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Insulin for Type 2 Diabetes
Nothing raises as much fear in the minds of most people with type 2 diabetes as the thought of having to go on insulin. This is a tragedy, because, of all the medications available to diabetics, insulin is the only one capable of not just lowering, but of normalizing, their blood sugar.
There are a lot of things about diabetes that should be terrifying: blindness, amputation, kidney failure, impotence, and, worst of all, the very high likelihood of dying, much too young, of a heart attack. All of these are caused by prolonged exposure to high blood sugars.
Insulin can prevent all these terrifying things from happening. So why waste your fear on it?
Let's look at what it is that people with Type 2 fear about insulin and why these fears are unnecessary.
Needles: They Are Painless!
It's a shock to many type 2s, but it turns out that the ultra-thin short needles used for injecting insulin under the skin are far less painful than the lancets you use to test your blood. Most of the time they are so painless that you may have to visually check to see if you actually have penetrated the skin, because you can't feel the needle!
The key to making injections painless is to equip yourself with a very thin needle, 30 or 31 gauge, and to use the shortest needle compatible with your body size.
Many family doctors seem to be unaware that there are newer thinner, shorter needles available for insulin. Mine, for example, had his nurse teach me how to inject with a 1 inch, 28 gauge needle.
The needles I ended up using, after doing some web research, was 5/16" 31 gauge which is almost 1/4 of the size of her railroad spike.
The second important thing to know about injecting insulin is that when you first start out and are panicking at the idea of giving yourself a shot, it helps to "throw" the syringe at your target the way you'd throw a dart, holding the syringe with three fingers and tossing it at your target--usually a big pinch of tummy fat-- starting from 6 or 7 inches away. The swift motion of the needle completely eliminates any sting or feeling of the needle going in.
Hypos: Learning How To Dose Correctly Avoids Hypos
The other major fear people with Type 2 diabetes have when confronting insulin is the fear of dangerous, or even fatal, hypos.
Extremely low blood sugars--hypoglycemic attacks--are always a possibility with insulin, but no more so than they are with drugs like Amaryl. But unlike the case with a pill that causes insulin secretion, you have a lot more control over the dose of insulin you inject. If you take some time and study how to use insulin you should be able to avoid serious hypos completely.
As of 2018, you can now get an inexpensive continuous glucose monitor, the FreeStyle Libre, which will make it much easier to see exactly what your blood sugar is doing so that you can address swiftly falling blood sugars before they cause hypos. These devices cost about US$80 for the reader, a one time purchase, and about US$32 for a sensor that lasts 10 to 14 days depending on the model and the country you live in. You will need a prescription to buy one even if your insurance doesn't cover it. It is well worth buying if you are using meal-time insulin. There are several helpful closed groups on Facebook where you can get your questions answered about these monitors.
Fear: Why Starting Insulin USED to Go Along with Developing Horrible Complications
If you watched a beloved family member with Type 2 deteriorate, you may have gotten the message that starting insulin marks the beginning of the end. No sooner did your loved one start insulin than they lost their vision, their feet, their kidneys, or their life.
There is a reason for this: It has nothing to do with insulin. It has to do with the fact that a generation ago doctors ignored extremely high blood sugars for many years, as research had not yet proven that lowering blood sugar could prevent complications. Until this was learned in the 1990s, doctors allowed people with Type 2 to walk around with A1cs of 12% or higher, put them on high carbohydrate/low fat diets and ineffective oral drugs, and only put these patients on insulin when their blood sugars became so high they were life threatening. By then the years of high blood sugars had done irreversible damage.
We now know that lowering blood sugars with insulin as soon as possible after diagnosis makes a dramatic drop in the incidence of complications even if insulin is subsequently stopped.
A study published in August 2009 found that patients put on insulin at diagnosis had no more hypos and less average weight gain than patients put on oral drug regimens. Most importantly, "100% of patients randomized to insulin willing to continue such treatment."
You can read the details of the studies that found this to be true here:
Diabetes Update: Insulin Right after Diagnosis Dramatically Improves Type 2 Outcome.
