The first treatment for people newly diagnosed with type 2 diabetes is usually lifestyle changes, such as improvements in diet and exercise. If these measures do not sufficiently control blood glucose levels, one or more oral medications (often metformin [Glucophage] and/or a sulfonylurea drug) are prescribed.
Over time, however, type 2 diabetes usually worsens, oral medications become less effective, and more than a third of people must add insulin injections to their treatment regimen.
New research is now challenging this treatment approach, suggesting that adding insulin earlier can greatly improve blood glucose control.
Why Some People With Type 2 Diabetes Need Insulin
Unlike people with type 1 diabetes, who are unable to produce their own insulin and require insulin injections to survive, people with type 2 diabetes do produce insulin. The problem in type 2 diabetes is that the cells are less responsive to the actions of insulin. The pancreas compensates by producing more insulin, but over time it cannot produce enough to overcome the cells’ reduced response.
In addition, as type 2 diabetes progresses, the ability of the pancreas to produce insulin may become impaired, and the body does not have enough insulin to move glucose into cells.
Evidence for Change
An in The American Journal of Medicine points out that many people with type 2 diabetes are not prescribed insulin until 10 to 15 years after their diagnosis and often not until complications from diabetes have already occurred. The author calls this practice outdated and ineffectual and points to an emerging trend that involves the earlier use of insulin to help people with type 2 diabetes control their blood glucose levels and reduce their risk of complications.
The article points out that for many people, lifestyle changes and oral medication are not enough. For example, a substudy of the United Kingdom Prospective Diabetes Study—which compared subjects on a diet and exercise program with those also receiving medication—found that six years after diagnosis, more than 50% of people with type 2 diabetes treated with a sulfonylurea drug alone needed insulin injections to achieve their target blood glucose levels. In addition, 50% of those who took insulin plus a sulfonylurea had a desirable median HbA1c level of 6.7% after six years.
In addition, newer insulin formulations such as insulin glargine are convenient to take and less likely than older types to cause hypoglycemia—a big concern for many people who are beginning insulin therapy.
The Bottom Line on Insulin and Type 2 Diabetes
The author of the article, as well as another author in the same issue of The American Journal of Medicine, suggests that in treating people with type 2 diabetes, the ideal may be aggressive treatment to keep patients at an HbA1c level of less than 7% for life.
In practical terms, for a newly diagnosed person with type 2 diabetes, the treatment plan might still follow the same pattern: lifestyle changes, followed by oral medications, followed by the addition of insulin. However, each step might be given only a few months to work; if the target HbA1c level is not reached, treatment would progress to the next step.
Many people are reluctant to begin insulin therapy, feeling that the change means they have failed or their diabetes will worsen. These and other obstacles—such as the fear of hypoglycemia, weight gain, or pain caused by the needles—are surmountable, suggests the author of the first review article mentioned above.
He adds, “Most importantly,…the concept of insulin as expected therapy in the management of type 2 diabetes should be introduced on diagnosis, whether or not the patient’s blood glucose levels at the time can be adequately controlled by other means. Better adherence and more successful outcomes will result when the erroneous idea that insulin therapy is a sign of failure or worsening disease is permanently dispelled.”
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Posted in Diabetes on March 8, 2006
Reviewed May 2007
