therapy lies in the correct selection of the dosage of insulin and the choice of treatment regimen, therefore, a patient with diabetes mellitus must be especially carefully monitored throughout the entire treatment process. It seems difficult only at the beginning, and then people usually get used to it and cope perfectly with all the difficulties. Since diabetes mellitus is a diagnosis for life, they learn to handle a syringe in the same way as a knife and fork. However, unlike other people, patients with diabetes cannot afford even a little relaxation and “rest” from treatment, as this threatens with complications.

Lipodystrophy

This complication develops at injection sites as a result of a violation of the formation and breakdown of adipose tissue, that is, seals appear at the injection site (when adipose tissue increases) or indentations (when adipose tissue decreases and subcutaneous fatty tissue disappears). Accordingly, this is called hypertrophic and atrophic type of lipodystrophy.

Lipodystrophy develops gradually as a result of prolonged and constant trauma to small peripheral nerves with a syringe needle. But this is only one of the reasons, although the most common. Another cause of complications is the use of insufficiently pure insulin.

This complication of insulin therapy usually occurs after several months or even years of insulin administration. The complication is not dangerous for the patient, although it leads to impaired insulin absorption, and also brings a certain discomfort to the person. Firstly, these are cosmetic skin defects, and secondly, soreness in the places of complications, which increases with weather changes.

Treatment of atrophic type lipodystrophy consists in the use of porcine insulin along with novocaine, which helps to restore the trophic function of the nerves. The hypertrophic type of lipodystrophy is treated with physiotherapy: phonophoresis with hydrocortisone ointment.

Using preventive measures, you can protect yourself from this complication.

Prevention of lipodystrophy:

1) alternation of injection sites;

2) the introduction of only heated to body temperature insulin;

3) after treatment with alcohol, the injection site must be thoroughly rubbed with a sterile cloth or wait for the alcohol to dry completely;

4) slowly and deeply inject insulin under the skin;

5) use only sharp needles.

allergic reactions

This complication does not depend on the actions of the patient, but is due to the presence of foreign proteins in the composition of insulin. There are local allergic reactions that occur at the injection sites and around them in the form of skin redness, seals, swelling, burning and itching. Much more dangerous are general allergic reactions, which manifest themselves in the form of urticaria, Quincke's edema, bronchospasm, gastrointestinal disorders, joint pain, enlarged lymph nodes, and even anaphylactic shock.

Life-threatening allergic reactions are treated in the hospital with the administration of the hormone prednisolone, other allergic reactions are removed with antihistamines, as well as the administration of the hormone hydrocortisone along with insulin. However, in most cases, it is possible to exclude allergies by transferring the patient from porcine insulin to human insulin.

Chronic insulin overdose

Chronic overdose of insulin occurs when the need for insulin becomes too high, that is, it exceeds 1–1.5 units per 1 kg of body weight per day. In this case, the patient's condition worsens greatly. If such a patient reduces the dose of insulin, he will feel much better. This is the most characteristic sign of an insulin overdose. Other manifestations of complications:

Severe course of diabetes;

High fasting blood sugar;

Sharp fluctuations in blood sugar levels during the day;

Large loss of sugar in the urine;

Frequent fluctuations in hypo- and hyperglycemia;

Tendency to ketoacidosis;

Increased appetite and weight gain.

Complications are treated by adjusting insulin doses and selecting the correct regimen for administering the drug.

Hypoglycemia and coma

The reasons for this complication are the incorrect selection of the dose of insulin, which turned out to be too high, as well as insufficient intake of carbohydrates. Hypoglycemia develops 2–3 hours after the administration of short-acting insulin and during the period of maximum activity of long-acting insulin. This is a very dangerous complication, because the concentration of glucose in the blood can decrease very sharply and the patient may experience hypoglycemic coma.

Prolonged intensive insulin therapy, accompanied by increased physical activity, often leads to the development of hypoglycemic complications.

If the blood sugar level is allowed to fall below 4 mmol/l, then in response to a lower blood sugar level, a sharp rise in sugar can occur, that is, a state of hyperglycemia.

Prevention of this complication is a decrease in the dose of insulin, the effect of which falls on the time when blood sugar falls below 4 mmol / l.

Insulin resistance (insulin resistance)

This complication is caused by addiction to certain doses of insulin, which over time no longer give the desired effect and their increase is required. Insulin resistance can be both temporary and long-term. If the need for insulin reaches more than 100–200 IU per day, but the patient does not have attacks of ketoacidosis and there are no other endocrine diseases, then we can talk about the development of insulin resistance.

The reasons for the development of temporary insulin resistance include: obesity, high blood lipids, dehydration, stress, acute and chronic infectious diseases, lack of physical activity. Therefore, you can get rid of this type of complication by eliminating the listed causes.

Long-term or immunological insulin resistance develops due to the production of antibodies to administered insulin, a decrease in the number and sensitivity of insulin receptors, and impaired liver function. Treatment consists of replacing porcine insulin with human insulin, as well as the use of the hormones hydrocortisone or prednisolone, and the normalization of liver function, including through diet.

