Are You Overdue for Insulin?

Diabetes Spectrum
Volume 13 Number 4, 2000, Page 223

Diabetes Spectrum / Patient Information

Are You Overdue for Insulin?

Matthew C. Riddle, MD, and Diane M. Karl, MD

Adapted with permission from Riddle MC, Karl DM: Are you overdue for insulin? Diabetes Forecast Aug. 1999

Did you develop diabetes as an adult?
Do you take pills to control your blood glucose?
Despite your best efforts, do you still have blood glucose tests over 140 mg/dl all of the time?
Are your hemoglobin A_1c (HbA_1c) tests higher than 8%?

If so, you might be overdue for insulin.

But wait—how can a person who gets diabetes as an adult need insulin? Isn't this the kind of diabetes called non-insulin-dependent diabetes?
That's what this disorder was called in the past, but that name is now history. The new name for the kind of diabetes you have is type 2 diabetes. One reason for the change was clear evidence that many people with this disorder really do need insulin.

Then why haven't I needed insulin before now?
When you were first diagnosed, you may have been able to control your blood glucose by losing a little weight (just 5–10 pounds can make a difference), eating a healthy diet, and upping your activity level.

If your diabetes pills
aren't doing the job,
you may be overdue
for insulin.

But even with your best efforts, before long, you probably needed treatment with prescription drugs. There are several types of pills that can help you control your blood glucose levels. If one of them isn't working well by itself, you may be able to use two or even three together.

However, type 2 diabetes gets harder to control as the years pass. Your body's ability to make insulin declines over time. Eventually, you will probably need to take injections of insulin.

How can I tell if I need insulin?
An HbA_1c test lets you know your average blood glucose level over the past 2–3 months. Its normal range is usually 4–6%. If your HbA_1c is between 6 and 7%, you're doing very well.

But recent studies have shown that having HbA_1c levels above 7% puts you at greater risk for complications. The United Kingdom Prospective Diabetes Study (UKPDS) tracked about 4,000 people with type 2 diabetes. It showed that an HbA1c increase of 1% corresponded to a greater risk of eye, nerve, and kidney complications.

The American Diabetes Association recommends an HbA_1c of 7% as a target for control and 8% as a signal to step up treatment. If your HbA_1c stays over 8% on pills, you should consider insulin.

I have lots of friends and relatives with type 2 diabetes. Why don't they use insulin?
To answer that, we need to take a hard look at what we've thought and done in the past. No one likes the idea of injecting insulin. Most people think it hurts, takes a lot of time, and causes low blood glucose (hypoglycemia). Insulin can be a daily reminder that you have a serious illness. And it may bring bad memories of a friend or relative who developed complications.

Those may be your perceptions, but here are the facts:

The new syringes and pen-injectors are small, easy to handle, and almost painless. They take very little skill to use.
Low blood glucose is much less common in people with type 2 diabetes than in those with type 1 diabetes.
Needing insulin doesn't mean that the pills have failed entirely, just that insulin should be added.
People who are very ill with diabetes probably got that way because of years of high blood glucose before they started insulin. Had they used insulin earlier, they might have been spared some problems.

Another reason so many people with type 2 diabetes have not used insulin is that, before the UKPDS showed us otherwise, some doctors worried that insulin may cause low blood glucose or contribute to heart disease in people with type 2 diabetes. And, finally, some health insurance organizations have not supported the use of insulin for type 2 diabetes.

But the UKPDS showed that insulin is safe and effective for people with type 2 diabetes, and other studies have shown that a new way of starting insulin may be simpler and cheaper.

What is the new way to start on insulin?
It goes like this: When your HbA_1c stays over 8% despite other treatments, you and your doctor add insulin to your regimen. You start with a very low dose. You may be asked to take intermediate-acting insulin (called NPH) at bedtime. Or you'll take a mix of NPH and short-acting regular insulin before dinner. Depending on your doctor's advice, you can mix the insulins yourself or buy premixed 70/30, which contains 70% NPH and 30% regular insulin. A new long-acting insulin called glargine will be another alternative when it becomes available. You might continue to take one or more diabetes pills.

You check your blood glucose levels as directed by your doctor or diabetes educator and record the results. These will help your doctor decide when and how much to increase the insulin dose. As you slowly increase the evening dose under your doctor's guidance, you will see your before-breakfast glucose levels and the 24-hour average gradually come under control.

Taking two or three injections a day may be necessary later, but there's no hurry in most cases.

Demand the Best
There's strong agreement that we can't ignore poor blood glucose control any longer. If you have type 2 diabetes and pills aren't doing the job, you may be overdue for insulin. Talk to your doctor. Talk to other people who have started insulin. If your health plan makes starting on insulin difficult, tell your consumer representative you won't settle for second-best treatment. You deserve the best that medicine has to offer to limit your risk of diabetic complications.

Permission is granted to reproduce this material for nonprofit educational purposes. Written permission is required for all other purposes. 11/00

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