Type 2 Tidbit: Many kids with type 2 diabetes don't take insulin. But they may take pills to help their body to use the insulin it already has or to make more insulin. As you get older, insulin shots could be added to your diabetes treatment. If this happens, remember that shots are not a punishment. They are just one more way to keep your diabetes in control.

Types & Action

Before you developed diabetes, your pancreas made all your insulin. And it knew exactly when to release the insulin to the body. Like a smoke detector, your body sensed when there was more sugar in the bloodstream. It sent out the alarm: time for more insulin!

Manufactured insulin comes in several types. Each type works at a different pace, and most people have to use more than one kind to mimic what their bodies used to do all by themselves.

Different types of insulin are like different types of Olympic runners. Some types of insulin are like sprinters. They start quickly, get to their top speed, and finish fast. Other types of insulin are like marathon runners. They start slower, and they keep going slow and steady for a long time. Then there are the ones in between-not as fast as a sprint and not as slow as a marathon. No one type of insulin is better than another. All types are important to keep your diabetes in control.

Rapid-acting insulin, often called Lispro or Humalog, is the fastest insulin of all. Once you inject it, it starts to work within 15 minutes. It works hardest (or "peaks") at about an hour or so after you inject it. It's usually used up in four or five hours. This kind of insulin is designed so you can inject it right before meals. It starts to work about the time you start to eat. By the time your meal is digested and sugar is beginning to move into the bloodstream, rapid-acting insulin is working the hardest at moving that sugar into the cells.

Short-acting, or "regular," insulin is also used around mealtime. It takes longer to work than rapid-acting insulin does. So you take short-acting insulin about 30 to 45 minutes before you plan to eat and it peaks at about two or three hours. It can keep working for as long as six hours. Rapid-acting and short-acting insulin are both "clear" insulins.

There are two types of intermediate-acting insulin, NPH and lente. Intermediate-acting insulin is insulin mixed with a substance that makes the body absorb the insulin more slowly. That's why this type of insulin looks cloudy and has to be mixed before it's injected. It takes longer to start to work, and it stays in your body for a longer time. 

NPH usually begins to work about two to four hours after you inject it. It peaks four to 10 hours after injection, and it keeps working for 10 to 16 hours.

Lente lasts even longer. It peaks at four to 12 hours after injection and stays in the body from 12 to 18 hours. Intermediate-acting insulin works all day if you take it in the morning. A shot of intermediate-acting insulin in the evening keeps insulin in your body during the night.

Then there's the marathon runner of the bunch, long-acting insulin, also called Ultralente. It starts to work in six to 10 hours and can stay in the body for 20 hours or more. It has a peak, but its top speed looks a lot like its normal speed. Long-acting insulin is usually taken in the morning or before bed, like intermediate-acting insulin.

Insulin Storage

Just like you take care of yourself, you also need to take care of your insulin. Good insulin care begins with how the insulin is stored. Insulin doesn't work well when it's kept for too long or is exposed to extreme temperatures (like heating or freezing). If you buy several bottles of insulin at once, keep the unopened ones in your refrigerator. Don't put them in the freezer. Insulin clumps at temperatures below 36ºF. Before you open a new bottle, check the date printed on it. If it's more than a month past that date, don't use the insulin, it's too old.

If you use a whole insulin bottle in a month or less, keep the bottle you're currently using at room temperature. Good spots are on the kitchen counter or in your diabetes kit. It will stay fresh for up to month without refrigeration, as long as its temperature stays under 86ºF.

If you don't use a whole bottle in a month or less, then keep it in the fridge. Be sure to warm up the insulin before injecting it. Cold insulin can make the shot uncomfortable. Draw up the right amount into the syringe, then roll the syringe gently between your hands until it feels warm. Opened bottles of insulin will keep in the refrigerator for up to 3 months.

Always check the insulin before you use it. Rapid- and short-acting insulin should look clear. There should be no cloudiness, little bits floating in the liquid, or change in color. Intermediate- and long-acting insulin should look cloudy, but you should not see any large clumps floating around. If you see any of these signs, throw out that bottle and open a new one.

Administration

Most kids get help from their parents when they first start getting shots. As you get older, you'll need less and less help. You and your parents can use this guide to make shots easier.

