Insulin Therapy in Type 2 Diabetes
At Children's National Medical Center, we have an approximate total of 1,650 patients from our region. Eighty-nine percent of our patients have type 1 diabetes and the remainder has type 2, maturity onset diabetes of youth (MODY), cystic fibrosis related diabetes, steroid or medication induced diabetes and permanent neonatal diabetes. The vast majority of the remaining 12 percent are those patients with type 2 diabetes.
The presentation of children/adolescents with type 2 diabetes is changing. Previously, these youth were found to have type 2 diabetes during school physicals when urinalyses were positive for glucose. Occasionally, they would present with the triad of polyuria, polydipsia, and polyphagia. Unfortunately, some of the children/adolescents arrive in our Emergency Department in diabetic ketoacidosis (DKA), are very ill, and are at great risk for acute complications including brain swelling. In the past DKA was usually limited to those children who were totally insulin dependant as in type 1 diabetes. The line between these diagnoses is blending. Youth may be insulin deficient initially in type 1 diabetes, type 2 diabetes, and type 1.5 (a hybrid of type 1 and type 2 in which children/adolescents have the physical characteristics of type 2 diabetes, but also have positive GAD-65 antibodies).
We generally begin insulin therapy in children and adolescents with new-onset diabetes of unknown type that are clearly insulin deficient and very ill. If it becomes clear that the child has type 1 diabetes based on presentation, symptoms, and positive antibodies, insulin therapy will be the mainstay of treatment. However, in type 2 or 1.5 diabetes, we often start insulin when the child is ill and begin an insulin taper in association with the initiation of an insulin sensitizer such as metformin. In many cases, we can wean those with type 2 diabetes (and some with type 1.5) off insulin for a period of time.
In Diabetes Care, Volume 35, March 2012, "Attitudes toward diabetes effect maintenance of drug-free remission in patients with newly diagnosed type 2 diabetes after short-term continuous insulin infusion treatment," Chen and Huang et. al noted that treatment of insulin for a short period of time in patients with newly diagnosed type 2 diabetes improved B-cell functioning, as well as increasing insulin sensitivity. As a result of the insulin therapy, patients were able to stay off diabetes medication for a long period of time. The authors then used a tool, Diabetes Care Profile, to document patient attitudes toward their newly diagnosed type 2 diabetes to evaluate the "impact on maintaining long-term remission."
The patients in the "treatment" group (187) with newly diagnosed type 2 diabetes were actually begun on insulin pump therapy for 2 to 3 weeks, received hospital based diabetes self-management training and completed the questionnaire at diagnosis, 3, 6, and 12 months after discontinuation of insulin pump therapy.
What were the results?
1. 150 (80 percent) achieved blood sugars that were near normal after discontinuation of insulin pump therapy
2. 20 patients relapsed within 1 month
3. 12 dropped out of the study
4. The remaining 118 patients were followed for at least 12 months
5. 65 patients remained off diabetes medication for more than 1 year
6. All had better glycemic control and greater "restoration of acute insulin response" after insulin pump therapy
7. Higher scores were achieved in positive attitude, belief in the importance of care, care ability, self-care adherence, and less negativity
8. Differences between the two groups became greater over time
9. For those who relapsed, 50 received oral hypoglycemic medications and 3 were treated with insulin
10. Correlation analysis also demonstrated that "positive attitude," "importance of care," "care ability," and "self-care adherence" were negatively correlated to hb A1c. ( i.e., the more of the above qualities, the lower the hb A1c)
11. Correlation analysis demonstrated:
a. That "negative attitude" was positively associated to hb A1c (i.e., the more negative the attitude, the higher the hb A1c)
b. "Self-care adherence" and increased insulin resistance before treatment were independent predictors for remaining in remission
c. Higher post-prandial glucose after insulin pump therapy was a risk factor for relapse
It appears that insulin therapy may become the first line of "offense" for all types of diabetes to preserve beta cells. The conventional wisdom of type 2 diabetes treatment may therefore become reversed by providing intensive insulin therapy initially instead of starting with diet and exercise, oral medications and insulin initiation, only when all else fails.