Also see,
Beneficial Effects of Insulin on Glycemic Control and ß-Cell Function in Newly Diagnosed Type 2 Diabetes With Severe Hyperglycemia After Short-Term Intensive Insulin TherapyHarn-Shen Chen et al. Diabetes Care 31:1927-1932, 2008
Insulin-Based versus Triple Oral Therapy for Newly-Diagnosed Type 2 Diabetes: Which is Better? Ildiko Lingvay et al. Diabetes Care, Published online before print July 10, 2009, doi: 10.2337/dc09-0653
The Most Important Thing You Must Know About Insulin
The most important thing you must understand about insulin is that the dose that works for you is going to be different than the dose that works for someone else. Because each of us has a physiology that is different, both in terms of insulin sensitivity and in terms of what is actually broken in our blood sugar control, getting insulin to work initially requires a lot of testing and tweaking.
You'll have to start at a very low dose, recording your blood sugars, and then slowly raise that dose until you gradually reach the level you want your blood sugars to be at.
If your doctor isn't willing to work with you to pick a starting dose and then work towards getting it just right, so that your blood sugars approach normal, you probably need to find a better doctor or a Certified Diabetes Educator who can help you do this.
All too often, doctors give Type 2s generic doses of insulin. These may be high enough that the patient is always hungry and has to keep eating to balance out the insulin, which will cause weight gain, or the dose may be too little and avoid hypos at the cost of not lowering blood sugar enough to restore health.
Only if your doctor or educator takes the time to help you "walk up" to the correct dose that doesn't leave you hungry or with post-meal blood sugars spikes will you end up with the correct insulin dosage.
Even then, you'll still have to test and check on what is going on because your insulin needs change with changes in your health and even with changes in the seasons.
There are Three Very Different Kinds of Insulin
Most Type 2s, when they do go to insulin, are put on Lantus or Levemir, which are basal insulins. In spring of 2015, a new basal insulin, Toujeo, was introduced. It is another version of the same insulin molecule found in Lantus, sold in a more concentrated form. Two other basal insulins. Tresiba, a longer acting insulin was approved in late September of 2015. Basaglar, a biosimilar version of Lantus will not be sold in the U.S. until 2017,
You can learn more about the new basal insulins in these blog posts which go into the properties of each extensively:
Toujeo, a More Concentrated Version of Lantus
The Newly Approved Basal Insulin Tresiba's Label is Disappointing.
It Is Important to Understand What a Basal Insulin Can Do--and What it Can't.
One major reason that doctors believe they can't normalize the blood sugars of Type 2s with insulin is that they are prescribing the wrong kind of insulin.
Basal Insulin
Basal insulin, once injected, slowly dribbles into the body for anywhere from 12 to 24 hours, providing a low level of "background" insulin throughout the day.
Lantus lasts from 18-24 hours. Levemir lasts 12 hours or more depending on dose size. At small doses both these insulins last for a shorter amount of time. These insulins do not peak at at once, but deliver a small but steady dose with perhaps a mild peak in the case of Lantus, several hours after injection.
The new basal insulins are being marketed with the claim that they last 24 hours and have an even flatter activity curve. However, given that all the well-known insulins can perform differently from what the marketing materials say they will, we will have to wait for a year or two until a significant number of users in the online diabetes community have reported on their results to know know how true this is.
The new basal insulins are also being marketed, where possible, with the claim that they are less likely to cause hypos. However, the FDA has refused to let Toujeo be marketed with this claim, though the European authorities allow it.
NPH, an older basal insulin, is not steady in its action but does peak, significantly and unpredictably, which can make it very tough to use. The poor performance of NPH insulin and its tendency to cause hypos because of its peaks is one reason that doctors worry so much about hypos. But the newer insulins are much more predictable in their effect than NPH, and if you get your dose set right with Lantus or Levemir, you should not have to worry about hypos.
The point of basal insulin is NOT to counteract the blood sugar spikes caused by eating carbohydrates. In fact, when dosed properly, basal insulin should have little or no impact on your post-meal numbers.
The point of basal insulin is to control your blood sugar when you are fasting. It should lower your morning fasting blood sugar and your reading before a meal.
But if you've paid any attention to the rest of this site, by now you should realize that high blood sugars after meals are a major cause of organ damage. And knowing that, you should be able to see what the problem is with an insulin regimen that only involves basal insulin: It doesn't lower post-meal spikes enough to prevent a high A1c, which is why all too many Type 2s on insulin still have A1cs over 7%--often quite a bit over 7%.