Site Rotation

In baseball, you have to touch all the bases to get a home run. No matter how far you hit the ball, jumping up and down at home base just doesn't cut it. Injection site rotation is like that. Giving yourself a shot in the exact same spot all the time gets to be no fun, real fast. That's because repeated shots in the same spot can cause fat deposits, called lipohypertrophy, which make your skin look lumpy.

These fat deposits can be prevented by regularly changing where you give your shots, or "site rotation." It doesn't mean you never re-use a site. It's more like running the bases; you move to various spots and eventually come back to where you started.

You can give yourself insulin shots pretty much wherever there's enough fat under the skin. The main areas are your stomach, your thighs, and the back of your upper arms. The stomach is generally most popular. It's easy to reach, and the insulin is absorbed from your stomach at a more consistent rate from shot to shot. Site rotation is different for every person. Here are the basics.

Each injection site should be about the size of a quarter. You only have to move about a finger-width away from your last shot each time you rotate. Of course, you have to remember where the last shot was!

Don't inject too close to moles or scars.
Some people rotate only within a certain body area, like the stomach. Others may use the stomach for morning injections and the thigh or some other area for evening injections.

Talk to your parents, doctor, or diabetes educator about the best option for you.
If you inject in the arm, use only the outer back area of the upper arm (where the most fat is). Otherwise, you run the risk of injecting into a muscle (ouch!).

If you inject in the thigh, stick to the top and the outside area. Stay away from your inner thighs-rubbing between the legs can make the injection site sore.

If you inject in the stomach, don't do it too near your belly button. The tissue there is tougher and makes the insulin absorption less predictable.

Sometimes, you can develop fat deposits even if you rotate sites. If the skin around where you inject starts to look funny, stop injecting there and let your parents know. They may decide that it's time for a quick visit to the doctor.

There are many different ways to keep track of site rotation. If it's always the same people giving you shots (you or your parents), then it's pretty simple. You write in your log book the body part where your last shot was given, and move to a new site (about an inch away) each time. Always going the same direction (like clockwise) around the area helps.

Another method is to use the same site for the insulin at a certain time of day. For example, breakfast means you use a leg, dinner is abdomen, and bedtime is arms. This also works well if you have different people helping you with your shots all the time. It's easier to track.

Syringe Safety/Sharps

Throwing out syringes is a little more complicated than pitching them in the nearest trash can. Needles can accidentally cut whoever takes out the trash or collects the garbage. To protect others, it's important to dispose of your syringes carefully.

An easy way to get rid of used syringes is to put them in a heavy-duty plastic or metal container with a tight-fitting lid. An empty laundry detergent container could do the trick. Or your parents could ask your doctor or diabetes educator what containers they recommend. If you go this route, put the used syringes in the container. You should also put your lancets in this container. When the container's full, put the lid on securely and throw the whole thing in the trash.

You can also buy a gadget that clips the needle off the syringe. Then it keeps the needles safely. It's called a safe-clip. Your parents can buy them at any pharmacy. Once the needle's off, you can safely toss the rest of the syringe into the trash. Whatever you do, don't try to clip needles off with scissors. That can send the needle flying across the room, and hurt you or others in the process.

When you're away from home, keep your used syringes and lancets until you can dispose of them properly. You might want to carry a metal or hard plastic pencil box to keep used syringes in until you get home.

Some areas of the country have special laws about how to throw out items like syringes. Ask your parents to call the local health department and find out about the laws where you live.

Troubleshooting

Nobody's perfect. Everyone runs into problems with their diabetes care once in a while. Here's what to do after you say "oops!"

Too much insulin: If you give yourself too much insulin, check your blood glucose about every two hours for the rest of the day. (If it happens before bed, set an alarm clock or ask your parents to wake you every two hours to test during the night.) If you remember how many extra units you injected, eat the right amount of food to cover the extra amount. Watch for symptoms of low blood glucose, and treat the symptoms promptly. Don't forget to tell your parents!

Too little insulin: If you know right away (within 1 hour) that you didn't get enough insulin, give yourself another shot with the rest of the dose. If don't realize it until later, watch your blood glucose and ketone levels for the rest of the day. (For more on ketone levels, click here) If your ketone level is OK, try to get some extra exercise. And let your parents know.

