insulin & pumps

Comparing Insulins for Type 2s

David Mendosa Health Guide April 05, 2009
  • Some of our doctors don't help us when they use insulin as a threat: "Unless you reduce your blood glucose, I am going to have to put you on insulin."

    So it's no surprise that many of us who have type 2 diabetes think we have failed when our doctors prescribe it. This comes from thinking of injecting insulin as a last resort.

    It isn't. More and more of us are now starting to take insulin as soon as our doctors have diagnosed our type 2 diabetes. Probably half of the men in my diabetes support group started taking insulin as a first choice.

    This makes sense when our blood glucose levels are way out of control. No other diabetes medication works more quickly.


    Some people think that few people other than those with type 1 diabetes take insulin.
    But more than one-fourth of all people with type 2 diabetes use insulin. This is according to responses to questions in the 1999-2001 National Health Interview Survey conducted by the U.S. Centers for Disease Control and Prevention.

    But taking insulin is more complicated than popping pills like metformin, the most commonly prescribed drug for type 2 diabetes. Even Byetta, which like insulin is an injection, is simple by comparison. With Byetta you just take the same dose every day shortly before eating breakfast and dinner.

    When you take insulin, you have to be careful to avoid hypoglycemia -- dangerously low levels of blood glucose. By comparison, the only diabetes pills that typically cause hypos are the
    sulfonylureas and the rarely prescribed Prandin.

    Insulin injections also usually lead to weight gain. For most people with diabetes this is the last thing we need.

    When you take insulin, you need the help of your doctor and Certified Diabetes Educator to work out the timing and the amount. You need to carefully calibrate it to what you eat, the exercise you get, and the stress that your body is under.

    And unlike diabetes pills, insulin comes in a bewildering variety of choices. You've got basal, you've got bolus. You've got fast acting or rapid acting. You've got premixed or multiple injections. You've got a choice of human insulin or analogues.

    Usually your doctors will make these choices. But don't be surprised if the medical establishment doesn't know what's best for you. Diabetes is a disease that perhaps more than any other depends much more on the patient than on the doctor.

    And now a branch of the U.S. Department of Health & Human Services has published a great pair of guides. They
    compare the efficacy, effectiveness, and side effects of newer premixed insulin analogues to conventional human and other insulins used to control type 2 diabetes.

    The Agency for Healthcare Research and Quality on March 25 released "Premixed Insulin Analogues: A Comparison With Other Treatments for Type 2 Diabetes" for clinicians. At the same time the agency released "Premixed Insulin for Type 2 Diabetes: A Guide for Adults," a consumer guide for those of us who need to take insulin.

    Most of us don't need to bother with the consumer guide. It's basically a dumbed down version of the clinician guide
    .


  • Here are some of the conclusions in the new guides:


    When they compared the newer premixed insulin analogues to long-acting insulin analogues, which last all through the day, the premixed insulin analogues were better at lowering A1C and at lowering blood glucose after meals. On the other hand, the long-acting insulin analogues are better at lowering fasting blood glucose levels and lead to fewer hypos and less weight gain.

    When they compared conventional premixed human insulin with newer premixed insulin analogues, the latter was better at lowering blood glucose after meals. But both kinds of insulin were equally effective at lowering A1C and at lowering fasting blood glucose levels. Hypos and weight gain were similar with both of these kinds of insulin.


    Is it better to control our fasting or post-meal level? It depends on your A1C.


    Recent research based on studies of hundreds of people with type 2 diabetes show that high levels after meals has a greater effect on A1C levels among people who have their diabetes under good control than among those with poor control.

    When A1C results are lower – less than 7.3 – mealtime glucose contributes about 70 percent of the A1C. However, when A1C results are higher – greater than 10.2 – fasting blood glucose contributes 70 percent of the A1C value.

    These guides also have a neat chart showing when the different types of insulin work on our bodies:


    One of the biggest problems that new users of insulin have is the timing of their injection. Gary Scheiner's article "Postprandial Hyperglycemia: It's All In the Timing," which he wrote for my website, deals with these questions.

    But if you are using oral medications to control your type 2 diabetes instead of insulin, the Agency for Healthcare Research and Quality has addressed those questions too. Those are easier questions to answer, which is probably the reason why the agency published those guides more than a year ago.

    "Pills for Type 2 Diabetes: A Guide for Adults " is the consumer guide. The clinician guide is "
    Comparing Oral Medications for Adults With Type 2 Diabetes."

    Either the insulin or the pill guides will probably have something to say to you. After all, only about 15 percent of people with diabetes take neither insulin or diabetes pills. And I wonder how many of them have their diabetes under control.