12) DIABETES MEDICATIONS
d) Insulin Injections
Individuals with type 2 diabetes can end up taking insulin itself by injection. Type 2 diabetes is typically a progressive disease (although it can be reversed with weight loss, exercise and diet) and about one third of type 2 diabetics will progress to a point where they need insulin.No one should feel ashamed that they have to take insulin. It is not a personal failure. This added insulin is required either in order to overcome severe insulin resistance or because the pancreas has lost most of its ability to produce insulin. Insulin is typically recommended when the A1c readings hit 7.5 to 8.0 or above. If the blood sugar level one hour after a decent meal is consistently at 200 or above, even with medication, an individual typically will need insulin. There are a large number (about 20 as of last count) of options when it comes to insulin, from very rapid acting to very slow acting to mixtures. The insulin can be injected by syringe from vials, injected via a multi-dose "pen" device with cartridges, injected in a pump through a small needle (pumps are typically only used for type 1 diabetes, not type 2), or it can be injected by a fine high pressure spray mechanism ("jet" injectors). It should be noted that the needles used today are so small and so well designed that they can hardly be felt when they penetrate the skin, especially if a very rapid insertion is used. So those that hate pain in any form need not worry.
Adjusting insulin levels in the blood is crucial, and being guided by a medical doctor or a trained specialist is the best way to do this; individuals with type 2 diabetes should not try it alone. Patients who use insulin typically follow either a "conventional" or "intensive" insulin injection plan. "Conventional plans" are the simplest, but may be considered more limiting. This sort of diabetes management involves taking insulin less than three times per day at fixed times, and often in fixed doses. In other words, the insulin dose doesn't change depending on food or exercise. Obviously any individual on this type of plan needs to spread out food intake and exercise very uniformly and consistently over each and every day. If this consistency is not maintained for even a day (say a sedentary individual on this plan decides one day to climb the local mountain), then low blood sugar, unconsciousness, coma and even death can result.
In contrast, people who use "intensive plans" take three or more injections a day. Their doses and the timing of the doses are usually adjusted depending on how much food they are eating, the type of food, how much they are exercising and what their blood sugar readings are. This takes more education, practice and a lot of monitoring using blood sugar (glucose) meters and test strips, but allows for greater flexibility in food choice, food timing and exercise regimen. Adjusting insulin safely requires effort; training and self discipline but allows much more freedom and flexibility in lifestyle. Research has generally shown that intensive plans result in a slower progression of the disease and a longer, healthier life. Evidence from the landmark Diabetes Control and Complications Trial (DCCT), and the U.K. Prospective Diabetes Study (UKPDS) show that improved glucose control to a A1c level of approximately 7.0% reduces the complications of diabetes dramatically.
There needs to be some caution exercised however. It is neccessary to consult with a physician as to the appropriateness of an intensive program. It appears that individuals with "heart disease" (macrovascular large blood vessel disease) are at increased risk of death if they use an intensive program that combines some drugs with insulin to bring A1c levels to below 6.0. The ACCORD trial randomized patients with diabetes and vascular disease or multiple cardiovascular risk factors to an intensive treatment program (using insulin) targeting normal blood glucose values and an A1C less than 6 percent or a standard treatment program (no insulin) with an A1C between 7 percent and 7.9 percent. The intensive participants in ACCORD were switched to the standard treatment program in February 2008 because of an increased death rate in the intensive treatment program (14 deaths per 1000 patients per year versus 11 per 1000 patients per year in the standard treatment program; a difference of 0.3 deaths per 100 patients per year). The ACCORD study very carefully avoided making any conclusions about why the study had to be halted. It has to be emphasized that this study looked at individuals who normally would not be prescribed insulin but were prescribed insulin versus individuals who were not prescribed insulin.