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Types of insulin therapy

If the patient does not have problems with being overweight and does not experience excessive emotional overload, insulin is prescribed ½ - 1 unit 1 time per day in terms of 1 kg of body weight. At the same time, intensive insulin therapy acts as an imitator of the natural secretion of the hormone.

The rules for insulin therapy require the fulfillment of these conditions:

the drug in the patient's body should be supplied in an amount that will be sufficient for the utilization of glucose;
externally administered insulins should become a complete imitation of basal secretion, that is, that produced by the pancreas (including the highest point of release after a meal).

The requirements listed above explain the regimens of insulin therapy, in which the daily dosage of the drug is divided into prolonged or short-acting insulins.

Long insulins are most often administered in the mornings and evenings and absolutely imitate the physiological product of the functioning of the pancreas.

Taking short insulins is advisable after eating a meal rich in carbohydrates. The dosage of this type of insulin is determined on an individual basis and is determined by the number of XE (bread units) at a given meal.

Traditional insulin therapy

The combined method of insulin therapy involves the combination of all insulins in one injection and is called traditional insulin therapy. The main advantage of this method is to reduce the number of injections to a minimum (1-3 per day).

The disadvantage of traditional insulin therapy is the lack of the possibility of absolute imitation of the natural activity of the pancreas. This flaw does not allow to fully compensate for the carbohydrate metabolism of a patient with type 1 diabetes, insulin therapy does not help in this case.

The combined scheme of insulin therapy in this case looks something like this: the patient receives 1-2 injections per day, at the same time he is given insulin preparations (this includes both short and prolonged insulins).

Intermediate-acting insulins account for about 2/3 of the total volume of drugs, short-acting insulins account for 1/3.

It is also necessary to say about the insulin pump. An insulin pump is a type of electronic device that provides round-the-clock, subcutaneous insulin delivery in mini-doses with an ultra-short or short duration of action.

This technique is called insulin pump therapy. The insulin pump works in different modes of drug administration.

Insulin regimens:

Continuous delivery of pancreatic hormone in microdoses that mimics the physiological rate.
Bolus rate - the patient himself can program the dosage and frequency of insulin administration.

When the first regimen is used, background insulin secretion is simulated, which makes it possible, in principle, to replace the use of prolonged preparations. The use of the second mode is advisable immediately before a meal or at those moments when the glycemic index rises.

When you turn on the bolus mode of administration, insulin pump therapy provides the ability to change insulins of different types of action.

Important! With a combination of these modes, the most approximate imitation of the physiological secretion of insulin by a healthy pancreas is achieved. The catheter should be changed at least once every 3 days.

Application of insulin therapy methods in type 1 diabetes

The treatment regimen for patients with type 1 diabetes involves the introduction of a basal preparation 1-2 times a day, and immediately before meals - a bolus. In type 1 diabetes, insulin therapy should completely replace the physiological production of a hormone that is produced by the pancreas of a healthy person.

The combination of both regimens is called "basic bolus therapy", or regime with multiple injections. One of the types of this therapy is intensive insulin therapy.

The scheme and dosage, taking into account the individual characteristics of the body and complications, the patient should choose his attending physician. Basal preparation usually takes 30-50% of the total daily dose. The calculation of the required bolus amount of insulin is more individual.

Insulin treatment for type 2 diabetes

Treatment of type 2 diabetics requires a specific scheme. The essence of this therapy is that the patient begins to gradually add small doses of basal insulin to sugar-lowering drugs.

When first exposed to a basal preparation, which is presented as a peak-free long-acting insulin analog (eg, insulin glargine), patients should stop at 10 IU per day. Preferably, injections are given at the same time of day.

If diabetes mellitus continues to progress and the combination of sugar-reducing drugs (tablet form) with injections of basal insulin does not lead to the desired results, in this case the doctor decides to completely transfer the patient to the injection regimen.

At the same time, the use of all kinds of traditional medicine is welcomed, but any of them must be approved by the attending physician.

Children are a special group of patients, so treatment with insulin in case of childhood diabetes always requires an individual approach. Most often, for the treatment of babies, schemes of 2-3 times the introduction of insulin are used. To reduce the number of injections for young patients, a combination of drugs with short and medium exposure times is practiced.

It is very important to achieve the most simple scheme, which will achieve good compensation. The number of insulin injections does not affect the improvement in blood sugar levels. Children over 12 years of age are prescribed intensive insulin therapy.

The sensitivity of children to insulin is higher than in adult patients, so the dose adjustment of the drug should be done in stages. The range of changes in the dosage of the hormone must be laid in 1-2 units at a time. The maximum allowable one-time limit is 4 units.

Note! It will take several days to understand and feel the results of the change. But doctors categorically do not recommend simultaneously changing the morning and evening dose of the drug.

Insulin treatment during pregnancy

Treatment of diabetes during pregnancy is aimed at maintaining the concentration of sugar in the blood, which should be:

In the morning on an empty stomach - 3.3-5.6 mmol / l.
After eating - 5.6-7.2 mmol / l.

Determination of blood sugar for 1-2 months allows you to evaluate the effectiveness of the treatment. The metabolism in the body of a pregnant woman is extremely shaky. This fact requires frequent correction of the regimen (scheme) of insulin therapy.

