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Treatment of Diabetes



Points to take note are:

Remember Diabetes is an Interplay of ‘Insulin Resistance‘, raising the needs of Insulin and on the other hand “Inability of B cells” to cope up with the demands; together called as Insulin Resistance and Secretory defect ;unless these two happen , Diabetes can not take hold in an individual, therefore, any treatment has to address these two basic problems.

1. Secretory defects in response to raised demands are best declared by Fasting Blood Glucose levels whereas Insulin resistance causing severely increased demands is best seen as peaking blood glucose levels, in response to a normal or glucose challenge meals. In Pre-diabetes state both may present separately or together but in a full blown Diabetic both of these are present together ,as a rule 

2. No two patients are same and no single treatment can be exactly workable for two different patients even if they are twins! In other words- No medicine is going to give exactly same effects or side effects in two different individuals

3. Every patient passes from different stages of disease and may fluctuate from higher levels to lower and vice versa

4. Over the years, Insulin producing B cells in every Pancreas go down in numbers and productivity in fact Diabetes declares on the scene when almost 50% of B cells are either non functional or dead ! Remaining B cells keep losing their Insulin making powers with the passage of time In fact over 4 to 11 % people or may be more, every year, keep losing B cells completely. At this point you need to have Insulin support from Exogenous sources!

5. The rate of loss of B cells, though genetically determined, can be slowed for the sure, by Good weight and Diet management at Pre-Diabetes state and when Diabetes sets in, with a good control of Diabetes in addition to these two factors helps in maintaining good health of your B cells.

6. Also note that in a Diabetic Individual, the mechanisms of slowly Increasing Insulin needs due to Insulin Resistance, after meals or Post- prandial rise in Glucose, followed by B cells “giving up” with Insulin secretion and then secretory capacities going down and down, all happen over the years and all these are stage wise progressions with many modifiable variable like Body weight, Meal size and composition, total calories per day, physical activity and stress, intercurrent diseases and medicines’ intake, are few important ones.

7. A progressive disease like this ,needs to be matched with progressive and scientific improvisations in the treatment plans; therefore in a single individual at different times and situations we must have different strategies and plans with different Diet, Exercise and Medicinal formulations/combinations and this clearly means a treatment once prescribed ,to successfully control your blood glucose, may not remain efficient for long and sooner or later all this must be redesigned and restructured once again. Here lies the importance of Regular periodic monitoring and consultations.

8. Metabolic Memory: Another Important fact-more aggressive you are in maintaining your Glucose levels to near normal, more benefits you will get from the treatment , an early and appropriate control is remembered by the Metabolic system in your body and rewards are sure similarly an undisciplined approach with bad controls in earlier phase ,are also similarly remembered by your system and damage control is less rewarding.

*** For all Indian Individuals above 35 yrs of Age it should be mandatory to Test for Fasting Blood Glucose and for Post-Prandial Glucose at TWO hrs after 75 Gs of Glucose load and if found normal then it should be repeated at every 2 yrs! AND Also all overweight(85th percentile weight and above) adolescents of above 10 yrs of age, should be subjected to active screening , because with “soon arriving” puberty and hormonal changes/surges ,this age group will not give you enough time for interventions while progressing from Pre-Diabetes to Diabetes, in fact within few months the damage and progress to Diabetes may be complete and the Intervention phase for Pre-diabetes gets totally missed /lost in the process !

Adolescent Overweight /Obese Children are SPECIAL HIGH RISK CATEGORY: 
Moreover an adolescent if develops Diabetes will pose a bigger problem for the society. Let me explain you how. Let us assume that complications take 10 years to take roots into the system and another 10 yrs. to cripple and killyou.If Diabetes comes at 15 yrs of age then by the age of 25 when you are getting married and settling down in a job you start facing the music from Diabetes related complications, you are afraid of facing your wife because of Erection difficulty or getting transient ischemic attack while on Honeymoon! and by the age of 35 yrs when your career graph is in full swing, your children are gearing up for greater postures, you are settling down with issues like property ,assets and are consolidating your final positioning in life , and then suddenly you are getting your first heart attack! which lands you in ICU !You may or may not survive, survival thereafter may be just symbolic and for the name sake, all energies,plans,dreams and ambitions going down the drain ! Just think what kind of life we are giving to our children

 

                             

                         Treatment of Diabetes - Before We Start….

