Type 2 Diabetes Insulin Therapy

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Most patients with diabetes type 2 eventually need insulin, due to progressive decline in the production of insulin by pancreatic beta cells. The question before every type 2 diabetes is when to start the insulin therapy and what is the appropriate insulin regime?

Anti-diabetic treatment is an evolving field with many new drugs: oral drugs, injectable analogues of glucagon-like peptide-1 (GLP1) and insulin formations.

Does a diabetes type 2 is really in need of insulin therapy?

Patients with type 2 diabetes on oral diabetes medication may need insulin therapy for a while when they are sick or have surgery. At these instances, diabetes pills may not work as expected in lowering your blood-glucose level, thus need insulin therapy.

If triple-therapy (diabetes treatment with three different classes of drugs) of maximum dosage does not produce a result (i.e., A1C of 7% or FBG of 130 mg/dl or 7.223 mmol/l), then you need to initiate insulin therapy along with one class of diabetes drug.

Most people with diabetes type 2 are having much fear, as they have advised to go on insulin. Even though there is numerous oral medications available in the market to treat diabetes type 2, insulin is the only one capable of not only lowering and even normalizes your blood glucose level.

In adequate management of diabetes for a long time may lead to diabetes complications such as nerve damage, diabetic eye problems, kidney failure, impotence, heart attack and stroke. Insulin therapy can prevent all these complications, so why still panic about insulin treatment. Start insulin treatment and keep yourself away from diabetes complications.

Fear of Needles - Now they are painless.

A person with type 2 diabetes normally has fear of needles. However, there are ultra-thin short needles are available to inject insulin under your skin. These needles are far less painful (almost painless) than a lancet (used to prick the skin for the blood test). They are painless to an extent that you may have to do visually check if you actually have pierced the skin and injected the insulin.

The important thing to make your injection painless is to choose a very thin needles, 30 or 31 gauge, and use  a shortest needle suitable for your body size, maybe 5/16 inch will do.

When should I start the insulin therapy?

At the early stages, patients can be able to manage with diabetes lifestyle modification and oral diabetes drug or injection of a GLP1 analogue, either alone or in combination. However, most patients at the later stages need insulin therapy, similar to diabetes type 1 for effective management of blood-glucose and for prevent diabetes complications.

If lifestyle changes along with a combination of diabetes oral medication failed to produce the expected result; that is A1C of less than 7%, or fasting blood-glucose level of less than 130mg/dl or 7.223 mmol/l.

Here are the three important situations that warrant insulin therapy for type 2 diabetes, they are:

  • When your blood-glucose is very high over 250 mg/dl (13.89 mmol/l), you need to begin insulin therapy. Once your diabetes is in control then you might stop insulin and can manage with oral medication.
  • If you are elderly, having heart diseases or kidney problems, then insulin therapy is considering as the safest diabetes treatment.
  • If cost of treatment is bothering, you can consider changing to insulin therapy, because it is the least expensive, effective and safest diabetes treatment available.
  • About one in three individuals with diabetes type 2 requires insulin therapy when their diabetes age crossed 10 to 15 years.

How do you motivate for insulin therapy?

In 1990's doctors ignored strict blood-glucose control and allowed their diabetes patients with an A1C of 12 % or higher by putting them in ineffective oral drugs. They put their patient on insulin only when their blood glucose became so high, which are perfectly not responding to oral medications. Before this time, diabetes can make enough irreversible damage. This leads to diabetes complications and numerous patients experiencing vision losses, amputations, kidney failures, heart attacks and strokes.

Most of the patients on insulin, feel better once their blood-glucose levels are under good control. This is a major motivation for initiating and adhering to insulin therapy. The anticipated reduction of risk for diabetic complications further enhances the compliance.

Insulin treatment in type 2 diabetes

Including basal insulin to the existing oral glucose-lowering medication can help achieve good glycemic control in the majority of diabetes type 2; however, few may require a twice-daily dosage. You can initiate your insulin therapy with either once-daily NPH insulin or a long-acting insulin analog. They should target fasting plasma glucose less than equal to 100 mg/dl (or 5.6 mmol/l) can safely achieve an A1C of 7.0%.

For several reasons, NPH insulin is considering as the preferred option. The relative benefit of the long-acting insulin analogs is limited to a reduction in (nocturnal) hypoglycemia.

The best timing for once-daily basal insulin injection is in the evening as compared with morning.

Combination therapy of insulin with metformin indeed produces a better glycemic control; fewer episodes of hypoglycemic and fewer weight gains than treatment with insulin alone.

What is the reasonable blood-glucose target?

Patients should try to achieve their best possible blood-glucose control with fewest adverse effects. Proper diet with a regular mealtime and predictable carbohydrate intake helps to avoid or minimize the two important insulin side effects (i.e., weight gain and hypoglycemia).

For most A1C of below 7% and FPG of 130 mg/dl or 7.223 mmol/l is considering as a reasonable target; a less stringent goal may be an A1C of less than 7.5% and FPG of 140 mg/dl or 7.779 mmol/l.

Several factors influence your decision in fixing the target; willingness to follow complex insulin treatment (basal-bolus therapy), lifestyle factors, how long you have diabetes, other coexisting medical conditions, hypoglycemia frequency, hypoglycemia awareness, age, life expectancy, and cost factors.

The target should be relaxed in difficult to treat individuals; those with frequent hypoglycemia, hypoglycemia unawareness, and widely fluctuating in blood-glucose levels in patients with advance stage of diabetes.

What are the drawbacks of insulin therapy in type 2 diabetes patients?

The two major drawbacks are increased hypoglycemia episodes and weight gain.

Intensive glucose-lowering therapy inevitably leads to an increased hypoglycemia episode. Hypoglycemia hampers stringent glycemic control and is considering as the restricting factor in diabetes control. In type 2 diabetes, the frequency of hypoglycemia is generally lower compared to type 1 diabetes. Type 2 diabetes is having protection against hypoglycemia by internally secreted insulin & glucagon, insulin resistance, higher glycemic thresholds for counter regulatory and symptomatic responses to hypoglycemia.

The two to four kg weight gain is associating with increased energy intake due to insulin therapy.

Learn how to dose correctly to avoid hypos

Extremely low blood glucose is called as hypoglycemia is always possible with insulin therapy. However, overtime you can learn to manage or change the insulin dosage with respect to your blood-glucose level, food intake, physical activity you undergo, and the symptoms you are experiencing.

Risk of hypoglycemia is high if you are in alcohol use, smoking, advanced age, intensive therapy, low body mass index, long diabetes duration, low-carb meals, fasting, delayed meals, vigorous exercise (without carb to compensate), and medical conditions (such as depression, sleep disorder, cerebrovascular disorder, liver failure, malnutrition, renal insufficiency, hypothyroidism).

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