MY DOCTOR USED THE "I" WORD - SHOULD I CONSIDER INSULIN?

Ryan Bradley, ND, MPH March 2008

Despite efforts to exercise frequently, eat a healthful diet of nutritious, low-glycemic index foods, and taking medication and supplementation, many people with Type 2 diabetes remain poorly controlled. Although pharmaceutical companies would like you to believe otherwise, there are relatively few medications that are effective at controlling blood glucose for longer than a few years; most medications in the prime of their action still only reduce hemoglobin A1c by 1-2%, and this effect may not last. In addition, no medication is without side effects, and recent reports suggest some medications may actually increase the complications we are trying to prevent through the use of the medications in the first place. This precarious balancing act - of glucose reduction balanced with safety and tolerability - leads to a dilemma for patients and doctors alike. Suffice it to say, I think all doctors, regardless of their credentialing, would like to be able to provide patients with treatment options that are well tolerated, improve function, increase lifespan, and are easy to take. Unfortunately neither you nor I have a portfolio of these treatments available. In this article I will present my thoughts on when insulin therapy is the best option for the treatment of diabetes.

Few patients are eager to use insulin to control their blood sugar (at least until they give it a try). Although oral insulin is in development (inhaled insulin has been approved by the FDA and since removed due to low prescribing rates by physicians), insulin doses still require self-injection and frequent blood sugar checks to ensure safety. It is understandable to wish to avoid finger sticks and needles. As a result, insulin has a certain taboo about it - almost as though the battle feels lost. I would suggest that the battle is over, but not lost - rather you have won. Let me explain…

Diabetes is fundamentally a condition created and continued by concurrent insulin resistance and insulin deficiency. The statistics suggest that upon diagnosis of Type 2 diabetes, the pancreas’s insulin producing capacity is 35% of normal; Type 2 diabetes does not routinely occur overnight (some forms of diabetes, like latent autoimmune diabetes and perhaps virally-initiated Type 1 diabetes do develop rather quickly) but rather is a continuation of cellular processes that have been ailing for some time. The chicken vs. the egg argument applies here: does insulin resistance cause an increased need for insulin, causing the pancreas to fail? Or does reduced insulin lead to higher blood glucose leading to oxidative stress causing damage to insulin receptors? The answer is debated heatedly by diabetes researchers and physicians alike, but once the cycle begins it certainly perpetuates. The result at the time of diabetes diagnosis is the same: a known reduced capacity for the pancreas to produce and secrete insulin in response to food. So it makes sense medically and logically to replace the missing hormone. In other conditions of reduced hormone production, thyroid disease for example, patients are typically thrilled to be able to replace the missing hormone - and as a result feel better, have reduced pain, increased energy and improvements in lab values like cholesterol. So what’s different about insulin?

What’s The Big Deal?

The obvious answer is the needles - both the lancets needed to check blood sugars and the needles required to give insulin. Another contribution to this issue is the perceived inconvenience of taking insulin. Allow me a few words to convince you otherwise.

Let’s start with the lancets. Improved technology in glucometers now allows patients to use a very small drop of blood to check their sugars - which means finer lancets and less pain for you. If you are still using a glucometer that requires a slice rather than a fine poke, then ask you doctor for an improved meter. Most medical insurance will cover periodic meter replacement, and some clinics even provide free meters (the meter companies make more money on the test strips!). Finally, this is an area where brand names are best; generic lancets from the pharmacy may be cheaper to purchase, but are larger gauge than brand name lancets and therefore more painful.

Now onto the insulin needles. Similarly to the lancets, insulin syringes are now available with very fine needles and insulin pen systems use even finer needles. Since insulin is given right under the skin - and not into the muscle - with new needles there is very little, if any, pain. Admittedly injection sites do need to be rotated to avoid bruising and reduce the risk of infection. So although there is some potential discomfort from using injectable insulin, the pain can be minimized by 1. Selecting the right meter and lancets 2. Using an insulin pen system and 3. Rotating injection sites. An important point is that the pain from the injection goes away rather quickly (I recognize sore fingers take longer to recover- so use the smallest lancets possible!). For any of you who have experienced the chronic nausea that can accompany metformin, or the swelling and weight gain from medications like rosiglitazone, the brief pain of insulin may be a welcomed exchange! Similarly if insulin can help prevent painful complications like neuropathy (which it can, based on the findings of the Diabetes Control and Complications Trial), short term pain can translate into less pain in the long term.

Now let’s discuss the inconvenience. I do not have diabetes, but I do spend a lot of time with people with diabetes and their families and I can empathize with how tiring it must be to be thinking constantly about what to eat, not to eat, when to check, when to inject, when to take medications, etc. However I would suggest the short-term inconvenience of insulin can translate into a lot less inconvenience down the road. Similarly to my argument on the pain of insulin, the inconvenience of measuring and injecting sure beats the inconvenience of daily dialysis, hospitalization or more doctor visits due to worsening health from poor control.

What’s the Difference Between Insulins?

