Last updated: Oct 11, 2010
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If you have type 2 diabetes, you have more options to control blood sugar than ever before, including no less than six classes of oral medication and an injectable drug based on lizard venom, Byetta.



Still, just because one certain drug—insulin—has been around for nearly a century doesn't mean that it should be considered as less useful or less important than other "more modern" medications. In fact, insulin's tried-and-true safety record and ironclad ability to lower blood sugar in all patients make some doctors more likely to recommend it sooner rather than later in some people with type 2 diabetes.

"Insulin is an appropriate choice at any point," says John Buse, MD, PhD, director of the Diabetes Care Center at the University of North Carolina School of Medicine, in Chapel Hill. "You can start it as the first therapy for diabetes. In some countries, such as Germany, many doctors advocate that as the best approach."
 

Insulin therapy has gotten easier over the years, making the drug less painful and simple to use than in the past.

But even if this therapy doesn't seem suitable for you right now, don't be afraid to use it if your doctor thinks it can help control your blood sugar in the future. Elevated blood sugar basically acts as a poison in the body, so if other treatments aren't working, you'll need to do whatever it takes to get it into the safe zone.

Most fears about insulin are unwarranted, or at least outdated, says Dr. Buse.

 
 


Why insulin?
About 90% to 95% of people with diabetes have type 2 diabetes, while 5% to 10% have type 1. Of adults with either type 1 or 2 diabetes, only 14% use insulin, 13% use insulin and oral medication, 57% take oral medication only, and 16% control blood sugar with diet and exercise alone, according to the CDC.

Unlike type 1 diabetes, type 2 is sometimes defined by the development of insulin resistance—a loss of sensitivity to the hormone—which causes the insulin-producing cells of the pancreas to work hard to overcome the resistance, and over time, stop functioning at all.

Most people with this type of diabetes eventually stop making natural insulin at some point. (As opposed to early on in the course of the disease, when insulin resistance can cause the pancreas to produce higher-than-normal levels of insulin.)

People with type 2 diabetes can benefit from insulin therapy because it can lower blood sugar by overcoming insulin resistance or supplement their own natural production of insulin—if there is any. It can be used alone or in combination with oral medication to get blood sugar down.

Sometimes oral medications are sufficient to lower blood sugar, but they may not help everyone or may stop working over time, notes Robert Rizza, MD, professor of medicine and executive dean of research at the Mayo Clinic, in Rochester, Minn.

"Nearly everyone with type 2 diabetes will eventually need to start taking insulin," says Dr. Rizza.

However, this can depend on how young you were when you were diagnosed with type 2, how well controlled your blood sugar has been over time, or the progression of the condition over time.

The younger a person is when he or she gets diabetes, the more likely that milestone will be reached, Dr. Buse speculates. Someone diagnosed in their 60s, for example, may only have a one-in-three chance of ever needing external insulin.

 
 


How safe is insulin?
When blood sugar or hemoglobin A1C tests—a measure of blood sugar control over the previous three months—rise despite oral medications, it is probably time to look for further help.

"Insulin has been around for almost 90 years and we robustly understand its issues," Dr. Buse notes. "On the other hand, there's actually some fear of the unknown with the newer oral therapies." Most oral medications have a very safe track record, but not all. For example, the U.S. Food and Drug Administration recently restricted Avandia due to a link with heart attacks and strokes.

But insulin has its pros and cons too. It can trigger weight gain, which is not uncommon with diabetes treatments that improve the body's ability to absorb and process blood sugar.

Lifestyle changes and blood sugar monitoring, for example, can usually compensate for any effects on weight. And insulin can cause blood sugar to go too low, a condition known as hypoglycemia. However, this is uncommon, and usually treatable with a source of sugar, such as glucose tablets.

One thing insulin is not, however, is painful. While that may have been true 90 years ago, insulin needles are much smaller and thinner nowadays.

"As a middle-aged man, if you hold the needle up to the face, it's a little hard to even see the width of the needle," says Dr. Buse. "They are very polished and lubricated. It's basically a painless experience—definitely less painful than pricking your finger to get a blood sugar result, which most patients already do at least daily."

There is even evidence to suggest that early insulin therapy can increase the body's natural insulin secretion, although it is not yet clear if this actually benefits patients over the long term.

 
 


Going off insulin
And many people also assume that starting insulin therapy means a lifetime of shots. This is not always true. "Lots of people come off insulin after getting the religion," Dr. Buse says, referring to the improvements in insulin sensitivity sparked by weight loss and exercise.

If a patient starts off overweight and sedentary, his or her body might require 100 units of insulin to keep the blood sugar controlled, offers Dr. Rizza. "Maybe their pancreas can secrete 80, so they need to take insulin to top it off," he explains. "But if they lose weight and their requirement subsequently drops to 60 units, they may be able to stop using insulin."

The example of a bariatric surgery patient is even more dramatic, he adds. After losing a substantial amount of weight with the procedure, he or she often no longer needs the outside help of the hormone.

Some patients also hold the misconception that insulin injections lead to an increased risk of diabetic complications. "This, too, results from the old days when we didn't treat the condition as intensely and doctors only put people on insulin after they had recognized problems brewing," Dr. Buse explains.

"We now know that insulin is as, or arguably more, effective than any other therapy as far as preventing the disabling complications of diabetes," he adds. "Insulin doesn't cause complications; it prevents them."