Pregnant women with type 1 diabetes are prescribed insulin therapy according to the following scheme: in order to prevent morning and postprandial hyperglycemia, the patient needs at least 2 injections per day.

Short or medium insulins are administered before the first breakfast and before the last meal. Combined doses may also be used. The total daily dose must be properly distributed: 2/3 of the total volume is intended for the morning, and 1/3 before dinner.

To prevent nocturnal and dawn hyperglycemia, the dose "before dinner" is changed to an injection made just before bedtime.

Insulin in the treatment of mental disorders

Most often, insulin in psychiatry is used to treat schizophrenics. In the morning on an empty stomach, the patient is given the first injection. The initial dose is 4 units. Every day it is increased from 4 to 8 units. This scheme has a feature: on weekends (Saturday, Sunday) injections are not made.

At the first stage, therapy is based on keeping the patient in a state of hypoglycemia for about 3 hours. To normalize the level of glucose, the patient is given sweet warm tea, which contains at least 150 grams of sugar. In addition, the patient is offered a carbohydrate-rich breakfast. The level of glucose in the blood gradually returns to normal and the patient returns to normal.

At the second stage of treatment, the dose of the administered drug is increased, which is associated with an increase in the degree of the patient's unconsciousness. Gradually, the stupor develops into a stupor (oppressed consciousness). Elimination of hypoglycemia begins approximately 20 minutes after the onset of sopor development.

The patient is brought back to normal with a dropper. He is injected intravenously with 20 ml of a 40% glucose solution. When the patient regains consciousness, he is given sugar syrup (150-200 grams of product per glass of warm water), sweet tea and a hearty breakfast.

The third stage of treatment is to continue the daily increase in the dose of insulin, which leads to the development of a condition bordering on stupor and coma. This condition cannot last more than 30 minutes, after which an attack of hypoglycemia should be stopped. The derivation scheme is similar to the previous one, that is, the one used in the second stage.

The course of this therapy covers 20-30 sessions, in which a sopor-coma state is achieved. After the required number of such critical conditions is reached, the daily dose of the hormone begins to be gradually reduced, until it is completely canceled.

How is insulin treatment done?

Insulin treatment is carried out according to the following plan:

Before making a subcutaneous injection, the injection site is slightly kneaded.
Eating after the injection should not move more than half an hour.
The maximum dose of administration cannot exceed 30 IU.

In each individual case, the exact regimen of insulin therapy should be made by a doctor. Recently, insulin syringe pens have been used for therapy, you can use the usual insulin syringes with a very thin needle.

The use of syringe pens is more rational for several reasons:

Thanks to a special needle, the pain from the injection is minimized.
The convenience of the device allows you to inject anywhere and at any time.
Some pens are equipped with vials of insulin, which provides for the possibility of combining drugs and the use of different schemes.

The components of the insulin regimen for type 1 and type 2 diabetes are as follows:

Before breakfast, the patient should enter the drug of short or prolonged action.
The insulin injection before dinner should consist of a hormone with a short exposure period.
The shot that precedes dinner includes short insulin.
Before going to bed, the patient should inject a prolonged drug.

There are several areas of administration on the human body. The absorption rate of the drug in each zone is different. The stomach is more susceptible to this indicator.

If the area for injection is not chosen correctly, insulin therapy may not give positive results.

Complications of insulin therapy

Treatment with insulin, like any other, may have contraindications and complications. The appearance of allergic reactions at the injection sites is a vivid example of a complication of insulin therapy.

Most often, the occurrence of allergic manifestations is associated with a violation of technology during the administration of the drug. This may be the use of blunt or thick needles, too cold insulin, the wrong injection site, and other factors.

A decrease in the concentration of glucose in the blood and the development of hypoglycemia are pathological conditions that are manifested by the following symptoms:

strong feeling of hunger;
profuse sweating;
tremor of the limbs;
tachycardia.

This condition can be provoked by an overdose of insulin or prolonged fasting. Often, hypoglycemia develops against a background of mental excitement, stress, or physical overwork.

Another complication of insulin therapy is lipodystrophy, which is accompanied by the disappearance of the subcutaneous fat layer at the injection site. To avoid this phenomenon, the patient should change the injection site, but only if this does not interfere with the effectiveness of the treatment.

diabethelp.org

TREATMENT AND PREVENTION

N.I. Buglak

National Medical Academy of Postgraduate Education. PL. shupik

Insulin therapy (IT) is still one of the most important treatments for diabetes mellitus (DM). Depending on the nature of the course of the disease, it is indicated in 1/3 of cases of this pathology. All patients with type 1 diabetes mellitus and 15-25% of patients with type 2 diabetes (insulin-requiring subtype) need it. Sometimes, in particular in stressful situations (infection, intoxication, trauma, surgery, etc.), temporary administration of insulin is necessary for patients with even mild and moderate disease who have not previously received it.

The vast majority of patients tolerate insulin treatment well, and only some of them may develop various complications, such as insulin allergy, hypoglycemia, inulin resistance, the appearance of lipodystrophy, insulin edema, the development of the Somogyi phenomenon, inoulin presbyopia, and skin hyperalgesia.

