Would Insulin Be A Good Choice?   (March 9, 2010)

I recently received an e-mail from a patient, describing their multiple diabetes medications now and previously, and ending with the question: Would insulin be a good choice?

The simple answer is "Yes" -- insulin is always a good choice for treating type 2 diabetes (and of course, it's mandatory for treating type 1 diabetes). But for varying reasons, some patient-related, and some physician-related, it's frequently the last choice after messing around with numerous combinations of numerous diabetes pills and Byetta (and soon, Victoza).

Why is insulin a good choice?

First and most important, it always works. The dose that's needed may be small, or large, but with time and careful adjustment based on home glucose levels, sooner or later a dose that "works" to control the blood glucose levels will be found.

Second, the side-effect profile is well-known. Insulin can cause hypoglycemia, and insulin can cause weight gain. Very rarely, insulin can cause local reactions at the injection site, and very very rarely, it can cause other allergic phenomenon. But it doesn't cause liver, pancreas, or other organ damage as other diabetes medications might.

The hypoglycemia associated with insulin use is more a matter of insulin overdosing than anything else, and with reasonable attention to meals, exercise, and with frequent blood glucose monitoring, the hypoglycemia will be minimal. Simple guidelines, such as checking blood glucose levels before and after exercise, and before driving an automobile, will help assure that hypoglycemia doesn't result in bad things.

Insulin-associated weight gain is always an issue. Insulin is, after all, a storage hormone: it takes extra calories that are floating around the bloodstream in the form of glucose, and stores them away, rather than allowing the extra calories to be wasted in the urine. So folks starting insulin therapy frequently gain weight, unless they are paying close attention to their meal plan and avoiding excess calories. (Of course, for an underweight person with type 1 diabetes, weight gain with insulin is a very good idea!)

Third, insulin is relatively inexpensive compared to brand-name diabetes pills. Yes, the older diabetes pills that are available as generics (such as metformin) are even cheaper, but the general rule is that new brand-name pills for any condition always are the most expensive therapy around -- so if your physician has had you on combinations of brand-name pills, it's a huge hit to the wallet!

Why do physicians and patients dawdle on starting insulin? I suspect that there are differing reasons for different folks. The inconvenience of giving injections might be one, but with the insulin pen injector devices, it's not that big a hassle. The concern about hypoglycemia, or weight gain, may discourage both patient and physician.

The fear of the pain of the needle-poke is always a factor, until the patient is coaxed into giving the first injection -- then the universal response is that the pain of finger-poking is much more than that of the needle poke.

It's sad that so many patients go for some many years with elevated A1C levels, and with elevated risk of the nasty complications of diabetes, rather than start insulin therapy. So, if you have type 2 diabetes, and your A1C levels remain elevated despite fiddling with your diabetes program, I'll remind you: insulin is always a good choice for treating diabetes.