Points to take note areRemember Diabetes is an Interplay of  
‘Insulin Resistance‘, raising the needs of Insulin and on the other hand “Inability of B cells” to cope up with the demands; together called as Insulin Resistance and Secretory defect ;unless these two happen , Diabetes can not take hold in an individual, therefore, any treatment has to address these two basic problems.

 

1.)Secretory defects in response to raised demands are best declared by Fasting Blood Glucose levels whereas Insulin resistance causing severely increased demands is best seen as peaking blood glucose levels, in response to a normal or glucose challenge meals.
In Pre-diabetes state both may present separately or together but in a full blown Diabetic both of these are present together ,as a rule

2.) No two patients are same and no single treatment can be exactly workable for two different patients even if they are twins! In other words- No medicine is going to give exactly same effects or side effects in two different individuals

3.) Every patient passes from different stages of disease and may fluctuate from higher levels to lower and vice versa.

4.) Over the years, Insulin producing B cells in every Pancreas go down in numbers and productivity in fact Diabetes declares on the scene when almost 50% of B cells are either non functional or dead !
Remaining B cells keep losing their Insulin making powers with the passage of time
In fact over 4 to 11 % people or may be more, every year, keep losing B cells completely. At this point you need to have Insulin support from Exogenous sources!

5.) The rate of loss of B cells, though genetically determined, can be slowed for the sure, by Good weight and Diet management at Pre-Diabetes state and when Diabetes sets in, with a good control of Diabetes in addition to these two factors helps in maintaining good health of your B cells.

6.) Also note that in a Diabetic Individual, the mechanisms of slowly Increasing Insulin needs due to Insulin Resistance, after meals or Post- prandial rise in Glucose, followed by B cells “giving up” with Insulin secretion and then secretory capacities going down and down, all happen over the years and all these are stage wise progressions with many modifiable variable like Body weight, Meal size and composition, total calories per day, physical activity and stress, intercurrent diseases and medicines’ intake, are few important ones.

7.) A progressive disease like this ,needs to be matched with progressive and scientific improvisations in the treatment plans; therefore in a single individual at different times and situations we must have different strategies and plans with different Diet, Exercise and Medicinal formulations/combinations and this clearly means a treatment once prescribed ,to successfully control your blood glucose, may not remain efficient for long and sooner or later all this must be redesigned and restructured once again. 
Here lies the importance of Regular periodic monitoring and consultations.

8.) Metabolic Memory: Another Important fact-more aggressive you are in maintaining your Glucose levels to near normal, more benefits you will get from the treatment , an early and appropriate control is remembered by the Metabolic system in your body and rewards are sure similarly an undisciplined approach with bad controls in earlier phase ,are also similarly remembered by your system and damage control is less rewarding.

***For all Indian Individuals above 35 yrs of Age it should be mandatory to Test for Fasting Blood Glucose and for Post-Prandial Glucose at TWO hrs after 75 Gs of Glucose load and if found normal then it should be repeated at every 2 yrs!And once the age crosses 40 years ,testing should be annually.

AND Also all  overweight(85th percentile weight and above) adolescents of above 10 yrs of age, should  be subjected to active screening , because with “soon arriving” puberty and hormonal changes/surges ,this age group will not give you  enough time for interventions while progressing from Pre-Diabetes to Diabetes, in fact within few months the damage and progress to Diabetes may  be complete and the Intervention phase for Pre-diabetes gets totally missed /lost in the process !

Adolescent Overweight /Obese Children are SPECIAL HIGH RISK CATEGORY:
Moreover an adolescent if develops Diabetes will pose a bigger problem for the society & the family. Let me explain you how. Let us assume that complications take 10 years to develop into the system and another 10 yrs. to cripple you. If Diabetes comes at 15 yrs of age, then by the age of 25 years, when you are getting married and settling down in a job, you start facing the music from Diabetes related complications, for example 
you are afraid of facing your wife because of Erection difficulty or getting transient ischemic attack while on Honeymoon! By the age of 35 yrs when your career graph is in full swing, your children are gearing up for higher classes, you are settling down with issues like property ,assets and are consolidating your final positioning in life , 
and then suddenly you get your first heart attack! which lands you in ICU ! You may or may not survive or survival thereafter may be just symbolic.

All energies,plans,dreams and ambitions go down the drain !