The most significant complications of insulin therapy can be divided into 2 groups:

Reactions associated with the body's response to the administration of insulin as a foreign protein (or to the components that make up the drug).

Phenomena due to the influence of insulin as a hormone that regulates carbohydrate metabolism.

Until recently, a frequent complication of IT was the development of local and general allergic reactions. The formation of the latter can be influenced by various factors, namely: the type and type of insulin, the degree of purification and its state of aggregation, the auxiliary components included in the preparations, the pH of the medium, the method and scheme of administration, the state of the patient's body, age and genetic predisposition.

The most pronounced immunogenic property is inherent in bovine insulin, less so in porcine insulin. Allergic reactions with the use of highly purified insulins, in particular urine components and human insulins, are observed relatively rarely. The content of surfen and protamine in prolonged forms of insulin increases their immunogenicity. Any slowdown in the absorption of protein from the subcutaneous tissue contributes to the development of immune responses. A similar effect is exerted by the auxiliary components included in the preparations (zinc, buffer stabilizers, preservatives), as well as the acidic reaction of insulins,

Intradermal and subcutaneous insulin administration contributes more to the immunological response than intravenous. With a constant intake of insulin, immunological tolerance is usually formed, in which antibody formation is inhibited. The introduction of insulin preparations intermittently, on the contrary, significantly stimulates the formation of antibodies and increases the risk of developing pathological reactions. Often in children, some time after the onset of the disease and the appointment of insulin, there is a noticeable improvement in well-being (“honeymoon”), and against this background, they are generally canceled the introduction of insulin. But after such a break in insulin therapy, they have serious allergic reactions to all types of insulin in the future.

Clinical observations indicate that local allergic reactions to the administration of insulin often develop in childhood, adolescence and postmenopausal age. Their frequency largely depends on the state of the body and increases in the presence of concomitant liver diseases, infectious diseases, allergic diathesis, genetic predisposition (the appearance of antibodies to insulin in genotypes

niche15/drc iNYA/DYAU).

The development of local allergic reactions to the introduction of insulin in the form of compaction, soreness, the appearance of erythema, itching, burning is facilitated by the ingress of alcohol under the skin, tissue trauma with needles, non-compliance with aseptic rules and infection, the introduction of a highly chilled drug.

A generalized reaction to insulin is characterized by the occurrence of urticaria, first on the skin of the face, neck, and then throughout the body, severe itching, chills, fever, dyspepsia, joint pain, angioedema, and sometimes erosive lesions of the mucous membranes. . There are cases of an extremely severe reaction to insulin in the form of anaphylactic shock with the development of collapse and respiratory failure. The generalized form of allergy is most often observed with intermittent IT against the background of allergic diathesis.

There are 2 forms of insulin allergy: immediate, occurring 15-30 minutes after the administration of the drug, and delayed, which develops after 24-30 hours with the formation of an infiltrate at the injection site. Various skin manifestations are more often observed, disappearing within 4-8 weeks. Rare cases of unusual allergic reactions with a slow gradual development of a feverish state and pulmonary edema have been described, which disappeared after discontinuation of insulin.

Therefore, caution should be exercised when prescribing insulin, especially when resuming

IT. In order to prevent possible allergic reactions, all patients should undergo an intradermal drug tolerance test before administering insulin. It is carried out as follows: insulin at a dose of 0.4 IU in 0.2 ml of physiological saline is administered intradermally to the patient in the region of the medial surface of the forearm. If there is no local reaction, this insulin can be used for therapeutic purposes.

With a mild local reaction (hardening, hyperemia), these phenomena can be leveled by a deeper (intramuscular) administration of insulin, preliminary infiltration of the injection site with a 0.25% solution of novocaine, or administration of the drug along with microdoses (less than 1 mg) of hydrocortisone. Sometimes it is possible to prevent the development of a local allergic reaction with the help of antihistamines (diphenhydramine, suprastin, tavegil, fenkarol, etc.), antiserotonergic (peritol) agents, calcium preparations, ointments containing corticosteroids (hydrocortisone, sinalar). Preliminary boiling of insulin in a water bath for 5-6 minutes, which eliminates its immunogenic property, also helps to prevent the development of allergies and continue IT. Although this may slightly decrease the hypoglycemic effect of the drug.

But even with a slightly pronounced local reaction, it is recommended to change the type of insulin. Sometimes this measure is sufficient, especially in patients allergic to insulin impurities. To accelerate the resorption of skin seals in the absence of other manifestations of allergy, electrophoresis with calcium chloride is prescribed to the affected areas. While maintaining an allergy to all types of insulin, if the patient's condition allows, it is necessary to try to achieve compensation for the disease with the help of oral hypoglycemic agents and other auxiliary measures. If it is impossible to replace insulin, it is advisable to carry out desensitization, which can be done at a fast or slow pace.