I'm leaking! Sometimes insulin can leak out after your shot. If this happens, check your blood glucose more often during the day. With your parents' help, you may need to adjust a later insulin dose. If you have this problem a lot, try one or all of the following tips to prevent leaking. For more suggestions, talk to your doctor.

• Push the plunger more slowly while injecting the insulin.
  
• Count to 5 or 10 after pushing in the plunger and before removing the needle.
  
• Check the angle of the needle. You may need to straighten it a little (to a 90° angle).
  
• Check the injection site for lumpiness. If it's lumpy, choose another site.

Ugh! I just don't feel well! Feeling woozy, moody, or tired for no apparent reason? First, check your blood glucose. (For a step-by-step guide to blood glucose checking, click here.) If it's too low (hypoglycemia), eat or drink something with carbs right away, like glucose tablets. When you start to feel better, eat a snack high in carbohydrates. If it's too high (hyperglycemia), you may want to plan some extra exercise. If your glucose is too high on a regular basis, talk to your parents about making some changes in your diabetes care. Also, keep in mind that getting sick, even with a cold, can make your blood glucose levels unpredictable. (For more on hypoglycemia, click here. For more hyperglycemia, click here. For more on sick days, click here.)

Pens, Pumps, and Injectors, Oh My!

Years ago, the only way to get insulin inside our bodies was to use big glass syringes that needed to be boiled (to sterilize them) after each use. These days we have more choices. You may use syringes, or you could be on a pump, or using any of several different options.

Syringes

You already know a lot about syringes. The majority of people who take insulin use a syringe - a shot - to deliver it. Why? Syringes work well, and are fast, easy, and cheap to use. Plus, they're easy to find in any drugstore in the United States or in other countries.

Pumps

Insulin pumps are little computerized insulin deliverers. You insert a short needle under the skin. The needle is connected to some tubing, which leads to the pump. This is called the infusion set.The pump is usually clipped to your waistband, like a beeper. You fill the pump with insulin (usually enough for two or three days). Then it drips a steady flow of insulin through the tubing, into the needle, and into your body. This steady flow is called your basal insulin dose. Before meals, you hit a button to tell the pump to delivery your mealtime dose. This is called your bolus. ( Think of it this way-bolus rhymes with "bonus" and a bolus dose is kind of a bonus dose you need to take to help your body turn your meal into energy.)

People who use pumps (some call themselves "pumpers") must change their infusion sets and use a new insertion site every few days. Pumpers can adjust their insulin dose easily by programming the pump. This helps them fit their insulin dose to what they do and eat each day. Pumpers have to check their blood glucose a lot. In fact, most pumpers check their blood glucose more often than they did when they used syringes.

What are the pros and cons of pumping? Well, most pumpers love the freedom they get from wearing a pump. Some say it's the closest you can get to not having diabetes. Some say that while you're wearing a pump you can almost forget that you have diabetes for a little while and let the pump take over.

On the minus side, pumps are very expensive (though your parents' health insurance might pay for some of it) and it takes some time and practice to learn how to use it correctly. Usually, your doctor will want you to be in really tight control before even considering putting you on the pump. And, you do have to find a place to carry your pump all the time: on your waistband, in a pocket, or pinned inside your clothes somewhere. But many people say its worth it.

Pens

Insulin pens look a lot like regular pens. Under their cap is a small needle instead of a ballpoint. Insulin pens are already filled with insulin. You just turn a dial to measure your dose. They're easier to take with you than bottles of insulin and syringes. Some people use syringes when they're home and pens when they're out. Pens do have one limitation, though. If you take a mix of insulins, you may not be able to find a pen that has that particular mixture.

Automatic Injectors

Some people have trouble actually pushing the syringe into their skin. If that sounds like you, try an automatic injector. Automatic injectors shoot the needle into you at the touch of a button. Some will even release the insulin automatically. Or you can push the plunger in yourself.

Jet Injectors

Right now, the jet injector is the only delivery system that doesn't involve needles. Instead, the insulin is shot out so fast that it goes through your skin like a liquid needle. What are the plusses and minuses? It takes more work to keep jet injectors clean than it does to toss out disposable syringes. Jet injectors can bruise some people. They're fairly expensive. So it's a good idea to talk to your doctor and to someone who's used an injector if you're thinking about getting one.

