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Diabetes Developments - A blog on latest developments in diabetes by David Mendosa

Comparing Insulins for Type 2s

April 5th, 2009 · 4 Comments

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Some of our doctors don’t help us when they use insulin as a threat: “Unless you reduce your blood glucose, I am going to have to put you on insulin.”

So it’s no surprise that many of us who have type 2 diabetes think we have failed when our doctors prescribe it. This comes from thinking of injecting insulin as a last resort.

It isn’t. More and more of us are now starting to take insulin as soon as our doctors have diagnosed our type 2 diabetes. Probably half of the men in my diabetes support group started taking insulin as a first choice.

This makes sense when our blood glucose levels are way out of control. No other diabetes medication works more quickly.

Some people think that few people other than those with type 1 diabetes take insulin. But more than one-fourth of all people with type 2 diabetes use insulin. This is according to responses to questions in the 1999-2001 National Health Interview Survey conducted by the U.S. Centers for Disease Control and Prevention.

But taking insulin is more complicated than popping pills like metformin, the most commonly prescribed drug for type 2 diabetes. Even Byetta, which like insulin is an injection, is simple by comparison. With Byetta you just take the same dose every day shortly before eating breakfast and dinner.

When you take insulin, you have to be careful to avoid hypoglycemia — dangerously low levels of blood glucose. By comparison, the only diabetes pills that typically cause hypos are the sulfonylureas and the rarely prescribed Prandin.

Insulin injections also usually lead to weight gain. For most people with diabetes this is the last thing we need.

When you take insulin, you need the help of your doctor and Certified Diabetes Educator to work out the timing and the amount. You need to carefully calibrate it to what you eat, the exercise you get, and the stress that your body is under.

And unlike diabetes pills, insulin comes in a bewildering variety of choices. You’ve got basal, you’ve got bolus. You’ve got fast acting or rapid acting. You’ve got premixed or multiple injections. You’ve got a choice of human insulin or analogues.

Usually your doctors will make these choices. But don’t be surprised if the medical establishment doesn’t know what’s best for you. Diabetes is a disease that perhaps more than any other depends much more on the patient than on the doctor.

And now a branch of the U.S. Department of Health & Human Services has published a great pair of guides. They compare the efficacy, effectiveness, and side effects of newer premixed insulin analogues to conventional human and other insulins used to control type 2 diabetes.

The Agency for Healthcare Research and Quality on March 25 released “Premixed Insulin Analogues: A Comparison With Other Treatments for Type 2 Diabetes” for clinicians. At the same time the agency released “Premixed Insulin for Type 2 Diabetes: A Guide for Adults,” a consumer guide for those of us who need to take insulin.

Most of us don’t need to bother with the consumer guide. It’s basically a dumbed down version of the clinician guide.

When they compared the newer premixed insulin analogues to long-acting insulin analogues, which last all through the day, the premixed insulin analogues were better at lowering A1C and at lowering blood glucose after meals. On the other hand, the long-acting insulin analogues are better at lowering fasting blood glucose levels and lead to fewer hypos and less weight gain.

When they compared conventional premixed human insulin with newer premixed insulin analogues, the latter was better at lowering blood glucose after meals. But both kinds of insulin were equally effective at lowering A1C and at lowering fasting blood glucose levels. Hypos and weight gain were similar with both of these kinds of insulin.

Is it better to control our fasting or post-meal level? It depends on your A1C.

Recent research based on studies of hundreds of people with type 2 diabetes show that high levels after meals has a greater effect on A1C levels among people who have their diabetes under good control than among those with poor control.

When A1C results are lower – less than 7.3 – mealtime glucose contributes about 70 percent of the A1C. However, when A1C results are higher – greater than 10.2 – fasting blood glucose contributes 70 percent of the A1C value.

These guides also have a neat chart showing when the different types of insulin work on our bodies:

One of the biggest problems that new users of insulin have is the timing of their injection. Gary Scheiner’s article “Postprandial Hyperglycemia: It’s All In the Timing,” which he wrote for my website, deals with these questions.

But if you are using oral medications to control your type 2 diabetes instead of insulin, the Agency for Healthcare Research and Quality has addressed those questions too. Those are easier questions to answer, which is probably the reason why the agency published those guides more than a year ago.

Pills for Type 2 Diabetes: A Guide for Adults ” is the consumer guide. The clinician guide is “Comparing Oral Medications for Adults With Type 2 Diabetes.”

Either the insulin or the pill guides will probably have something to say to you. After all, only about 15 percent of people with diabetes take neither insulin or diabetes pills. And I wonder how many of them have their diabetes under control.

This is a mirror of one of my articles that Health Central published. You can navigate to that site to find my most recent articles.

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4 responses so far ↓

  • 1 william // Jun 29, 2009 at 11:42 am

    Update. As I posted here several months back, I was put on insulin for type 2 diabetes back in January. My readings were stuck around 200 for months. The good news is that I’m starting to see the 170 range as the occasional high. Most of my pre meal readings (with the exception of breakfast) are around 120 average. Still high, but coming down. My mornings, however, are still stuck in the 140s and 150s. I’m taking Januvia and Glumetza and I’m on two formulations of insulin – Novolog and levamir. I have my next checkup with my diabetes specialist in july. My question is, should I be asking him about byetta or different oral meds to add/substitute to get my morning readings down? My doctor mentioned the posibility of doing a split dose of levamir. Any suggestions you have would be greatly appreciated.

  • 2 David Mendosa // Jun 29, 2009 at 11:47 am

    William,

    I think your doctor’s suggestion of splitting your dose of basal insulin is a good one. Many people need to do that.

    Byetta could well help you. But that depends on your A1C and BMI levels. Please let me know what they are.

    Best regards,

    David

  • 3 Mohamed saleh // Dec 1, 2011 at 7:09 pm

    First sorry for my weak english,iam type 2 diabetic for more than 15 years ,I am 50 years old and iam mixtard painfull user for about 6 months ,and iam on diet control for about 3 months now ,my measurment looks good now ,especially after diet control,my question is, I am not happy using this type of insulin ,as i heard from my friends lievs in united state that mixtard is no longer use their,and now the trend is lantus insulin with metformin pills,is that true ,shoud i start using this combination…….by the way I am a pharmacist and have a family history of diabiets ,thanx for your help

  • 4 David Mendosa // Dec 1, 2011 at 8:13 pm

    Dear Mohamed,

    I wish that I could tell you want kind of insulin to use. But that would not be right, since you doctor needs to examine you and make that determination.

    David

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