Slow desensitization is carried out in the absence of urgent indications for the introduction of the drug. At the same time, starting from an insulin dose of 0.0001 IU, it is doubled daily. When the dose reaches 0.1 IU, it is increased more intensively for 3 months. In the diabetology department of the Institute of Endocrinology and Metabolism. V.P. Komissarenko of the Academy of Medical Sciences of Ukraine uses a special desensitization technique: 4 IU of insulin is diluted in 400 ml of saline and 0.1 ml of the mixture (dilution 1:1000) is injected intradermally into the patient's forearm. Every 30 minutes, the administration is repeated at a concentration of 1:500, then 1;250 and 1:125. On the second day, the administration of insulin is repeated at a dilution of 1:100, then 1:50,1:25,1:12. On the 3rd and last day, 1/4, then 1/2, 1 and 2 units of the drug are administered at the same interval. If an allergic reaction occurs, the insulin dose is not increased and desensitization is continued the next day from the previously tolerated dose. In rare cases, while maintaining a sharply increased response to insulin, desensitization has to be abandoned. In the diabetology department of IE and CG of the Russian Academy of Medical Sciences, a rapid desensitization scheme has been developed. In this case, the patient is first injected with 0.02-0.04 IU of porcine insulin, and then every 2-3 hours in the absence of an allergic reaction, the dose of insulin is doubled and then it is administered fractionally.

In the case of anaphylactic shock, in response to insulin injection, intravenous administration of glucocorticoids, norepinephrine, cardiac glycosides, ascorbic acid, rheopolyglycine infusion, and the appointment of sedatives are indicated. In order to slow down the absorption of insulin, 1 ml of a 0.1% solution of adrenaline must be injected at the injection site.

Hypoglycemia is the most common complication of IT, caused by a drop in blood sugar below 2.78 mmol / l, or a rapid decrease in a short time from high numbers to normal or subnormal levels. Such relative hypoglycemia is possible when patients with a high level of glycemia have a relatively good state of health. A decrease in its level to normal leads to a deterioration in the condition with the appearance of general weakness, headache, dizziness. Intravenous administration of a 40% glucose solution in this case eliminates these phenomena. It is known that in patients with a labile course of diabetes, with frequent hypoglycemic conditions, adaptation to low blood sugar develops, and the clinical symptoms of hypoglycemia develop in them at blood sugar levels lower than 2.78 mmol/l.

Various factors can contribute to the development of hypoglycemia in patients with DM: a violation of the diet (inadequate food intake or low calorie intake, lengthening the intervals between meals) and the presence of indigestion (diarrhea, vomiting, malabsorption), alcohol consumption, taking β-blockers, fatty degeneration of the liver , deterioration of kidney function with the development of chronic renal failure, as well as excessive physical activity. An overdose of insulin, as well as a change in its type without first reducing the dose: can also lead to the development of hypoglycemia. The probability of this complication in patients increases with the addition of concomitant pathology (hypopituitarism, hypocorticism, hypothyroidism).

The pathogenesis of hypoglycemia is primarily due to a deterioration in the nutrition of the central nervous system, brain hypoxia, an increase in the tone of the sympathetic-adrenal system, and an increase in the production of contrainsular hormones.

Clinical symptoms are due to dysfunction of the central and autonomic nervous system.

The following stages of development of hypoglycemia are distinguished:

stage - characterized by irritability, the appearance of hunger, headache. At this stage, the cerebral cortex is involved in the process. These early signs of hypoglycemia are absent in patients receiving human insulins.

stage - there is an involvement of subcortical-diencephalic formations of the brain and a manifestation of vegetative reactions; drooling, tremors, sweating, double vision, behavioral changes (aggressiveness or fun). Consciousness during this period is not disturbed.

the stage is due to the involvement of the midbrain and is accompanied by an increase in muscle tone, the development of tonic-clonic convulsions, reddening of the face, and hypertension. Sometimes there is a blackout of consciousness, accompanied by delusions and hallucinations.

stage (hypoglycemic coma) - characterized by damage to the upper parts of the medulla oblongata with delirium, convulsions and loss of consciousness.

stage - associated with damage to the lower parts of the medulla oblongata and is accompanied by deep coma, tachycardia, hypotension, respiratory failure of central origin. A dangerous complication of hypoglycemia is cerebral edema, which is characterized by vomiting, meningeal symptoms, impaired cardiac activity and respiration.

Frequently repeated hypoglycemia contributes to the development of encephalopathy and leaves behind irreversible disorders of the psyche and memory, causing a decrease in intelligence. Based on these considerations, in cases of labile diabetes mellitus, it is sometimes necessary to allow slight hyperglycemia and even minimal glucosuria for some time.

Of particular danger is hypoglycemia for patients with affected cerebral and coronary vessels, as well as with advanced retinopathy. Proper treatment of diabetes involves maintaining the relationship between the dose of insulin (or glucose-lowering drugs), the quantity, quality of food taken, the regimen of its intake and the degree of physical activity. If one of the factors changes, the others must be corrected as well. All patients receiving insulin and their close relatives should be aware of the signs of hyloglycemic conditions, know their causes, preventive measures and emergency care. This is especially important for patients who feel the onset of hypoglycemia, which allows them to stop its development in time.

Mild hypoglycemia is usually eliminated by the intake of easily digestible carbohydrates (sugar, honey, sweets, biscuits, jam).

When the hypoglycemic state is caused by the influence of long-acting insulin, the addition of carbohydrates that are slowly absorbed from the intestine (bread, potatoes, cereals, biscuits) is recommended.

