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Use of insulin to treat diabetes, called insulin therapy, has two main goals:

1. To maintain blood sugar (glucose) at near-normal levels
2. To prevent long-term complications of diabetes

A successful treatment plan takes into consideration what you eat and how much you exercise in determining the amount of insulin you need each day. The most widely used form of insulin is synthetic human insulin. It's called human insulin because its chemical makeup is identical to that of insulin produced by the human pancreas, but this insulin is made in a laboratory. It's easier to understand the importance of insulin therapy if you understand how insulin normally works in your body. Food is made up of carbohydrates, protein and fats. All three affect your blood sugar, but carbohydrates affect it the most. Carbohydrates are broken down and absorbed into your bloodstream in the form of sugar (glucose), raising your blood sugar level. Your pancreas releases insulin continuously, whether or not you're eating. When the amount of sugar in your blood rises, however, such as after a meal, secretion of insulin increases. The main job of insulin is to keep your blood sugar level within its normal range. It does this by "escorting" sugar - your body's main energy supply - from your bloodstream to your individual cells. As sugar enters your cells, the amount of sugar in your blood drops. Insulin also influences your liver, which plays a key role in maintaining normal blood sugar levels. After you eat, when insulin levels are high, your liver accepts and stores extra sugar in the form of glycogen. Between meals, when insulin levels are low, your liver releases glycogen into your bloodstream in the form of sugar, keeping your blood sugar level within a narrow and normal range. All people with type 1 diabetes and some people with type 2 diabetes need insulin medication to make up for the insulin that their pancreas is unable to produce. The medication is administered by injection with a syringe or an insulin pen, or through constant infusion from an insulin pump. Insulin isn't available in pill form because its chemical structure is destroyed during digestion, making the hormone ineffective by the time it gets to your bloodstream. Many types of insulin are used, and they differ in the time it takes for them to begin working and in their duration. These include:

1. Short-acting insulin. Short-acting insulin works quickly, but its effects last for only a limited time.
2. Intermediate-acting insulin. Intermediate-acting insulin starts working later than short-acting insulin, and its effects last longer.
3. Long-acting insulin. Long-acting insulin takes several hours to work, but the duration of its peak action is greater than that of other forms of insulin.

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The goal of any insulin program is to keep blood sugar within or close to its normal range by mimicking normal pancreatic secretions of insulin. Ideally, this regimen would provide continuous (basal) secretion of insulin as well as periodic meal-related secretions. As useful as the current types of human insulin are, they're not perfect. Their action and rate of absorption vary. Researchers have discovered that by rearranging the chemical structure of synthetic human insulin, they can create modified forms of insulin called insulin analogues. The onset and duration of these newer types of insulin more closely resemble those of natural insulin.

Lispro (Humalog) and insulin aspart (NovoLog). These forms of insulin are called rapid-acting because they're absorbed more quickly than regular insulin. They also peak faster and their effects wear off sooner. Lispro and insulin aspart work just long enough to keep your blood sugar from rising too high after meals. One of the downfalls of rapid-acting insulins - which also can occur with other types of insulin - is that they can cause your blood sugar level to drop too low (hypoglycemia) if they're administered too early before a meal. To prevent this from occurring, these medications should be taken at the time you eat.

Glargine (Lantus). Researchers hope long-acting insulin analogues can provide more consistent blood sugar control. Development of these medications has been slow, but one such insulin analogue has received Food and Drug Administration approval. Glargine requires only one injection a day, begins working 1 to 2 hours after injection and has no distinct peak effect. The type and dosage of insulin you need depends on the characteristics of your disease. Your daily insulin regimen may involve one or two types of insulin. Mixing two types of insulin often can more accurately mimic normal insulin production. You might take a short-acting insulin to simulate insulin secretion at mealtime and a longer-acting insulin to mimic basal insulin secretions. Your doctor will help you decide which insulin regimen will work best for your diabetes and your lifestyle. Several types of insulin regimens exist:

1. Single dose. You inject a dose of intermediate-acting insulin once each day. This regimen is the least beneficial for people with type 1 diabetes.
2. Mixed dose. You inject both short-acting and intermediate-acting insulins - mixed in one syringe - each morning.
3. Pre-mixed single dose. You inject a dose of pre-mixed insulin each morning.
4. Split dose. You give yourself two injections of intermediate-acting insulin each day. These injections are usually given before breakfast and before the evening meal, or before breakfast and at bedtime.
5. Split mixed dose. You give yourself two injections that contain a combination of a short-acting and an intermediate-acting insulin - mixed in one syringe - each day. These are generally given before breakfast and before the evening meal.
6. Split pre-mixed dose. You give yourself two injections of pre-mixed insulin daily. These are usually given before breakfast and before the evening meal, or before breakfast and at bedtime.
7. Intensive insulin therapy. This regimen involves multiple daily injections of insulin or use of a small portable pump that continuously administers insulin.

