— Anne, Minnesota For someone to go back to oral diabetes medicines after starting insulin, the pancreas must be able to produce enough insulin to maintain normal sugar levels. That being said, there are several instances in which insulin injections may be stopped. Here are a few:
- In some individuals who have had untreated or poorly controlled diabetes for several weeks to months, glucose levels are high enough to be directly toxic to the pancreas. This means that the pancreas has not completely lost its ability to produce the critical level of insulin, but it does not work properly as a result of high glucose levels. In this instance, injected insulin can be used for several days or weeks to reduce glucose and help the pancreas to revert back to its usual level of functioning — a level that can control glucose supported by oral medicines. Once this occurs, insulin can be stopped. Remember, oral diabetes medicines work well only if the pancreas can still produce and release insulin.
- Sometimes insulin is given during an acute illness such as an infection, when glucose levels can be high and the demand for insulin is greater than the pancreas can handle. After the illness is treated adequately, oral medicines can be started again.
- Many obese individuals with diabetes who require insulin can reduce their dose or control their diabetes by taking oral medicines if they lose weight. However, the choice of insulin to manage diabetes does not always come after exhausting all oral or non-insulin options. Insulin has several advantages and is now more frequently introduced early in the management of type 2 diabetes. Q2. I have gestational diabetes. I am 34 weeks pregnant and I am on approximately 108 units of insulin per day. My OB has expressed concern that I am on very high doses and that I could “cap out” on insulin, meaning that I could reach the maximum dose possible. Is this true? I thought that there was no max as long as my sugar is being controlled. — Karen, Massachusetts Your doctor might be referring to the balance that you should have between good glucose control and low nighttime glucose levels. Having said this, higher than 140 units per day of total insulin dose is not usually necessary to achieve this balance. I will first explain why insulin requirements increase during pregnancy. In normal pregnancy, there is a 50 percent decline in glucose metabolism due to the secretion of specific hormones from the placenta and the fetus. This translates into a higher insulin requirement, making the body produce 200 to 300 percent more insulin. The increase in fat cells, insulin resistance, and increased fat metabolism are all factors in the increase in insulin requirement. The insulin requirement is greater among diabetic women in general, and it is also larger in those whose glucose has not been well-controlled or who are obese, regardless of glucose control. Insulin dosage during pregnancy takes into account these factors as well as your weight, the amount of carbohydrates in your diet, and how much physical activity you are getting. While it is true that you can take higher insulin doses, there is a downside to taking large amounts of insulin during pregnancy. During the long fasting state that occurs each night during sleep, the baby in the uterus will continue to require glucose, as does the mother, so higher insulin doses increases the risk of hypoglycemia (low sugar level) during sleep. Instead of continuously increasing insulin, working on your diet and physical activity to reduce your glucose is a safer alternative. Q3. Is it okay to use two different insulin pens? My doctor has me taking Lantus Solostar at night and Humalog at every meal. The Lantus Solostar has a warning on the pen that says not to use with other insulins. What should I do? — David, Texas You should continue to take both types of insulin as recommended by your doctor — that is, injecting Lantus at night and Humalog before your meals. Using a Lantus-type basal insulin and a mealtime Humalog-type insulin is not only safe, it will give you the best control of high blood glucose. That’s because this regimen approximates the body’s natural pattern of insulin release from the pancreas. The warning on the Lantus package insert is not to dilute or mix Lantus with any other insulin. Mixing Lantus insulin in the same pen or syringe might change the onset of the insulin’s action and result in erratic glucose control. Q4. What can you tell me about the use of alpha-lipoic acid for type 2 diabetes? I’ve read that it has an effect on insulin resistance. Is that true? — Carol, Michigan In animal studies, alpha-lipoic acid (ALA) has been shown to reduce insulin resistance, which is the main mechanism for type 2 diabetes. But studies in humans have not confirmed that taking the oral form of ALA reduces or improves diabetes control. However, there is limited evidence to suggest that ALA given intravenously enhances insulin sensitivity and reduces nerve damage due to diabetes. The rationale for its use is follows:
Having high blood sugar levels causes increased oxidative stress. This means that the body has a high concentration of free radicals — substances that can damage cells — and low capacity to clear these free radicals.Oxidative stress, in turn, causes insulin resistance and neuropathy (nerve damage).ALA is an antioxidant and helps eliminate free radicals, thus reducing insulin resistance and nerve damage.
