American Diabetes Association Guide to Insulin and Type 2 Diabetes. Marie McCarren
STEP IT UP
When should insulin be added to your diabetes plan? The American Diabetes Association, with the European Association for the Study of Diabetes, offers guidelines based on expert opinion in Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy (published in 2006). While this is not a list of rules for how doctors “should” treat every person with type 2 diabetes, it is what works for many people. These guidelines are described on Step 1.
Step 1: Make Lifestyle Changes and Take Metformin
Lifestyle changes are very important at all stages of the disease. Losing some excess weight (even just 10–20 pounds) and being more active will reduce insulin resistance and lower the risks of heart attack and stroke.
Metformin is a good first medication for most people newly diagnosed with diabetes. Metformin doses should be raised to the maximum effective dose over one to two months.
Step 2: Add Another Medication
If A1C is still not at the goal of less than 7%, another medication is needed. But which one?
When Metformin Is Not Enough
Option 1: Add insulin. This is the most effective option. No matter how high your A1C, you can get it down to your goal if you use enough insulin.
Option 2: Add a sulfonylurea. This is the least expensive option but carries the risk of hypoglycemia (low blood glucose level).
Option 3: Add a glitazone. The advantage is that there is no risk of hypoglycemia.
Step 3: Start or Intensify an Insulin Plan
If lifestyle changes, metformin, and a second medication do not get you to your blood glucose goals, these experts recommend using insulin. If you’re already on insulin, you and your health care team should tweak the plan by raising your doses of insulin, using more injections per day, or trying different insulins.
What about adding a third oral medication before moving to insulin? This is not recommended by these experts. If your A1C is more than 8% when you’re on two oral medications, a third oral medication will probably not get you to the goal of less than 7%. If your A1C is less than 8%, a third oral medication may get you to less than 7%, but it will be more expensive than adding insulin.
SUBJECT: WHEN IS IT TIME FOR INSULIN?
FROM: zs
Just curious for those of you who have diabetes and used pills for a while and then were put on insulin. What caused the dr. to put you on insulin? Did you get to a certain number and the dr. felt it was time for insulin?
FROM: VV
I have been diabetic for 18 years now. Over those years I have had to increase doses, change meds, and add meds in order to keep my numbers under control. This past summer I had an episode where my numbers were no longer responsive to the oral meds. I was eating around 15–20 carbs per meal just to keep my numbers down to the high 200s and low 300s. We tried all kinds of new medicines, but you would think I was trying to treat my diabetes with Tylenol for all the good they did. That is when the decision was made to put me on insulin.
Honestly, as much as I did not want to give myself injections several times a day, being put on insulin was a relief. I felt so bad walking around all that time with my numbers so high. How good I feel now far outweighs any inconvenience or the occasional discomfort from a needle. Hope this helps answer your question.
FROM: EB
I have been on Lantus insulin since August. It has made all the difference in the world to my diabetes management. I had never been able to get my numbers under 140, no matter how carefully I ate or how much I exercised (not even when I was teaching backpacking to Girl Scouts). This had become so discouraging that I had really quit trying to manage my diabetes. (I have been diabetic for over 20 years.) I had even quit doing any exercise due to arthritis. When I went on the Lantus, I also went back to eating right, and once I felt better I joined the YMCA and began swimming again. Now my numbers hover around 100, and I find I am much more likely to do the things I should.
FROM: jj
I am 49, and have been a type 2 diabetic for over 10 years. I maintained it with diet and exercise and lost over 75 pounds. I had to add oral medications within 5 years. Then last September came along
No matter what I did, my sugar levels did not want to come down in the normal range. Everyone’s blood chemistry is different, but eventually your body quits producing insulin to the point of requiring that you add insulin to your regime along with the oral meds. It really has made a huge difference in the way I feel and act. I use an insulin pen with the new micro needles—it is SOOO easy.
FROM: CN
I was diagnosed type 2 about 17 years ago. Started controlling it with diet and exercise, then as time progressed, went to oral medication. About two years ago, my fasting was getting close to 150, and my doctor seemed to think that was OK. I didn’t. We had a heart to heart talk and I started Lantus. One year later, I added Humalog before meals. I brought up the subject of an insulin pump with my doctor and September of last year, became a pumper.
“BUT I FEEL FINE!”
Not having enough insulin in your system is like having termites. You don’t notice when termites first infest your house. You don’t see piles of sawdust. The corner of your house doesn’t sag. It’s only when they’ve been there a long time that you see a sign. In a panic, you call a termite inspector. His probe sinks right into a stud. “Too bad you didn’t call us 5 or 10 years ago,” he says. “We could have treated your house and saved you all this damage.”
When you don’t have enough insulin, your blood glucose levels are too high. That causes damage that is unseen and goes unnoticed. Over time, you’ll begin to notice the damage. Years of high blood glucose can lead to vision loss, kidney problems, and amputation.
Don’t go by how you feel. Look to your blood glucose levels.
Blood glucose levels: Normal, nondiabetic (A1C less than 6%).
How you feel: No symptoms.
What’s happening in your body: No ill effects.
Blood glucose levels: A bit above normal.
How you feel: No symptoms.
What’s happening in your body: Some damage to cells and blood vessels.
Blood glucose levels: Well above normal.
How you feel: Mild symptoms that you might not realize are from high glucose levels. You lack energy. You’re irritable. You might think, “It’s just age” or “It’s stress.”
What’s happening in your body: More damage. It takes fewer years to develop the signs of eye, kidney, and nerve damage.
Blood glucose levels: Very high.
How you feel: More obvious symptoms. You’re getting up at night to urinate. You may be so tired and moody that your family is thinking, “Mid-life crisis? Depression?”
What’s happening in your body: Laying the groundwork for major complications and shorter lifespan.
SUBJECT: INSULIN MAKES ME FEEL GOOD
FROM: Hml
I have been dealing with diabetes for about 20 years now. After trying and trying to keep control with oral medications,