An unconscious patient should be given intravenous 40% glucose solution in an amount of 60 to 100 ml (no longer recommended due to the threat of cerebral edema). If the effect is doubtful, 100 ml of hydrocortisone with 5% glucose solution is additionally administered, as well as 1 ml of 0.1% adrenaline solution, which promotes the mobilization of liver glycogen, followed by an increase in blood sugar. Recently, when assisting patients, intramuscular injection of 1-2 ml of a 2% solution of glucvgon is used 1-2 times a day. The hyperglycemic effect of the drug is due to its glycogenolytic effect, therefore it is not effective in case of depletion of glycogen stores in the liver, for example, during starvation, hypocorticism, sepsis, hepatic and congestive heart failure, and the presence of frequent hypoglycemic conditions in patients.

If the patient does not regain consciousness after the measures taken, a drip intravenous injection of 5-10% glucose solution with small doses of insulin (4-6 units), cocarboxylase (100 mg) and ascorbic acid (5-10 ml) is prescribed. In order to prevent the possible development of cerebral edema, an intravenous drip of 100 g of mannitol in the form of a 10-20% solution or 1% lasix solution is also indicated (with glycemia not lower than 3.0 mmol/l).

To combat collapse, it is necessary to prescribe cardiac glycosides (1 ml of a 0.06% solution of Korglmkon, 1-2 ml of DOXA, and in the event of seizures, a 25% solution of magnesium sulfate up to 10 ml.

In especially severe cases, patients are shown a single-group blood transfusion in order to replace respiratory enzymes, as well as giving oxygen. The use of an artificial pancreas can also be an important help in helping these patients.

Patients who have undergone hypoglycemic coma are recommended to use drugs that stimulate metabolic processes in the brain: nootropics (glutamic acid, piracetam, encephabol, nootrolil, aminolone, etc.), drugs that selectively dilate cerebral vessels (stugeron, cinnarizine) or combined drugs ( phases, nooses) within 3-4 weeks.

Without medical assistance, patients in a state of hypoglycemic coma usually die, although in clinical practice there have been cases of spontaneous exit from this state within a few hours.

Prevention of hypoglycemia involves, first of all, adherence to the dietary regimen (in terms of energy value, quantitative and qualitative composition of food and the intervals between meals). Rational physical activity, the use of plant hypoglycemic agents with timely correction of the dose of insulin, therapeutic measures aimed at normalizing endocrine disorders (hypopituitarism, hypocorticism, hypothyroidism), improving the functions of the liver, kidneys, and sanitation of foci of infection in most cases make it possible to stabilize the course of the disease and eliminate hypoglycemia.

Insulin resistance is a condition characterized by an increase in the dose of insulin due to a weakening of its hypoglycemic effect in response to the necessary physiological needs of the body. In this case, the daily need for insulin outside of ketoacidosis and stress exceeds 150-200 units per day in adults, and in children - 2, 5 units per 1 kg of body weight. It can be absolute and relative. If absolute inulin resistance is due to hyperproduction of antibodies, a decrease in the number and decrease in the sensitivity of insulin receptors in tissues to the action of the hormone, then the relative is caused by malnutrition. hypercortisolism), also in obesity and in the presence of chronic foci of infection in the body (tonsillitis, otitis media, sinusitis, hepatocholecystoangiocholitis), collagenoses.

In clinical practice, it is advisable to distinguish between acute and chronic insulin resistance. Acute includes those cases when the patient's need for insulin increases rapidly and then decreases within 1-2 days. As a rule, diabetic ketoacidosis is combined with it.

The chronic form is observed in patients with diabetes for several months, and sometimes years. It develops most often after several years from the start of insulin therapy.

According to the classification proposed by Burson and Yalov, insulin resistance is divided into mild, moderate and severe. With a mild degree, the daily requirement for insulin is 80-125 IU, with an average degree - 125-200 IU, and with a severe degree - more than 200 IU. The literature describes cases of severe insulin resistance, when the required dose of insulin per day reached 50,000 IU. Severe insulin resistance is often observed in patients with lipoatrophic diabetes.

Treatment of insulin resistance is sometimes a difficult task. Strict adherence to the dietary regimen, rational physical activity, rehabilitation of foci of infection, treatment of concomitant diseases, prevention of stressful situations are important points in its solution. Increasing the dose of insulin up to the development of hypoglycemia, especially against the background of intravenous administration of the drug, often leads to an increase in the sensitivity of peripheral tissues to it and overcoming insulin resistance.

Changing the type of drug, in particular to monopeak, and especially human, helps to eliminate this complication.

With insulin resistance caused by an increase in the concentration of antibodies to insulin in the blood, glucocorticoids, which suppress the antigen-antibody reaction, are widely used. In this case, the appointment of prednisolone at a dose of 30-40 mg per day daily or every other day with a gradual decrease in dose over 1-2 months may have a positive effect.

Sometimes the elimination of insulin resistance can be achieved with the use of antipyretics of other drugs and immunomodulators (decaris, T-activin), oral hypoglycemic drugs (sulfonamides, biguanides, glucobay, glitazones), beta-blockers (anaprilin, obzidan), drugs that increase vascular permeability (reserpine , nicotinic acid, aspirin).