Insulins are broadly categorized based on how quickly they begin action; the categorization is long-acting, short-acting and rapid-acting. The reason for choosing one insulin versus another is best left up to your doctor (who has the best understanding of the history of your diabetes, its expected progression...and your willingness to follow instructions!), however some general rules apply.

At every moment, regardless of how long it has been since you have eaten, there is some insulin in your bloodstream; depending on the balance between your insulin production capacity and your level of sensitivity to insulin, this amount of background, or basal, insulin may be a lot or may be very little. The other time we need insulin is after we eat because, as you likely know by now, insulin is necessary to move the sugar (really carbohydrate, not just refined sugar because I know you are never eating refined sugar) you just absorbed from your meal - now in your bloodstream - out of your blood and into the tissues that need fuel for energy. So therefore, you really have need for a background, or basal insulin, and a meal-time insulin.

You can probably already guess which insulins are used when, but for clarity, long-acting insulins are used to replace the background (basal) insulin, while the short-acting or rapid-acting insulins are used to replace the insulin needed around the time of your meals. Whether a short - or rapid - acting insulin is right for your is really best left to your doctor.

How Do I Know Which Insulin I Need?

Background or basal insulins are typically used when your fasting blood sugar remains too high even when your blood sugar after meals is well-controlled. This usually implies more insulin resistance in the liver, which helps control your fasting sugar levels, and a reduced insulin production capacity. Basal insulins can be used alone, or with a short-acting insulin depending on your insulin production capacity and your control.

Shorter-acting insulins are used to correct elevations in your blood sugar after you eat; usually these insulins are used together with basal insulins, however sometimes people do have isolated elevation in their blood sugar after meals even though their fasting sugars are to target.

Pre-mixed insulins are also available and these combine longer-acting and shorter-acting insulins into one syringe in order to reduce the number of daily injections. While theoretically this sounds great, pre-mixed insulins are more difficult to titrate and using them often leads to periods of time with too much or too little insulin. However, pre-mixed insulins can be a good choice for people who simply cannot stand more injections or for those who have a very consistent meal pattern.

When I Recommend Insulin

I prefer using as many other options as possible (although not as many drugs as possible) to keep blood sugar at a healthy level before I recommend insulin. However, I do think using insulin is a safer approach than using every medication possible all at the same time in order to try to avoid insulin. Insulin is a hormone we all have and need, and therefore I consider it a more “natural” treatment than many of the medications available (as many of you may have heard, there is currently a big discussion in the world of diabetes care as to the best A1c goal for people with diabetes to get to- and the best approach using medications for how to get there; I hope to write an article soon on this topic, but we all need a little more information before I can form a clear opinion).

So I recommend insulin in the following situations:

For patients who are already following a healthy lifestyle, are on metformin and a medcation like glyburide or glipizide and are still not well controlled
For patients who have persistent elevations in their fasting blood sugars despite using oral medications and appropriate supplementation
For patients who have persistent elevations in their blood sugars after meals despite eating a low glycemic load diet and using appropriate oral medications and supplements
For all patients who have an hemoglobin A1c greater than 10% at the time of diagnosis despite healthy lifestyle choices (most medications will only lower A1c 1-2%, so even with many medications it is very difficult to achieve control when blood sugars are this high at diagnosis)
For patients who grow tired and frustrated of following a very restrictive diet to control their blood sugar

Interestingly, for many people, a low dose of a background, or basal, insulin can make all the difference in their quality of life. In my observations, for someone who follows a low glycemic index/load diet, a single nighttime injection of insulin can provide a little more flexibility and freedom in their day-to-day life allowing less stress if good food choices are not available or an exercise session gets missed. In many cases, a little bit of insulin to replace the background insulin can do wonders for reducing blood sugar after meals. The extra insulin seems to help the pancreas preserve some of the insulin it makes for use with meals, rather than struggling to keep up with the demand for more background insulin and the insulin needed for meals.

Insulin Should Not Replace a Healthy Lifestyle

Unfortunately, when some people begin using insulin they find it controls their blood sugar so well, they are tempted to use more insulin to compensate for less healthy food choices or use more insulin to compensate for a lack of exercise. While this flexibility is an advantage of insulin every now and then, it should not be used to enable complacency about the importance of a healthy lifestyle. Insulin resistance can continue to develop even when using injectable insulin - requiring higher and higher doses of insulin. This trend should be avoided at all costs as it becomes very difficult for your doctors to help you control your blood sugar when this happens - and it is not healthy for you either!

How Have I Won the Battle?

So you are probably still scratching your head a little regarding how exactly using insulin translates into your “winning the battle”. In my mind you have won the battle because you have chosen to replace a hormone that your body desperately needs (and may be the true cause of your diabetes), rather than filling your body with medications your body has never made and that may cause more harm than good. In addition, you add flexibility in your diet and exercise while still ensuring your blood glucose is well controlled. Also, a little bit of extra insulin can be extremely effective at giving your pancreas a rest, helping your sugar stay controlled throughout the day. Finally, insulin can actually help you feel better by providing the signal necessary to get that sugar out of your blood, into your muscle tissue to be used more normally.

In Health - Ryan Bradley, ND, MPH