Intensive insulin therapy involves monitoring your blood sugar frequently, using a combination of insulins and adjusting your insulin doses based on your blood sugar levels, your diet and changes in your routine. When practiced effectively, intensive insulin therapy can:

1. Reduce your risk of eye damage
2. Reduce your risk of kidney disease
3. Reduce your risk of nerve damage
4. Improve your cholesterol levels
5. Reduce your risk of cardiovascular disease


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Two methods for implementing intensive insulin therapy are:

1. Multiple daily injections (MDIs). Multiple daily injection therapy includes three or more injections of insulin daily to achieve good blood sugar control. Both a short-acting insulin and a longer-acting insulin are used.

2. An insulin pump. An insulin pump most closely resembles how your body delivers insulin. The short-acting insulin used with insulin pumps offers more consistent and predictable effects than longer-acting insulin.

Intensive insulin therapy has two possible drawbacks:

1. Low blood sugar (hypoglycemia). The tighter your blood sugar levels, the greater your risk of experiencing low blood sugar when your routine changes and your blood sugar varies from its normal range. You can counter this risk by being aware of the symptoms of low blood sugar and responding quickly when you begin to experience them.
2. Weight gain. This can occur because the more insulin you use to control your blood sugar, the more sugar that gets into your cells and the less sugar that's wasted in your urine. Sugar that your cells don't use accumulates as fat. Following a healthy eating plan can help limit weight gain. The most common way to receive insulin is by syringe. This method delivers insulin underneath the skin, where it's absorbed into the bloodstream. An alternative method for injecting insulin involves the use of an insulin pen. For many years a standard syringe containing a needle was the only tool used to inject insulin. Now other options are available:

1. Insulin pen injectors. Although a needle is still involved, insulin pens offer a convenient, more accurate and discreet means of receiving insulin. This device looks like a pen with a cartridge - but the cartridge is filled with insulin rather than ink. Some pens use disposable cartridges containing pre-filled insulin. Other pens are completely disposable. You place a fine point needle, much like the one on a syringe, on the tip of the pen. You turn a dial to select the desired insulin dose, insert the needle under your skin and then click down on a button at the end of the pen to deliver the insulin.

2. Insulin jet injectors. These devices use high-pressure air to send a fine spray of insulin under your skin. This can be a painful way to receive insulin, and it's not as accurate as other methods because some of the medication can be lost during injection. Jet injectors may be an option if you can't use needles. However, if you use the device incorrectly, you could injure your skin. Jet injectors cost more than pen injectors, generally $250 or more.

Insulin may be injected into any area of your body where a layer of fatty tissue is present and where large blood vessels, nerves, muscles and bones aren't close to the surface. Direct injection of insulin into your bloodstream - although sometimes done in a hospital - isn't recommended for day-to-day use because it's inconvenient and would make the insulin act too fast. Insulin is absorbed most evenly from injections in the abdomen except for the 2-inch radius around the navel. Rotate the site of each injection. Your doctor or diabetes educator may show you alternative areas for injection, such as your hips, buttocks, upper arms and thighs. It's generally best to administer insulin in your abdomen because insulin absorption in other areas is more variable and often dependent on your level of physical activity. After you determine the site for your insulin injection, clean it with an alcohol wipe or soap and water, and allow it to dry before giving yourself an injection.

With time and practice, the process of drawing insulin into a syringe becomes routine and is no longer so daunting. Here's how to do it:

1. Collect the materials you'll need: alcohol wipes, insulin and a syringe.
2. Check the label on the insulin bottle for the source, type, concentration and expiration date. You should use the same kind of insulin every time, unless your doctor tells you otherwise. Changing insulin types may affect blood sugar control.
3. Check the insulin bottle for any changes in the insulin. Make sure no clumping, frosting, precipitation or change in clarity or color has occurred. Any changes in appearance may mean that the insulin has lost potency.
4. Wash your hands with soap and water.
5. Gently roll the bottle of insulin between your hands to mix the insulin. Shaking it may decrease its potency. Check to make sure that no particles remain on the bottom of the bottle.
6. Wipe off the top of the insulin bottle with an alcohol wipe.
7. Remove the needle cap from the sterile syringe.
8. Pull the plunger to draw into the syringe an amount of air equal to the amount of insulin you need.
9. Insert the needle through the rubber stopper of the insulin bottle and push the air in the syringe into the bottle.
10. While keeping the needle in the bottle, turn the bottle completely upside down.
11. Pull the plunger on the syringe slightly past the number of units of insulin you are to inject. Be sure that you're withdrawing insulin, not air. Air isn't dangerous but it can decrease the amount of insulin in the syringe.
12. Remove air bubbles either by pushing the insulin back into the bottle and withdrawing it again or snapping the syringe sharply with your finger and then pushing the plunger to expel the air into the bottle.
13. Recheck the syringe for air. If air is present, repeat the previous step.
14. Double-check the amount of insulin in the syringe.
15. Pull the needle out of the bottle.

