Medicines to treat diabetes have come a long way since insulin was discovered in the 1920s.

Whether your child takes insulin or pills or both to control diabetes, it's important to follow the diabetes management plan prescribed by the diabetes health care team to avoid problems and reduce the risk of side effects.

Insulin

Insulin is a hormone that allows sugar, or glucose, to get into the body's cells to be used for energy. All people with type 1 diabetes and many people with type 2 diabetes need to take insulin every day.

The overall goal of treatment with insulin (and other diabetes medications) is to achieve the best match possible between the amounts of insulin given and the person's individual needs for insulin throughout the day and night. In this way, blood sugar levels can be kept as close to normal as possible to help avoid both short- and long-term problems from diabetes.

Treatment plans are designed around the pattern of insulin normally supplied by the pancreas throughout the day in someone without diabetes. In general, this involves providing a fairly steady "background" level of insulin to control blood sugar levels between meals and overnight, along with doses of rapid- or short-acting insulin to handle the fast rises in blood sugar that occur with meals.

The types of insulin used and the amount taken each day will vary depending on your child's diabetes management plan. Some plans include two injections each day, whereas others may involve several more injections or the use of an insulin pump to keep blood sugar levels under control.

The diabetes health care team will help you determine the best treatment approach.

Insulin Types

There are several kinds of insulin, and each can be described by its:

• onset (how long it takes to start working)
• peak (when it works the hardest to lower blood sugar)
• duration (how long it keeps working)

The table outlines the types of insulin and how they work. Remember that the actual time it takes for insulin to work, when it peaks, and how long it lasts will vary from person to person, and even from day to day as the body's need for insulin may change. That's why it's important to check your child's blood sugar levels frequently — you can achieve better blood sugar control by adapting the amounts of insulin given to meet your child's needs.

Insulin Type	Onset	Peak	Duration	How It Works
rapid-acting	10-15 minutes	30-90 minutes	4 hours	This type is used mainly to handle glucose absorbed when eating a meal. Usually taken right before eating, it can also be given just after eating. Looks clear and can be mixed with intermediate-acting insulin in the same syringe.
short-acting	30-60 minutes	2-4 hours	6-9 hours	Also used to handle glucose absorbed when eating a meal, but lasts longer than rapid-acting insulin. Should be taken 30 minutes before eating. Looks clear and can be mixed with intermediate-acting insulin in the same syringe.
intermediate-acting	1-4 hours	3-14 hours	10-24 hours	This type works to control glucose between meals and during the night. Looks cloudy or clear and can be mixed with rapid- and short-acting insulin in same syringe.
long-acting	1-2 hours	does not peak	18-24 hours	This type works to control glucose between meals and during the night. Looks cloudy and can't be mixed with other insulin in the same syringe.

Insulin Reactions

You can't "turn off" insulin once it's been injected — it's going to work no matter what — so it's important to time and match the amounts of insulin given with the body's needs throughout the day and night. Following a meal plan from day to day and getting regular physical activity will help make it easier for your child to achieve good control of his or her diabetes.

Despite the best efforts of parents, caregivers, health care providers, and kids with diabetes themselves, blood sugar levels cannot be perfectly controlled. In all kids with diabetes, there will be times when the amount of insulin taken is too much or too little for the body's needs and the blood sugar level will be too high or too low.

One of the most common problems that occur in people who take insulin is low blood sugar, or hypoglycemia. While hypoglycemia can occur at any time in people who take insulin, it's more likely to happen under certain conditions; for example, if the person eats less or exercises more than usual.

Hypoglycemia is also more likely in the first few weeks or months after someone develops type 1 diabetes. During this period — sometimes called a diabetic "honeymoon" — a child's pancreas may temporarily recover the ability to make insulin. If the insulin dose is not appropriately reduced, the combination of the child's own insulin and the injected insulin may be too much for the body, driving blood sugar levels down too low.

With the shift to using very pure, human insulin preparations to treat diabetes in the United States, allergic reactions to insulin and most other side effects have become uncommon. In some kids with diabetes, however, repeated insulin injections can cause a thickening or lumpiness of the fatty tissue beneath the skin, called lipodystrophy or lipohypertrophy. It's more likely to occur if injections are repeatedly given in the same area instead of rotating injection sites as recommended. Usually this is only a cosmetic problem; however, in some cases, insulin injected in areas of skin with lipodystrophy may not be absorbed into the bloodstream properly. This may make the insulin dose take longer than usual to work.