Just think what kind of life we are giving to our children.
Dear all , I am really very serious about these issues.

Chosing a Drug-Considerations

 

As we have already pointed in earlier pages that Diabetes Type 1 occurs due to total destruction of Insulin producing B cells and since no insulin is being produced by the body, survival is only possible if enough Insulin is supplied from outside the body.

Insulin itself is a protein and if taken by Mouth, our Intestines will simply digest it like any other protein in food and no insulin will be reaching into the Blood. Therefore, to ensure that intact Insulin reaches into the Blood Stream It has to be given as Injection.

 

For Type 1 Diabetes Insulin is the only answer 
But in Type 2 Diabetes we have seen that defect is Insufficient OR Inefficient Insulin,
for this twin defect state we have some more answers available additional to Insulin.

New Approaches to Managing Diabetes Type 2

The convergence of a more complete understanding of the physiologic characteristics of  type 2 diabetes with the availability of new therapeutic agents that target the multiple metabolic abnormalities of diabetes has led to new and innovative therapeutic strategies.

In simple terms either you increase the availability of Insulin or make better use of whatever Insulin is available; these two remain the central theme for any treatment plan.
Agents That Target “Insulin Resistance
(NOTE : Weight Reduction, Exercise, Diet planning are the most efficient and cost effective measures and always a part of all treatment plans)

Oral agents that specifically target insulin resistance include 
1.The biguanides (metformin) and 
2. TZDs or the thiazolidinediones e.g: pioglitazone and rosiglitazone
These agents act on insulin resistance by a different mechanism of action and provide beneficial effects beyond glucose control. Although its mechanism of action is not completely clear, metformin seems to lower fasting blood glucose by improving peripheral insulin sensitivity, reducing hepatic and renal glucose production, and slowing gastrointestinal absorption of glucose.

It does not stimulate insulin secretion or cause Hypoglycemia or weight gain..There is evidence that metformin has beneficial effects on lipids(fats), blood pressure, and pro-coagulant factors associated with the macrovascular morbidities of diabetes.

 The thiazolidinediones have been shown to improve glucose control, decrease peripheral insulin resistance, and favorably affect the cardiovascular risk factors of type 2 diabetes (ie, lipid profiles, coagulation and fibrinolysis, and vascular events).

Their tendency to cause edema(water retention leading to swollen feet)and weight gain-the commonest side-effects, may limit their use in some patients.TZDs ,but with expert hands and vigilant Physician these drugs remain an important tool for glucose control.TZDs as they are also called in short can also be a cause of fractures specially in post-menopausal females i.e.in females after cessation of monthly cycles.

But the biggest problem came after many years of use of Rosiglitazone,which by some researchers was reported to be associated with increased risk of Heart Attacks!For this very reason the drug has now been banned across the globe!

Now we are left with only Pioglitazone which again is being linked to Urinary Bladder Cancers but is being carefully watched!

If used wisely Glitazones are useful drugs. Remember every drug may not suit to everyone!

Agents That "Stimulate Insulin Secretion"-Secretagogues

Sulfonylureas, such as glyburide, glipizide, gliclazide and glimepiride are the agents most commonly used to treat patients with type 2diabetes. Sulfonylureas increase insulin secretion, regardless of the level of circulating glucose.

That’s why if these drugs are taken more then the prescribed dose or a meal is missed or delayed beyond your normal timings you may get abnormal reductions in your Blood Glucose known as Hypoglycemia & SMBG .Which can be potentially life threatening
Glitinides:Two recently introduced short-acting insulinotropic agents, repaglinide and nateglinide, are insulin secretagogues with a relatively shorter onset and duration of action than sulfonylureas.

These agents are specifically indicated to control postprandial glucose excursions and have a low risk for Hypoglycemia & SMBG. Patients are instructed to take these agents  before meals, which allows for more flexibility in varying meal patterns without compromising glycemic control.

Agents That Slow Intestinal Absorption of Carbohydrates

The alpha-glucosidase inhibitors, acarbose and miglitol, reduce postprandial glycemia by slowing intestinal glucose absorptionwithout increasing weight gain or the incidence of hypoglycemic events.However, these agents only have a modest effect onreducing blood glucose levels and their use is limited by gastrointestinal side effects.

