Who should use insulin? When and How?

[Super_sally888]

I prepared the following write-up as a reference and introduction for when and how insulin should be started:-

This write-up is for general information and should not replace the advice of your Dr. Please working closely with your Dr. for appropriate treatment of diabetes.

Insulin should be used by any person who is not consistently achieving target blood sugar goals with lifestyle measures and 1 – 2 oral medications. Persons with Type 1 or Type 1.5 (both of which are autoimmune) should use insulin either alone or in combination with appropriate insulin sensitisers (usually metformin) if there is insulin resistance.

So what should blood sugar goals be? These are very individual, but should be formulated with consideration that truly normal blood sugars in people who are non-diabetic would consist of fasting blood sugars typically in the low 80s, and post eating blood sugars that rarely if ever exceed 100 (and then not by much). A truly non-diabetic HbA1c is in the 4s. (Bernstein says 4.3 – 4.6).

Consider also that diabetic complications (eye, circulatory, nervous system damage) are known to start occurring when blood sugars are consistently over 100, and the rate of complications increase markedly with blood sugars over 140. Complications are also known to increase exponentially with every 1% rise in HbA1c over 5.0 .

I personally believe that optimal target blood sugars should be those recommended for pregnancy:- 80 – 120 (target fasting < 95, 1.5 – 2 hrs post eating < 120), and never over 140. An optimal HBa1c in the low to mid 5 range. This can be a pretty tough target to achieve and takes the right tools, knowledge, and skills; taking a combination of lifestyle measures (diet and exercise) and medication (correct timing, carb counting, etc). As a cautionary note though, such “tight” control may not be appropriate for everyone. However, ADA and other agencies do recommend that HbA1c below 6.5 should be targeted for most people.

Insulin should then be used to keep blood sugars as close as possible to non-diabetic blood sugars, but while also avoiding low blood sugar.

Insulin should also be used with careful and frequent testing to determine blood sugar patterns and to ensure that highs are treated appropriately and lows are avoided.

When starting insulin, there are 3 options:-
1. Add a long acting insulin (once or twice a day) to normalize base insulin levels. This is particularly appropriate if fasting blood sugars are high, but post eating levels are ‘normal’.
2. Add a short acting insulin before meals (or before selected meals) to prevent post meal highs. This is appropriate if fasting insulin is normal but blood sugars go high after eating. It may also be used only for selected meals, if there are only some meals / foods that cause problems.
3. Add both a long acting and a short acting insulin.

Initial doses may be very low (even 1/2 to 1 unit is still a valid dose) in cases where insulin is started early while pancreas is still working to some extent. This approach supports the pancreas so it can work comfortably within its remaining capacity (and hopefully will stay working for longer), while preventing the havoc that continually high blood sugars can bring.

When adjusting insulin, start low and go slow. Test frequently, particularly when making changes / taking up exercise and work closely with your Dr. or qualified diabetes educator.

Diabetes doesn’t cause complications! High Blood Sugar (from uncontrolled diabetes) causes complications.

[Super_sally888]

Bump

[Super_sally888]

Hi Diabetes86,

I absolutely agree with you.

This means that Sulfonurea drugs should not be used at all.

From my reading - state of the art approach is that if metformin doesn't work, insulin should be started.

The thing is that with oral meds there is no way to adjust or correct blood sugars when they are high (aside from exercise) and all the patient can really do is drink lots of water and hope and pray that things come down soon and don't do too much damage in the meantime.  

But once you add insulin to the equation you have a tool that really allows you to control and manage blood sugar and keep things at or close to normal.

[diabetes86]

Sounds good however I dont think ANY ONE should use drugs that FORCE the pancreas to make more insulin.

I like your last paragraph best.