Bottom line: ALA has not been approved for use in the United States. But it is an area of research interest, so stay tuned for further updates. Q5. I take insulin and it’s very hard for me to lose weight. I’ve read that this can happen — that insulin can contribute to weight gain. What can I do? I try to watch what I eat and have recently joined a fitness club, but I haven’t had much success yet. Any advice? Insulin can, in fact, lead to weight gain. Here’s how it works: Insulin is a potent hormone that regulates glucose, fat, and protein metabolism. In many cases, people with type 2 diabetes start insulin therapy when oral medicines cannot or no longer control their glucose levels. This means that blood glucose levels in the body have been elevated for an extended period of time. In this state, the body does not metabolize glucose, fat, or protein in a well-regulated or efficient way. Cells that require glucose to function properly begin starving because of inadequate amounts of circulating insulin. Fat metabolism becomes abnormal, which can lead to high triglyceride levels. The body’s metabolic rate then increases as it tries to convert this fat into a source of energy. These abnormalities are usually corrected when you begin insulin therapy. The body begins using glucose better, and the metabolic rate declines by about five percent. Insulin also helps the body gain fat-free mass, but on the flip side, it also helps it store fat more efficiently. Therefore, efficient glucose and fat metabolism and the reduction in metabolic rate cause most people to gain four to six pounds during the first two to three years of insulin therapy. Individuals who had poor glucose control, or who lost significant amounts of weight before beginning insulin treatment, usually experience the most weight gain. Losing weight in general requires persistent attention to energy balance — that is, the number of calories you take in versus the number you burn. During insulin therapy, the body does not need as much food to get the energy it requires, so reducing your caloric intake is quite important. This should be accompanied by an exercise regimen, as you have begun, to expend at least 200 to 300 calories a day. In addition, you should consult with your doctor to consider other kinds of diabetes treatments that could mitigate the weight gain. These include metformin, an oral medication that prevents weight gain; an insulin analogue called detemir, which has been shown to cause less weight gain than NPH insulin; and exenatide, an antidiabetes injection that can lead to weight loss. Q6. I was diagnosed with type 2 diabetes in 1979. I take two pills twice a day, but I’m having a hard time controlling my blood sugar with medication and diet. Will I eventually have to take insulin shots? — Donna, Ohio Congratulations on having good control of your diabetes for almost three decades! This is remarkable, and you should be proud. Diabetes is a progressive disease that eventually results in inadequate production of insulin by the pancreas. Medication has to be intensified periodically to overcome this progressive decline in insulin. Oral medicines are effective as long as the pancreas responds to therapy. However, when the underlying disease has affected a certain number of the pancreatic cells, oral medicines won’t work as well. If adding a third oral long-acting agent or pre-meal oral medicines does not control your sugar level, you will need to take insulin. Many diabetes experts today are prescribing insulin even before exhausting all the oral medicine options. Insulin is the natural hormone the body absolutely needs to metabolize sugar and perform other anabolic tasks. But don’t worry too much. Insulin has very few side effects, among them small amounts of weight gain and irritation at the injection site. Hypoglycemia (low blood sugar) can also occur if the insulin dose exceeds your body requirement or if you skip meals. If you are squeamish about needles, there are many options today that have made injecting insulin much easier, including insulin pens and thinner needles. Q7. I’m so tired of all the monitoring and measuring — is there a pump on the market that checks your blood sugar and then gives you insulin according to need? — Danna, Alabama You’re not alone in your frustration. Many of my patients would passionately agree that monitoring glucose using meters is tedious and inconvenient. However, at present there isn’t a system that makes finger stick-based glucose measurements completely unnecessary. The good news is that in light of current advances, I am hopeful there will be such a device in the near future. In fact, in April 2006 the Food and Drug Administration approved a continuous glucose monitoring system (CGMS) that transmits glucose readings in real time to an insulin pump. This is the first in a series of developments toward a system that will lead not only to fewer finger sticks but also to better glucose control. However, the currently available system has three major drawbacks.
First, individuals must ensure the accuracy of the CGMS using glucose values from their own finger-stick measurements. This calibration must be performed every 12 hours. In other words, the CGMS does not replace finger-stick measurements but does allow you to do them less frequently (if you were checking your glucose more than twice a day).Second, any insulin dose adjustment must also be preceded by a finger-stick glucose check using a meter. This means that if the CGMS transmits a high glucose value, a finger-stick measurement has to confirm it before the right insulin dose is programmed into the pump.Third, the insulin pump does not automatically adjust the insulin dose according to the transmitted glucose values. You must program the pump to inject a predetermined amount of insulin based on your current glucose reading.
Even with these drawbacks, many patients who meet the criteria for using an insulin pump report high satisfaction rates. So try to be patient: Within the next few months to two years, a closed-loop system that delivers insulin automatically as a response to your glucose reading — mimicking the action of the normal pancreas — will be brought to market. And you may well be a good candidate for it. Learn more in the Everyday Health Diabetes Center.