We had a possible interpetation of the ACCORD results. As we have pointed out elsewhere, the three major support legs of the diabetes "treatment stool" are weight loss, exercise and diet. Medication is not one of the legs because it typically has little effect on mortality rates. It can even be counterproductive to mortality (medication definitely is not counterproductive to quality of life isssues and the speed at which the disease progresses). Medication shunts excess blood carbohydrates into fat storage. Fat storage increases weight, increases insulin resistance, increases blood pressure, and increases heart disease and mortality. In the ACCORD study, 27.8% of the intensive drug treatment group gained more than 22 pounds while only 14.1% of the less intensive drug therapy group gained more than 22 pounds. Patients on diabetes medications have to control their weight! The American Diabetes Association has reviewed the results of the ACCORD study and other studies and concluded that it is still very beneficial to treat insulin dependent type 2 diabetes with an intensive insulin regime. They also feel that an intensive insulin regime is preferable to a conventional insulin regime. Remember, the ACCORD study looked at taking insulin versus not taking insulin and it looked at some questionable drug combinations (for reasons that are unclear, apparently the experimental group took a combination of a cholesterol lowering drug and an insulin stimulating drug which is not recommended by the manufacturers).
Doctors don't have time to teach patients how to use insulin. There are nurses, dieticians and Certified Diabetes Educators ("CDE") who give advice either on a one on one basis or in a classroom. Individuals who are put on insulin need to take one of these courses. Education is very important for anyone on insulin. There is a problem with education. In our lawsuit happy culture, anyone (including medical doctors and drug companies) who writes down a regimen for properly taking insulin risks a lawsuit. Each patient with diabetes is different and each patient with diabetes responds differently to insulin. So sometimes, unfortunately, a regimen doesn't work and the patient becomes very sick or dies. The relatives then sue. So as a result there is a lack of information available on the proper way to take insulin. No one wants to get hit with a lawsuit. And the type, amount and timing of insulin injections depends on many factors. Here are just some of the things that affect the need for insulin:
how much you weigh
how much you exercise
how fit you are
how much fat and muscle you have
how sensitive your body cells are to insulin
how much you eat and the foods you choose
what you eat
how much insulin does your pancreas make
when does your pancreas produce insulin
how does your liver react to insulin
what other medicines you takeIn order to take insulin properly a patient needs to become their own researcher. They need to constantly test their blood sugar and adjust their insulin accordingly. A patient taking insulin can take exactly the same amount of insulin at exactly the same time, eat exactly the same foods and amounts of food, exercise exactly the same for two days in a row and have widely divergent blood sugar readings on the two days. Doctors just don't know why this occurs. Patients on insulin need to track the timing, types and amounts of both insulin, food and blood sugar and adjust accordingly. One source of information on insulin is the Wikipedia site: http://en.wikipedia.org/wiki/Insulin_therapy. Other sites include those of the manufacturers of insulin, although they keep telling the patient to take the advice of their doctor. Lilly has some good data and a computer program that charts aproximate responses to different regimens, http://www.lillydiabetes.com/content. One website has a video on how to inject insulin (the way websites come and go we're hesitant to recommend it but try it if you're interested: http://www.videojug.com/film/how-to-give-yourself-an-insulin-injection). One great resource is a book by Richard K. Bernstein M.D., "Dr. Bernstein's Diabetes Solution", Little, Brown and Company Publishers, Copyright 1997, 2003. There are several very good chapters on using insulin and references to insulin use throughout this excellent book. The website for the book is www.diabetes-book.com. We are not a medical doctor so we are not going to give advice on taking insulin.
Note that anyone taking insulin needs to be aware of the signs of low blood sugar (weakness, dizziness, confusion, cold sweats and/or light headedness) and take steps to raise blood sugar immediately should it occur. This means always having available blood sugar (glucose) tablets, sweets, candy bars or sugary drinks, especially when exercising. Be forewarned, low blood sugar can occur unexpectedly to anyone with diabetes for no apparent reason, so always be close to a source of sugar. Individuals with even well controlled diabetes in its beginning stages can suffer sudden, unexplainable episodes of low blood sugar. Although typically people who are not dependent on insulin don't suffer severe low blood sugar, it does happen, so anyone with diabetes needs to have a source of sugar nearby. Definitely keep something sugary in your car and carry some with you when exercising. We recommend glucose tablets as they provide the most consistent and rapid reaction. Anyone on insulin should also have a medical alert bracelet or neck chain to identify their disease to appropriate medical personnel.
Current Chapter: 12) DIABETES MEDICATIONS
a) Introduction
b) Diabetes Medications
c) List of Potential Medications
d) Insulin Injections
e) Blood Sugar Testers
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