Type 2 Diabetes Insulin Therapy

Submitted by Thiruvelan on Wed, 03/06/2013
Type 2 Diabetes Insulin Therapy

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 insulin therapy, and what is the appropriate insulin regime?

Anti-diabetic treatment is an evolving field with many new drugs: oral drugs, injectable analogs 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.

Triple-therapy means diabetes treatment with three different classes of drugs. The target numbers are A1C of 7% or FBG of 130 mg/dl or 7.223 mmol/l. If triple therapy with maximum dosage does not reach the target, 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 going on insulin.

Inadequate 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 has typically fear of needles. However, there are ultra-thin short needles 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 the extent that you may have to do visually check if you have pierced the skin and injected the insulin.

The critical thing to make your injection painless is to choose a thin needle of 30 or 31 gauge. And use the shortest needle suitable for your body size, maybe 5/16 inch will do.

When should I start 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 analog, 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 to 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 crucial 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 the 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 required insulin therapy when their diabetes age crossed 10 to 15 years.

How do you motivate for insulin therapy?

In the 1990s, 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 not responding to oral medications. Within this time, diabetes can do enough irreversible damage. It 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 reasonable control. It is a significant motivation for initiating and adhering to insulin therapy. The anticipated reduction of risk for diabetic complications further enhances compliance.

Insulin treatment in type 2 diabetes

Including basal insulin to the existing oral glucose-lowering medication can help achieve reasonable 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 hypoglycemia 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 significant 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 an advanced stage of diabetes.

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

The two major drawbacks of insulin therapy in type 2 diabetes 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. And also due to insulin resistance, higher glycemic thresholds for counterregulatory 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 hypoglycemia. The hypoglycemic episode is always possible with insulin therapy. However, over time, you can learn to manage or change the insulin dosage concerning;

  • 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 or, delayed meals,
  • vigorous exercise (without carb to compensate), and
  • medical conditions such as depression, sleep disorder, cerebrovascular disorder, liver failure, malnutrition, renal insufficiency, and hypothyroidism.