 

WHAT IS NEW in Diabetes Treatment

 

INCRETINS & INCRETIN MIMETICS(Sensible Secretagogues with many more actions !):
Several newly available or emerging treatments in development for people with type 2 diabetes are based on new approaches to treating the disease. 
Incretin mimetics are glucagon-like peptide-1 (GLP-1) agonists.GLP-I ia an important product from the Intestines which improves Insulin production and secretion in normal persons and is grossly deficeinet in Diabetics.This hormone improve Beta Cells’ survival also. Exenatide is the one such GLP-1 agonist currently available in India as Byetta is approved by the U.S. Food and Drug Administration (FDA). Another GLP-1 agonist Victoza or liraglutide, which is a GLP-1 analog is once a day therapy and is also available now.Both are Injecctions.first one Twice a day and the second -Once a Day.That means GLP-1 which is deficient in Diabetics,it's action is replicated by these two molecules. Now in normal conditions GLP-1 once produced is destroyed in the body by an enzyme called DPP4 . Therefore the other mean by which you can increase the levels of GLP-1 in Diabetics could be by stopping it's destruction by this enzyme DPP4.Thus came the reason for the development of yet another froup of Drugs-DPP4 Inhibitors. 
Dipeptidyl peptidase-IV (DPP-IV) antagonists inhibit the breakdown of GLP-1 by blocking the action of the DPP-IV enzyme and therefore raise GLP-1 (and GIP) levels 2- to 3-fold. These agents have been called incretin enhancersSitagliptin was the first of the DPP-IV inhibitors to have received FDA approval.Saxagliptin has now also been apprioved. Sitagliptin,Saxagliptin,Vildagliptin and Linagliptin are FOUR DPP !V inhibitors presently available in India. Other DPP-IV inhibitors are also in development.These will soon arrive in India.Alogliptin is surely going to be with us soon!
Rimonabant was a selective CB-1(cannabinoid-1) receptor blocker,addition of rimonabant to a hypocaloric diet resulted in sustained weight loss and improvements in cardiometabolic risk factors, including waist circumference, high-density lipoprotein (HDL)-cholesterol, triglycerides, glucose and measures of insulin resistance. Rimonabant has been withdrawn (all over the globe) on account of serious Neurological and Psychiatric problems .Research is going on ,however , for safer and better molecules fo CB1 pathway modulation.

Pramlintide, a synthetic analog of another islet hormone, amylin, represents a fifth class of therapy. Pramlintide reduces gastric emptying, suppresses glucagon and enhances satiety, and is FDA-approved for use as an adjunct to meal time insulin in people with type 1 and type 2 diabetes who have failed to achieve glycemic control, despite optimal insulin therapy.
Finally, the first inhaled insulin was recently approved by the FDA.(Has been withdrawn fron market by the company after it’s launch.
Taken together, all of these new therapeutic options -- whether they are available now or in the near future -- have created a new sense of excitement and optimism in the field of diabetes care.

LATEST DRUGS:Dapagliflozin/Canagliflozin are drugs which will not allow kidneys to hold back Glucose.Whatever Glucose will be filtered out will be allowed to flow into the Urine and will get wasted. Blood Glucose levels will therefore get reduced.In natural conditionsKidneys tend to preserve Glucose.

Bromocriptin and Cloesevelam are two more drugs which I personally find not of much use though have been approved for Diabetes treatment!

There are a few other developments and drugs which are not relevant as far as day to day Diabetes control is concerned.


MONITORING TARGETS: TREATMENT TARGETS TO BE FIXED ARE:(Non Pregnant Adults)

Fasting Blood Glucose                             < 110 mg %
Postprandial at 2H after meals               < 140 mg%
Random at any time of the Day               < 140 mg% 
Yes we are indeed TIGHT on glucose!
HbA1c                                                       < 6.5%
Total Cholesterol                                      < 180 mg  %
HDL-Cholesterol(Good one)                    > 40 mg   % in males
&                                                                > 50 mg   % in females
Triglycerides                                             < 150 mg %
LDL-Cholesterol                                        < 100 mg %

And do not care what your lab gives you as normal reference range remember only these above given levels !
BUT if your patient is fragile,elderly ,living alone, has poor reflexes, already has serious Heart Problems,Cancer or has seriously compromised quality of life,then PLEASE DO NOT TRY TO BE VERY RIGID WITH THE GLUCOSE CONTROLS.