With insulin resistance, transfusion of isogroup blood, plasma substitutes, albumin, and in especially severe cases, hemosorption and peritoneal dialysis may be recommended.

With insulin resistance associated with excessive secretion of contrainsular hormones, treatment of the corresponding endocrine pathology is indicated.

Post-injection insulin lipodistro-

fii develop predominantly in women and children a few months or years after the start of IT. From a clinical point of view, hypertrophic lipodystrophy (more often in men) and atrophic - in women and children are distinguished. They usually occur in symmetrical areas (anterior abdominal wall, buttocks, thighs) at the sites of insulin injections or close to these areas - repercussion lipodystrophy. This complication is not only a cosmetic defect. It leads to a violation of insulin absorption, the appearance of pain that increases with changes in barometric pressure and can be combined with insulin resistance and allergic reactions.

The mechanism of development of lipodystrophy is unclear. But their occurrence is facilitated by the acidic reaction of insulins, a violation of the technique of drug administration (the ingress of alcohol under the skin, the introduction of cold insulin, prolonged traumatization of the same injection site with needles). An important role in the development of this complication has recently been assigned to immune mechanisms, which is confirmed by the detection of complexes from insulin and immunoglobulins in places of lipodystrophy. The most effective way to treat lipodystrophy is to switch to insulin with less immunogenicity, better than human, which confirms the hypothesis about the possible role of immune mechanisms in the occurrence of this complication.

Part of the daily dose of insulin (6-10 IU) should be used for chipping lipodystrophies around their circumference, sometimes together with a 0.25% novocaine solution. A positive effect was also noted with the use of hydrocortisone, lidase (chopping, electrophoresis), the appointment of anabolic steroids and massage of the affected areas.

In order to prevent lipodystrophy, it is recommended to regularly change insulin injection sites, use sharp needles, warm insulin to body temperature (36-37 ° C) before injection, avoid getting alcohol under the skin, inject insulin slowly for 15-20 seconds or more deeply.

Insulin edema develops, as a rule, in patients with newly diagnosed decompensated type 1 diabetes on the background of large doses of insulin. They can be local (periorbital fat, sacrum, legs) and generalized (sudden weight gain). Their development is due to several factors:

Fluid retention in the body due to increased secretion of vasopressin, observed in response to increased diuresis and a decrease in circulating blood volume during decompensation of diabetes.

A decrease (absolute or relative) in the production of glucagon during treatment with large doses of insulin. It is known that glucagon has a pronounced natriuric effect.

The direct action of insulin on the kidneys, which enhances the resorption of sodium and water in the renal tubules. The consequence of this action of insulin is an increase in circulating blood volume and inhibition of the renin-angiotensin system.

Insulin edema is a relatively rare complication that requires special treatment (lasix, uregit) only in cases of generalized edema due to the danger of fluid effusion into the pericardial, pleural, abdominal, and other cavities, threatening the life of the patient.

The formation of Somogyi syndrome (chronic overdose of insulin) is more often observed in young patients with non-compliance with the diet against the background of short-acting insulin administration. In this case, the daily dose of insulin usually exceeds! units/kg of body weight. This syndrome is characterized by a high level of fasting glycemia and the presence of acetonuria.

Attempts to increase the dose of insulin administered do not eliminate morning hyperglycemia. Despite the decompensation of the disease in patients, the massate gradually increases. The study of the glucosuric profile indicates the absence of sugar in the urine in some nightly portions, and the presence of sugar and acetone in other portions. An overdose of insulin in Somogyi syndrome leads to hypoglycemia at night and a compensatory release of contra-insulin hormones (somatotropin, catecholamines, glucagon, cortisol). The latter dramatically increase l ipolysis, promote ketogenesis and increase blood sugar levels. Therefore, if the Somogyi phenomenon is suspected, it is necessary to reduce the dose of INDUSTRIAL insulin (usually in the evening) by 10-20%, and sometimes more, which will speed up the achievement of compensation for the disease.

Insulin presbyopia (refractive error) is caused by a decrease in glycemia associated with the start of insulin therapy. It is observed in individuals with a labile course of diabetes with a sharp fluctuation in glycemic levels. The observed transient presbyopia is a consequence of a change in the physical properties of the lens due to the accumulation of water in it, followed by a violation of accommodation. This complication does not require special treatment and soon disappears after the normalization of metabolism.

Insulin cutaneous hyperalgesia occurs as a result of damage to the innervation apparatus of the skin by an injection needle and, possibly, chemicals (phenol) contained in insulin preparations as a preservative. Clinically, patients have pain when pressing on the parts of the body into which insulin is injected, or when the hormone is re-introduced into them. Occasionally, persistent hyperalgesia occurs in these, as well as neighboring areas of the skin located below the injection site on the extremities. Treatment for this complication is reduced to strict adherence to the rules of insulin administration, including using atraumas of ethical needles, changing the injection site.

Thus, a protective regimen, a rational diet, dosed physical activity, the use of plant hypoglycemic agents that stabilize the course of diabetes mellitus, and the timely elimination of comorbidities are important prerequisites for the prevention of complications of insulin therapy.