A Very Rare Problem with Lantus You Should Know About
Over the past year I've heard reports from four different people who have injected Lantus and then, within an hour, had their blood sugar drop very low. Apparently they hit a blood vessel and the Lantus all hit the system at once, instead of dissolving slowly as it is intended to do when injected into fat.
This is a rare occurrence, Many people use Lantus for many years without having it happen. But if you are using Lantus, it is one you should be aware of.
If you should feel strange within an hour of injecting Lantus, test your blood sugar. If it is lower than 70 mg/dl you should immediately take as much glucose as you would need to raise your blood sugar 60 mg/dl and then test every fifteen minutes and take more glucose until you are back at a safe blood sugar level. (Pure Glucose, found in Smarties or Sweetarts and Glucose pills will act within 15 minutes). If you are a Type 2, your liver has the ability to dump glucose into your bloodstream if you go dangerously low, so unlike many Type 1s you aren't likely to end up in the ER with a hypo. But you should always keep some Smarties around if you use insulin, just in case you need it.
Fast-Acting, Meal-Time Insulin
Fast-acting insulin is a short-acting insulin that is injected to cover a specific meal. Humalog, Novolog, Apidra, Fiasp, Lyumjev, Humulin R, and Novolin R are all fast-acting insulins.
Typically these fast-acting insulins are active anywhere from 3 hours to 5 hours after injection and reach a peak in their action within 1-2.5 hours after injection.
Fast-acting insulin is the "magic bullet" when it comes to controlling blood sugars, because, when used properly, it can eliminate dangerous post-meal blood sugar spikes.
Many people with Type 2 will find that if they control post-meal spikes their fasting blood sugar will decrease, too, so that they need a lot less, or even, sometimes, no, basal insulin.
But in order to use fast-acting insulin correctly, you have to be intelligent. You have to learn, with the help of your doctor or Certified Diabetes Educator, how many grams of carbohydrate are covered by one unit of your fast-acting insulin, and you have to learn how to accurately assess how many grams of carbs you are eating when you eat a meal. In all cases, you have to err on the side of conservatism, because if you use too much fast-acting insulin you can indeed have nasty hypos.
Dr. Bernstein makes the point in his book, Dr. Bernstein's Diabetes Solution that the only way to use fast-acting insulin safely is to use it with a lowered carb intake. This is because the more carbs you eat, the more likely you are to be wrong when you estimate how many grams of carbohydrate are on your plate and the more likely you are to inject too much or not enough insulin.
Another problem with injected insulin is that it is very tough to match the speed with which it reaches the bloodstream with the speed with which the carbohydrates you eat digest.
For example, if you take enough insulin to cover the 80 grams of carbohydrate in a plate of spaghetti and sauce, you may end up shooting as much as 16 units of insulin. If all that insulin arrives in the blood stream before the food does, which is almost guaranteed to happen, as spaghetti takes several hours to digest, you may end up with a severe hypo. Alternatively, if you take enough insulin to match a quickly digesting bagel, the carbs from the bagel may hit your blood sugar before the insulin does and cause a high blood sugar spike. Then later on, you might have a low low when the insulin finally shows up because since you are a Type 2, you have some residual beta cell activity that may kick in and mop up some of the bagel carbohydrate.
And that doesn't even get into the question of what happens if the plate of spaghetti you eat only has 50 grams instead of the 80 grams you dosed for.
This should make it clear why fast-acting insulin is tricky. But the other side of this is that if you are willing to learn how much carbohydrate is in your food--a food scale and nutritional software help here--and if you control your carbohydrate intake and to learn how to time your insulin, which you will only learn through weeks of careful measurement and experimentation--you can get extremely good control.
Using insulin correctly should result in A1cs in the 5% range rather than the 7-8% range guaranteed to result in complications.
If you want to learn more about insulin for type 2, there is no better reference than the book, Dr. Bernstein's Diabetes Solution by Dr. Richard K. Bernstein. Don't even consider using insulin until you have read through Dr. Bernstein's insulin chapters a few time and mastered the points he is making.
I have found I am able to eat more grams of carbohydrate safely,than he recommends, but that is largely a function of my own metabolism. You'll have to learn what your body can handle through careful testing and adjustment.
