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Insulin Myths

Most people with diabetes don’t want to go on insulin. Certainly nobody relishes giving themselves injections, but many people have a lot of misconceptions about starting insulin. So let’s begin with dispelling some common fallacies about taking insulin. It doesn’t make diabetes worse or cause you to lose your vision or lose your limbs. Injecting insulin isn’t painful. The injections cause very little discomfort today due to the thin, small needles available on syringes and the even smaller needles used on insulin pens.

What insulin does do is lower your blood glucose when other agents have failed. It is always effective. Diet and exercise may fail, pills may fail, incretins may fail, but insulin always works. And insulin usually comes with very few serious side effects. Those two properties make it the drug of choice when the beta cells of the pancreas have run dry.

There are many types of insulin on the market these days and they more precisely match the body’s own insulin delivery patterns than ever before. People with type 2 diabetes usually undergo a step-wise approach to insulin therapy. If your A1C is above goal (usually around 7 percent) and you are already on two to three oral medications or incretins (http://health.walgreens.com/expert_blogs/show/634927/The-Non-Insulin-Injectables), adding a third or fourth medication is unlikely to make enough of an impact to bring you back to target.

This is when most physicians will add basal insulin, such as Levemir® or Lantus®, to the pills you are already taking. Basal insulin is background insulin that supplies a steady delivery of insulin over a period of time, usually between 12 and 24 hours. Its purpose is to meet your insulin needs between meals and overnight. It helps keep the blood glucose steady by balancing the glucose being released from the liver in between meals. Levemir® and Lantus® are peakless insulins, meaning they have a flat profile. For example, if you take 24 units of Lantus® at bedtime, approximately 1 unit of insulin is delivered to the blood stream every hour. In type 2 diabetes, basal insulins are usually given once a day at the same time.

Peakless insulins were a real revolution in diabetes therapy. They allow people to have a more flexible meal pattern. Older background insulins, such as NPH (neutral protamine Hagedorn) have a peak—a time when the insulin works more forcefully—and this would often lead to hypoglycemia if a snack wasn’t consumed.

Although basal insulin can be given at anytime during the day, it is often given at bedtime. Since many people do not eat from the time they go to bed until they rise, comparing the blood glucose bedtime reading and fasting reading allows you and your healthcare provider to determine if you are on the correct dose. If the two readings are within 30 to 40 points of each other and the morning reading is under 130mg/dl, the dose is usually correct.  

Taking pills and basal insulin can control type 2 diabetes for a long time. However, sometimes this is no longer adequate to keep the A1C at goal. Even when your morning numbers are in good control, failing beta cells may not provide enough insulin to keep postprandial (after eating) glucose excursions from happening. At this point, bolus (mealtime) insulin should be added. Once short- or rapid-acting insulin is given, oral pills that stimulate the pancreas can be stopped. Often metformin, which reduces insulin resistance, is continued.

There are four bolus insulins available today. There is one short-acting one, known generically as regular. Regular starts working 30 minutes after it's injected, peaks in about two hours and lasts up to eight hours. Humalog®, Novolog ®and Apidra®, the rapid-acting insulins, more closely mimic the rise in blood glucose after a meal. They start working in 10 to 15 minutes, peak in about 2 hours and last about 4 to 5 hours. These insulins are used to “cover” meals and also to bring down high blood glucose between meals.

No matter where you take basal insulin or both basal and bolus insulin, you will need to be prepared for possible hypoglycemia by carrying a source of easily-absorbable carbohydrate, such as glucose tabs, jelly beans or juice packs. Other side effects of insulin are reactions at the injection site, and rarely, insulin allergy.

In my next post, I'll discuss the different ways bolus insulin can be given.

Live well and enjoy!

Nora
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