Proper storage, strict adherence to the technique of insulin administration with timely correction of its dosage, and the use of highly purified and human insulin preparations in most cases can prevent their development.

Literature

Balabolkin M.I. Endocrinologists I. - M. Univeroom Publishing. - 1998.

Balabolkin M.I. Diabetes mellitus - M., 1994.

B od Nar P.M. Endocrinology.-K.: Health.-2002.

Dedov H.H. Diseases of the endocrine system, - M., 2000,

Efimov A.S., Skrobonokaya H.A. Clinical Diabetology, - K .: Health. - 1998.

Efimov A.S. et al. Small encyclopedia of an endocrinologist, book. 3.- Medical book: Kyiv, - 2007.

Zhukovsky M.A. Pediatric endocrinology, -M, 1995.

Korpachev, V.V. Insulin and insulin therapy. - Kyiv, RIA "Triumph", -2001.

Lavin N. Endocrinology, - M. "Practice", -1999,

Yu.Starkova N.T. Guide lo clinical

endocrinology, - St. Petersburg. - 1996.

Content

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hypoglycemia

In case of an overdose, a lack of carbohydrate food, or some time after the injection, the blood sugar level may drop significantly. As a result, a hypoglycemic state develops.

The hypoglycemic state is accompanied by a number of symptoms:

severe hunger;
frequent heartbeat;
increased sweating;
tremor of the limbs.

With the progression of the complication, convulsions appear, the patient becomes inadequate and may lose consciousness.

Hypoglycemia is an extremely dangerous diabetic complication, because it can cause death. At risk are elderly patients with lesions of the heart, brain and blood vessels.

A constant decrease in sugar can lead to the appearance of irreversible mental disorders.

Also, the patient's intellect and memory worsen, and the course of retinopathy develops or worsens.

insulin resistance

Often with diabetes, the sensitivity of cells to insulin decreases. To compensate for carbohydrate metabolism, 100-200 units of the hormone are needed.

In some cases, glucocorticoids are indicated. To do this, increase the daily dosage of the hormone and prescribe a ten-day treatment with Prednisolone (1 mg / kg).

Allergy

When insulin is administered, complications can vary. So, in some patients there is an allergy, which manifests itself in two forms:

Local. The appearance of a fatty, inflamed, itchy papule or hardening at the injection site.
Generalized, in which there is urticaria (neck, face), nausea, pruritus, erosion on the mucous membranes of the mouth, eyes, nose, nausea, abdominal pain, vomiting, chills, fever. Sometimes anaphylactic shock develops.

To prevent the progression of allergies, insulin replacement is often performed. For this purpose, the animal hormone is replaced by a human hormone or the manufacturer of the product is changed.

If it is not possible to replace the drug, then insulin is combined with the introduction of minimal doses (up to 1 mg) of Hydrocortisone. For severe allergic reactions, the following drugs are used:

Calcium chloride;
Hydrocortisone;
Diphenhydramine;
Suprastin and others.

It is noteworthy that local manifestations of allergies often appear when the injection is not done correctly.

For example, in case of an incorrect choice of injection site, skin damage (blunt, thick needle), injection of a too cold agent.

Pastipsulip lipodystrophy

There are 2 types of lipodystrophy - atrophic and hypertrophic. The atrophic form of the pathology develops against the background of a prolonged course of the hypertrophic type.

In some cases, against the background of lipodystrophy, insulin resistance of varying severity occurs.

In addition, lipoatrophies have been found to disappear after injection with human insulin.

Other effects of insulin therapy

Often, insulin-dependent diabetics have a veil before their eyes. This phenomenon causes severe discomfort to a person, so he cannot write and read normally.

Many patients mistake this symptom for diabetic retinopathy. But the veil before the eyes is the result of changes in the refraction of the lens.

This consequence disappears on its own after 14-30 days from the start of treatment. Therefore, there is no need to interrupt therapy.

Other complications of insulin therapy are swelling of the lower extremities. But such a manifestation, like vision problems, goes away on its own.

Swelling of the legs occurs due to water and salt retention, which develops after insulin injections. However, over time, the body adapts to the treatment, so it stops accumulating fluid.

For similar reasons, at the initial stage of therapy, patients may periodically increase blood pressure.

In addition, the constant administration of insulin lowers the amount of potassium in the blood. You can solve this problem with a special diet.

To this end, the daily menu of a diabetic should be replete with citrus fruits, berries (currants, strawberries), herbs (parsley) and vegetables (cabbage, radishes, onions).

Prevention of the development of complications

To minimize the risk of the consequences of insulin therapy, every diabetic should learn self-control methods. This concept includes compliance with the following rules:

Constant monitoring of blood glucose concentration, especially after meals.
Comparison of indicators with atypical conditions (physical, emotional stress, sudden illness, etc.).
timely correction of the dose of insulin, antidiabetic drugs and diet.

The most accurate results can be obtained using double field strips. However, a blood test is a more effective method for determining sugar levels.

Also, in order for insulin therapy not to contribute to the development of complications, a diabetic must carefully monitor his own body weight. You can find out if you are overweight by determining the Kegle index or body weight.

Side effects of insulin therapy are discussed in the video in this article.

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