Monitoring Your Health and Treatment

 

At the beginning –Get the following done (Minimum):-

  • Fasting and PP-after meals- Blood Glucose.
  • Please note that if you are on treatment then glucose has to be tested with your regular dose of medicines and /or Insulin.Because the idea is to see and check how your treatmwent is working for you!
  • CBC, Kidney Function with Electrolytes, Liver Function Tests, Lipid Profile,HbA1c,Thyroid Function Test,complete Urine Examination.

 

Afterwards-take time and make a habbit of all the following things:

Daily:

->Take your Body weight with minimum of clothes
->Recapitulate what misadventures you did yesterday with meals etc
->Examine your feet(sloes with mirror)
->Have a close look of your teeth, skin, nails, eyes
->Plan your exercise and activity
->Consider your days’ meal plan and provisions for any outdoor meals!
->See that you have adequate and appropriate supply of your medicines
->Make a mental chart of your days’ final schedule!
->Look if any self monitoring is to be done with your glucometer

Weekly :

->Look at your weight chart-identify trends
->Measure your BP
->Look at your blood glucose readings over the past 6-7 days
->Attend to your feet, nails, skin, exercise etc at leisure on your weekly holiday
->Track your doctors’ prescriptions, review your treatment plan, plan your next visit

Monthly:

->Consult your diabetologist
->Get an fasting and PP Blood Glucose done at your neighborhood lab and cross check with    your glucometer,
->Check if Lipids,Creatinine,TSH,HbA1c,Urine Protein/Albumin,SGPT/SGPT or any other test in    the past which needs to be re-evaluated and revalidated-as per your doctors’ advice

Insulin - Things You Should Know

What is insulin?

Insulin is a hormone produced by the pancreas to control the amount of glucose (sugar) in the blood. In people who have diabetes, the pancreas does not produce any or enough insulin, or body is unable to effectively use the insulin it does produce. As a result, glucose builds up in the bloodstream
Insulin and type 1 diabetes
People with type 1 diabetes do not naturally produce any insulin. As a result, they need to take insulin every day.
Insulin and type 2 diabetes
If you have type 2 diabetes, you may be able to keep your blood glucose levels in your target range through healthy eating, physical activity and by taking diabetes medication. Ask your doctor to refer you to a registered dietitian to learn about healthy eating. You should follow PG Medical Guidelines for Healthy Eating, which includes limiting the amount of carbohydrates and fats you eat. THERE IS NO SUCH THING AS SPECIAL DIABETIC DIET!

(Contact Dr. Lalwani's Clinic for diet counseling)

Type 2 diabetes is a progressive condition and over the years most people (in fact all-if they survice long enough !) with type 2 diabetes will need to use insulin to properly manage blood glucose. If your body is not producing enough despite drugs being taken then you will have to take Insulin from "Outside"a! as simple as that!

The most important thing is to manage your diabetes and prevent complications. If you’re nervous about learning to inject insulin, take heart – even young children can master this skill with practice. As well, modern injection devices, such as insulin pens, are virtually painless.

Types of insulin-Available Now…..

When insulin was first made available for people with diabetes, there was only one kind: short-acting insulin, which required several injections a day. Today, many different types of insulins are available, offering more flexibility in the number and timing of injections you may need and making it easier for you to maintain your target blood glucose levels.

A)Conventional Insulins:
     Regular,  NPH,  Premixed 30/70 & now best of the Insulins as:

B)Rapid- and Long-Acting Insulin Analogues

New rapid-acting insulin analogues have been designed to mimic the normal physiologic insulin response that occurs in nondiabetics. Three insulin analogues, insulin Lispro ,Glulisine and Aspart, show improved glycemic control over human insulin in both type 1 and type 2 disease.

In particular, analogues improve postprandial blood(PP) glucose control with a lower risk of Hypoglycemia. Analogs work rapidly after injection, within 5-15 minutes, peak at 60-90 minutes, and last in body for about 4 hours. Human regular insulin(older ones), by contrast, begins to act 30 minutes after injection, peaks at 2-4 hours, and lasts 6-8 hours or longer.

In conjunction with a long-acting insulin, such as insulin glargine ,detemir or NPH insulin(this last one is practically no more used), the rapid-acting analogues provide tight control of blood glucose levels throughout the day. NPH insulin peaks at about 4-6 hours and lasts for about10-16 hours, whereas insulin glargine has a nearly peakless profile and lasts from more than 20 hours.