Understanding the Difference Between Regular (R) Insulin and Analogs (Humalog, Novolog, Fiasp, Lyumjev, and Apidra)
One more issue that arises with insulin is that there are currently two kinds of insulin on the market. The newer, more expensive insulins are what are known as "insulin analogs". This means they are genetically engineered molecules that are not identical to the stuff your body makes on its own. The analogs have a different protein somewhere in the insulin molecule than the stuff your body makes has. This is done to affect the way it absorbs and speed up the time in which it hits the body. Humalog, Novolog, Apidra, Fiasp, Lyumjev, Lantus and Levemir are all analog insulins.
Regular insulin, in contrast, is chemically the same molecule as what your body makes. Humulin and Novolin R and NPH are regular insulins. They are much cheaper than analogs. It is also possible that they are safer for long term use.
There is no reliable data about the long-term safety of analogs, and some people worry that the subtle changes in the insulin molecule may cause them to accumulate in the brain or spur cancer growth. Whether this is true or not is unknown because it has not been investigated over the long period it would take to answer the safety question.
Novolin R is available for about $25 a vial at Wal-Mart while the analogs may cost up to $85 a vial containing 1,000 units. Pens are only available for analog insulins and they are far more expensive--$185 for a pack containing 1,500 units.
The analog fast-acting insulins are much faster in action than R insulin, but they may, in some cases, cause allergic reactions or they may be more unpredictable in when they peak. Even so, most people who can afford them prefer them because of their speed. You can inject Humalog 15 minutes before a meal. Novolog works even faster for many people, and Apidra and Fiasp appear to be the very fastest. You can inject these insulins right before eating, or with Apidra and Fiasp, even a bit afterwards, while R usually requires that you inject 45 minutes to an hour before you eat if you want it to meet up properly with the food.
R insulin does not get the marketing push the analog insulins get so your doctor may have been convinced it is "obsolete", but this is not true. You can get very good control with R insulin, and because it is slower it is much less likely to cause dangerous hypos. It just takes some time to learn its ins and outs. If you are having trouble with fast-acting analog insulin, and are having highs followed by lows, R might be worth a try. It works best with a diet made up of slow-digesting carbohydrates as it is active for 3-5 hours after injection.
Research Finds R and NPH Have Same Effect on Blood Sugar as The Much More Expensive Insulins
A study published in November of 2008 is just one of several studies that compared the actual blood sugar impact in hospitalized people with Type 2 diabetes of regular human insulin with the more expensive analog insulins. It found no significant difference.
Comparison of Inpatient Insulin Regimens with Detemir plus Aspart versus NPH plus Regular in Medical Patients with Type 2 Diabetes. Guillermo E. Umpierrez, et. al. J Clin End & Metab,doi:10.1210/jc.2008-1441
If you have trouble paying for insulin, demand that your doctor prescribe the cheaper human insulins (R and NPH). Remember that the faster acting R insulin will not start to kick in until 45 minutes to an hour after injecting and that it will remain active for up to 5 hours. Remember too that NPH may act unpredictably, so test carefully when you first start using NPH to see how it affects your blood sugars.
Inhaled Insulin
A new inhaled insulin, Afrezza, was approved by the FDA on June 27, 2014. It is meant to be taken when you eat or just afterwards. It is much faster than injected insulin, peaking very quickly and then just as quickly leaving your body. It is very expensive and many plans will only cover it for people with Type 1 whose doctors are willing to fight for the approval. It is not approved for smokers or people with limited lung capacity. Your doctor is supposed to test your lungs before prescribing it.
Some people find it very helpful. Others do not. People with Type 2 diabetes typically need very large doses of insulin to cover their meals which may make Afrezza too expensive.
Some people with very mild Type 2 report that by using Afrezza to replace their damaged first phase insulin release they are able to get much more normal blood sugars. This may be because the early insulin burst stops their liver from dumping glucose into the bloodstream at meal times.
If your insurance covers Afrezza at an affordable level it might be worth trying it to cover high carb meals or bring down stubborn highs.
The units in which Afrezza is dispensed are less powerful than units of fast acting injected insulin. You will need 1.5 units to match ever 1 unit you are used to using. In addition, because of how fast Afrezza leaves your bloodstream, you may need to use two doses an hour apart to cover a meal that digests more slowly.