If you need to inject two types of insulin at the same time, write on a piece of paper the amount of each type of insulin to be injected and add the two to determine the total number of units. Follow the preceding steps for drawing up insulin until you reach the point that you remove the needle cap from the sterile syringe. From then on, do as follows:

1. Pull the plunger to draw into the syringe an amount of air equal to the amount of intermediate- or long-acting insulin you need.
2. Insert the needle through the rubber stopper of the intermediate- or long-acting insulin bottle and push the air in the syringe into the bottle. This will equalize air pressure in the vial. Without it, it'll be hard to withdraw the insulin.
3. Pull the needle out of the bottle without withdrawing any insulin.
4. Pull the plunger to draw into the syringe an amount of air equal to the amount of short-acting insulin you need.
5. Insert the needle through the rubber stopper on the short-acting insulin bottle and push the air in the syringe into the bottle.
6. Turn the bottle completely upside down, while keeping the needle in the bottle.
7. Pull the plunger on the syringe slightly past the number of units of short-acting insulin you are to inject. Be sure that you're withdrawing insulin, not air.
8. Remove air bubbles either by pushing the insulin back into the bottle and withdrawing it again or by snapping the syringe sharply with your finger and then pushing the plunger to expel the air into the bottle.
9. Recheck the syringe for air. If air is present, repeat the previous step.
10. Double-check the amount of insulin in the syringe.
11. Pull the needle out of the bottle.
12. Insert the needle through the rubber stopper of the intermediate- or long-acting insulin bottle.
13. Turn the bottle completely upside down, while keeping the needle in the bottle.
14. Carefully withdraw the required number of insulin units. If you draw past the correct amount, don't push the insulin back into the bottle. Throw away the syringe and begin again.
15. Double-check the amount of insulin in the syringe. It should equal the sum on your piece of paper.
16. Pull the needle out of the bottle.

Once you have the right amount of insulin in the syringe and you've removed the needle from the bottle, it's time to inject the medication:

1. Hold the syringe like a pencil. Quickly insert the entire length of the needle into a fold of your skin at a 90-degree angle. If you're thin, you may need to use a short needle or inject at a 45-degree angle to avoid injecting into your muscle, especially in the thigh area.
2. Release the pinched skin and inject the insulin by gently pushing the plunger all the way down at a steady, moderate rate. If the plunger jams as you're injecting the insulin, remove the needle and note the number of units remaining in the syringe. Contact your doctor, nurse or diabetes educator for more instructions.
3. Place the alcohol wipe on your skin next to the needle and withdraw the needle.
4. Apply gentle pressure with the alcohol wipe at the injection site for 3 to 5 seconds. Don't rub.
5. Discard the needle in a covered, puncture resistant container.

Some people develop indentations, hard lumps or thickened skin in areas where they inject insulin. Ask your doctor or diabetes educator what you can do to avoid this. Often, rotating the site of your injections will prevent or reduce this problem. Avoid injecting in areas of indentations, hard lumps or thickened skin because insulin isn't absorbed as well there.

Store your insulin in the refrigerator until it's opened. After a bottle has been opened, it may be kept at room temperature for 1 month. Insulin at room temperature causes less discomfort when injected. Throw away your insulin after the expiration date or after being kept at room temperature for a month. Never freeze insulin or expose it to extremely hot temperatures or direct sunlight. Before taking any medication other than your insulin, including over-the-counter products, read the warning label. If the label says you shouldn't take the drug if you have diabetes, consult your doctor before taking it.

Researchers have been experimenting with a preparation in which insulin is inhaled through the nose. However, absorption of insulin through membranes in the nasal cavity is varied and still too unreliable. Other studies that show promise involve administering insulin by means of:

1. A patch. An insulin patch is placed on the skin to provide a continuous low dose of insulin. Insulin levels can be adjusted before meals by pulling off a tab on the patch to release insulin. Because insulin doesn't permeate skin easily, the patch is still not as effective as a needle.
2. An inhaler. With this delivery method, dry powder is inhaled through the mouth directly into the lungs where the insulin enters the bloodstream. The inhaler is about the size of a flashlight and uses rapid-acting insulin