Now a days still longer acting analogs are being talked about like "Degludec Insulin".Idea is to have once or twice a week injections of a Basal Insulin!This will reach us soon! Degludec when used daily can be injected at anytime of the day unrelated to meals and still gives a good control!

Evidence from clinical studies indicates that more aggressive early treatment is clearly a way to reduce the many complications associated with diabetes and to improve the quality of life of people with this disease.

You may need one to four injections a day for optimal management of your blood glucose.
If you take insulin, you need to monitor your blood glucose levels regularly. Regular monitoring is the best way to keep your blood glucose levels in their target range. Regular checks also give you important information about how your blood glucose levels vary during the day, how much insulin you need and if you’re on track in managing your diabetes.

When prescribing an insulin regimen, your doctor will consider several factors, including your treatment goals, age, lifestyle, meal plan, general health, risk of low blood glucose (Hypoglycemia & need for monitoring and testing sugars is always considered), and your financial circumstances. There is no 'one size fits all' plan.

At PG Medical Center Your healthcare team will talk with you about the best insulin plan to meet your needs. Remember, it will take time to fine-tune your insulin regimen, which may change over time depending on life events (such as a major illness) and changes in your lifestyle (such as a new exercise plan).

Talk to your doctor or diabetes educator if you have any questions or concerns about your insulin regimen, or if you aren’t sure how to handle certain situations, such as adjusting your insulin when travelling.

 

Most Popular and convenient Insulin Delivery system: Insulin Pen

 

 

An insulin pen (or just "pen") is an insulin delivery system that

 

  1. generally looks like a large pen,
  2. uses an insulin cartridge rather than a vial, and
  3. uses disposable needles.

 

Pens are the predominant insulin delivery system in most of the world. Pens in India are avaibable from Novo Nordisk, Eli Lilly, Wockhardt and Aventis. 
Some pens use replaceable insulin cartridges, and some pens use a non-replaceable cartridge and are disposed of after use. All pens use replaceable needles. Most pens use special pen needles (see discussion below), which can be extremely short and thin.

 

Pens With Replaceable Cartridges

 

Pens with replaceable cartridges are made by Novo Nordisk, Eli Lilly, Wockhardt and Aventis.

Insulin cartridges for pens come in 3.0 ml sizes. These 3.0 ml contain 300 units of Insulin. Different Insulins & different combinations are available from all the four manufacturers.

 

Prefilled Pens

 

Pens that come with a prefilled insulin cartridge are thrown away when the insulin is used up. Prefilled pens are sold by insulin makers Eli Lilly, Novo Nordisk, and Aventis. Lilly only sells prefilled pens which come with a variety of Lilly insulins, including Humalog, Regular, NPH, and various mixes, including Humalog mixes. Novo Nordisk sells both prefilled pens and pens that take replaceable insulin cartridges with Novomix and other Novo Nordisk insulins. Novo Aspart is available as Novo Rapid. Aventis sells prefilled pens with Lantus. Lantus is available as vials, prefilled pens & replaceable cartridges.Levemir is Insulin Detemir from Novo. Apidra is rapid analog from Aventis

Prefilled pens using pre-mixed insulin are usually marketed for use by people with type 2 diabetes. The fixed ratio of insulins does not provide the flexibility needed to accommodate varying food and exercise.

Oral Insulin * Every one is waiting! 
Oral insulin is at the very advanced development stage 
Oral insulin is a reality: it is simply a matter of when. Insulin injections are extremely harrowing for many diabetics. 
Alternative insulin delivery methods
Many alternative delivery systems, although they work to some extent, leave the insulin broken down by digestive juices, usually too much for it to be of significant use to the body. 
Insulin like any protein will get digested in stomach.Only if it is made undigestible,it can be absorbed into the blood stream!
Through Nose, mouth and lungs
Nasal delivery issues
Nasal delivery into the upper airway presents severe problems, primarily that the transport system is too convoluted and ineffective.Would require massive, expensive quantities of insulin to reach the target area.
Insulin delivery via lungs
Insulin into the lungs is a promising area: the insulin can be directly absorbed into the bloodstream through the thin walls of the lung. “Insulin Technosphere” holds promise!

Scientists are trying hard to develop methods through which they can make Insulin reach your Blood, bypassing your Digestive system !