Changes

One more thing… Before you make any changes in your diabetes care, talk it over with your parents and your diabetes care team. Different people like different insulin delivery systems. You, your parents, and your team should decide together which is best for you.

Alternative Insulin Delivery Systems

Ever since insulin was first identified as the key to restoring normal glucose levels in people with diabetes, doctors and patients have been hoping for an alternative to insulin injections. Don't get us wrong; injecting insulin works pretty well. Many people have been able to lead relatively normal lives because of it. We have pretty advanced syringe and needle technology, and insulin pens and pumps have made getting insulin into the body even easier. Even so, the quest continues to find an alternative way of administering insulin.

Scientists have been working on a number of new advances in insulin administration.

Transdermal (through the skin)

Our skin is a remarkable organ. It's very good at letting almost nothing in, and letting just a few selected things out. Patches to help people quit smoking have made it seem almost easy to deliver a drug through the skin. In fact, nicotine is a small molecule that is readily absorbed into the skin. It only takes a tiny amount to have an effect on the body. Insulin on the other hand, is far too large to get through the skin without a lot of help. Trying to change that is tough.

Scientists have been working on patches using electrical currents, ultrasound waves, and chemicals to help transport insulin through the skin. Although some companies are hoping to develop products that could provide boluses of insulin through the skin for mealtime, any success for transdermal delivery is likely to come with basal delivery of relatively small amounts over time. Either way, we have a while to wait before insulin patches might be available in pharmacies.

Inhaled Insulin

Inhaled insulin is probably what you've been hearing the most about lately. Several products are being created in laboratories and have shown success at controlling blood glucose levels. Several of these are in phase 3 clinical trials (the final phase of testing before you can submit a device for FDA approval). Data has shown that inhaled insulin can work as well as injections of fast-acting insulin.

However, there are a few reasons to wonder about the long-term chance for success of inhaled insulin. First, you have to inhale a lot of insulin to get the amount your body needs. That's because only a small percentage of the inhaled insulin actually reaches the bloodstream and lowers blood glucose. So, a lot of it is "wasted." Because of that, the cost of inhaled insulin is fairly high because you have to pay for all that waste. Although the product developers are working to bring costs down, it's still likely to be fairly expensive.

Another problem with inhaled insulin - there are a lot of questions about the safety of delivering insulin to the lungs. After all, that's what you're doing when you inhale the insulin. You send it straight to the lungs. Many scientists think the lungs are a great place to deliver a drug because of the large surface area and ready absorption. The fact remains: that is not what lungs were designed to do. Although inhaling insulin has proven safe in short-term studies, the long-term safety remains a question. Some data suggest your lungs might not work as well after years of inhaling insulin.

But people who have tried inhaled insulin in research trials have really liked it. Companies are competing to get inhaled insulin on the market as soon as possible.

Buccal (through the mouth)

Buccal (BUCK-el) insulin is similar to inhaled insulin in some ways. Buccal, or delivery into the mouth, involves a device that delivers a spray of insulin like what you'd get out of a can of spray paint. Instead of going into the lungs, the insulin is absorbed in the lining at the back of the mouth and throat. The good part is that it avoids any problems from putting large amounts of insulin in the lungs. The problem is that even more of the insulin gets wasted.

Other than that, research shows that buccal insulin works about as well as inhaled insulin. One company plans to begin trials in people soon.

Oral

Okay, we've got shots, pumps, inhaled insulin, and insulin sprays. What's left? Pills. You probably already know that insulin taken as a pill is quickly broken down in the stomach, just like the food you eat. That makes it useless for lowering blood glucose levels.

So insulin can't be taken by itself in a pill form. Some scientists are trying to "package" insulin using special coatings, or by altering the insulin structure to get it through the stomach. Like inhaled insulin and insulin sprays, it's likely that a lot of the insulin will be wasted before it gets where it's going. It would probably also take a long time to start working after you swallowed the pill. Not much research has been done on insulin pills so far.

What does all this mean? The fact is, injected insulin (by syringe, pump, or pen) is a really effective way to lower blood glucose levels. Even if one of these insulin delivery methods does become available, it's possible people with diabetes (particularly people with type 1) will still be better able to control blood glucose with injections. For a while, anyway. Or, they may be able to use one of the other methods for their basal dose, but would still need injections for mealtimes and other bolus doses.