Tips for Using Insulin

The acids and digestive juices in the stomach and intestines would break down and destroy insulin if it was swallowed, so it can't be taken as a pill. For now, the only way to get insulin into the body is by injection with a needle or with an insulin pump.

Before giving an insulin injection, always check the bottle to make sure you're giving the right type of insulin and that it hasn't expired. You should also inspect the bottle for any changes to the insulin — for example, you should not use insulin that has particles or crystals floating in it.

Here are some guidelines on storing bottled insulin (check manufacturer's instructions for storage of insulin pens):

• Unopened bottles of insulin should be stored in the refrigerator. Discard insulin if it has been frozen or is past the expiration date on the bottle.
• Opened bottles of insulin can be stored in the refrigerator or kept at room temperature.
• Be careful not to let the vial become overheated by leaving it in direct sunlight or in a car on a sunny or hot day. For travel or outdoor activities, it's a good idea to store insulin as you would perishable food — but do not freeze it.
• Depending on the type of insulin, opened bottles of insulin should be discarded after 4 to 6 weeks (check manufacturer's instructions), whether they have been kept refrigerated or not.

When in doubt, call the diabetes health care team or your pharmacist for advice and guidance.

Pills and Tablets Used to Treat Diabetes

For some kids and teens with type 2 diabetes, taking diabetes pills or tablets (doctors sometimes call these oral medications) is an important part of keeping blood sugar levels under control. These diabetes medicines, in combination with a healthy diet and regular exercise, can help the body of a person with type 2 diabetes produce more insulin or help the body use the insulin it does make more effectively. These medications are not helpful for people with type 1 diabetes because their bodies have lost the ability to make insulin.

Blood sugar levels in kids with type 2 diabetes can sometimes be controlled with pills (in combination with diet and exercise) that help the child's insulin work normally again. But some kids with type 2 will also need insulin to help keep their blood glucose under control.

Diabetes pills are not a form of insulin. They help the body use insulin more effectively. This helps reduce the amount of glucose that appears in the bloodstream between meals and at night, which helps keep blood sugar levels under control. Diabetes pills can also assist with weight loss and help improve cholesterol and triglyceride levels, which tend to be abnormal in people with type 2 diabetes.

Common side effects of diabetes pills include loss of appetite, taste changes, abdominal pain, and nausea, vomiting, and diarrhea. Most of these side effects are temporary, however, and they will lessen or disappear after a few weeks as the person continues to take the medication. Stomach upset is also less likely to occur if the drug is taken with food.

In adults, a rare side effect of taking diabetes pills is lactic acidosis, a very serious condition caused by a buildup of lactic acid in the blood. Lactic acidosis can cause symptoms like rapid breathing, muscle pain, cool and clammy skin, sweet-smelling breath, nausea, and vomiting. This problem has mostly occurred in elderly people who have other medical problems in addition to their diabetes.

It's unclear whether this rare side effect poses a risk for otherwise healthy kids with diabetes taking the drug, but until this is known, the precautions recommended for adults should be followed. Because in adults lactic acidosis is more likely to occur when a person is ill, diabetes pills should be stopped when your child is sick or has the flu.

In addition, lactic acidosis can be triggered in people who take diabetes pills and drink alcohol, so make sure your child understands that mixing alcohol and diabetes pills could be dangerous.

If your child develops any side effects while taking diabetes pills, tell your doctor or diabetes health care team.

Glucagon

Children with diabetes can have extremely low blood sugar levels that can make them become confused or experience seizures or loss of consciousness. In these cases, a medicine called glucagon needs to be given. Glucagon, a hormone given via injection, raises blood sugar levels quickly (usually within 10 to 15 minutes).

Make sure that adult family members, school staff, and other caregivers have access to glucagon and know how and when to give your child a glucagon injection. Anyone responsible for supervising your child should also know when to call 911 for low blood sugar emergencies.

Taking medicines as prescribed is extremely important, and kids and teens with diabetes who take theirs properly can significantly reduce the risk of diabetes problems. If you have questions about diabetes medicines, talk to your doctor or diabetes health care team.

Reviewed by: Steven Dowshen, MD
Date reviewed: March 2012