By Martin Greenfield, M.D.
The three words that bring fear to most diabetic patients are: “You need insulin”. Unfortunately, this is something that should be accepted as not only necessary, but also as preventative of most of the complications that develop when one has diabetes. Most of us have had to deal with someone in our family who has had diabetes and have seen the devastating complications associated with it. Most patients equate the use of insulin with long-term complications when in fact it is the lack of diabetic control that causes these issues, not the use of insulin. Most often it is the fear of starting insulin therapy that leads to a delay in important control and the development of these complications.
The truth is that diabetes is a life-long, progressive disease in which the underlying cause of diabetes is a lack of insulin. By the time it is diagnosed, there is already a 50% reduction in the amount of insulin that is being produced. Most non-insulin therapy today, regardless of whether it is by the oral or injected, is designed to preserve and maintain insulin production from the patient’s pancreas. The bottom line is that, in almost all type 2, non-insulin dependent diabetics, eventually there will not be enough insulin production to maintain normal sugar control. This will result in blood sugar rising regardless of what medications are being offered to that patient. One of the ways to tract effective treatment is a blood test called Hemoglobin A1c (HgbA1c). This simple blood test evaluates the average control of a patient’s sugars over the last three months. The higher the level, the greater the average sugars. Once the HgbA1c is above 7, that patient is at a significantly higher risk for complications related to diabetes. These complications include eye, kidney, neurologic and circulatory problems. All therapy is aimed at reducing or preventing these complications.
When the patient fails to keep their HgbA1c below 7 on non-insulin treatment, we must advise the patient the he or she must go on insulin to bring the blood sugars back to normal. Today, the use of insulin is extraordinarily simple. We no longer need to use vials and syringes. We can use insulin pens with such small needles that there is actually no pain involved in the injection. Most patients, who initiate insulin therapy and receive their first injection, invariably state, “I didn’t even feel that.”
Very often, at the initiation of insulin therapy, we can use a single injection of long-acting insulin. We can also maintain some or all of the oral agents the patient is already on and use insulin to supplement treatment and reach the goal of a HgbA1c less than 7. When we accomplish this, we can often prevent the development of the previously mentioned complications. Sometimes we need to add a short-acting insulin before meals if we cannot achieve our goals with the one shot a day regimen. At that point, we can decrease or discontinue some or all of the patient’s oral medications.
As discussed, insulin should not be feared, but should be accepted as a natural therapy for type 2 diabetes. It can be used regardless of whether the patient has any other underlying disease states or is on any other medications. There are no contraindications or drug interactions and it is safe and effective.
I would hope that the above explanation goes a long way to prevent patients from feeling that being told that they need insulin is not a threat, but a way of giving them a longer, complication free life. If your physician states, “you need insulin”, please don’t panic and discuss your concerns with them. You may be surprised that your fears are unfounded.