Diabetes Forecast

Insulin for Type 2: 9 Things to Know

Myths and fears about insulin abound. Here’s a quick look at the truth

By Erika Gebel Berg, PhD , , ,

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Insulin is life—without it, the body can’t convert the food we eat into the energy that’s needed to survive. Type 1 diabetes targets for destruction the cells that make insulin, and so the disease absolutely requires that insulin be taken as a medication. The relationship between insulin and type 2 diabetes is more complicated. People with type 2 can make some of their own insulin, but it’s not enough to maintain normal blood glucose levels.

Type 2 diabetes can be treated with medication in several ways: encourage beta cells in the pancreas to make more insulin, help the body be more responsive to the insulin that’s there, or deliver more insulin by injection or pump. Without question, the last option is the right call for certain people with type 2 diabetes. Are you one of them? There are a lot of myths about insulin, leading some to view the medication with suspicion. It’s time to clear up what’s insulin fact, what’s fiction, and what’s not necessarily so.

1. Once you start, you can’t stop (FICTION)

Insulin has gotten a reputation for being an “end of the line” medication for type 2 that once started, can’t be stopped. “Patients ask if this is the rest of your life,” says Luigi Meneghini, MD, MBA, director of the Kosow Diabetes Treatment Center at the University of Miami Health System. Once glucose levels are controlled and lifestyle changes are in place, people may be able to use oral meds instead of insulin or reduce multiple daily injections to once daily.

2. Insulin means you failed at caring for your diabetes (FICTION)

In a large study that explored people’s beliefs about insulin, “some patients saw insulin use, or the need to start insulin, as a personal failure,” according to Andrew Karter, PhD, a researcher at Kaiser Permanente. It’s not. Type 2 diabetes is a progressive illness, which means that over time the body makes less and less insulin. Even people without diabetes produce less insulin as they age.

3. Insulin causes diabetes complications (FICTION)

While it may be true that people with type 2 diabetes who use insulin tend to have more diabetes-related complications—such as heart, eye, and kidney disease—this is a good example of an association that has nothing to do with cause and effect. The link exists, says Karter, because insulin users have had diabetes longer on average than those who take other medications. Having diabetes for a long time, even when it is controlled, makes some types of complications more likely. Plus, doctors may tend to prescribe insulin for people who are having trouble getting blood glucose under control. Uncontrolled blood glucose levels can raise the risk for complications. Insulin helps bring blood glucose to target, which can prevent complications, not cause them.

4. Insulin is only for people who’ve had diabetes a long time (FICTION) 

Sometimes insulin is the right choice for a person newly diagnosed with type 2 diabetes, says Meneghini, particularly if blood glucose levels are very high at diagnosis. “There are studies that show an intensive insulin approach for six months or a year tends to be more successful at preserving [insulin production] than oral medications,” he says. After blood glucose levels are under control, he adds, it may be possible to reduce or stop insulin and use another type of diabetes medication.

5. Oral medications are safer (NOT NECESSARILY)

It’s true that too much insulin can cause blood sugar to go too low (hypoglycemia), but it is otherwise quite safe and has no adverse effects on the heart, kidneys, pancreas, or liver, as do some other diabetes medications. “Insulin can be thought of as a clean medicine,” says Meneghini. That’s good news for people with liver or kidney problems, who may not be able to take diabetes medications that are processed through these organs.

6. Injections hurt (NOT NECESSARILY)

Insulin has to make its way under the skin to work, and for that you need a needle. Some people may experience discomfort when injecting insulin. However, today’s insulin needles are short and very thin—about the same thickness as three hairs laid side by side—making injections less painful than they once were. To help put his patients with new insulin prescriptions at ease, Meneghini injects himself with an insulin syringe containing saline a few times in the office before his patients leave. “They either think I’m completely crazy or that it doesn’t hurt so much,” he says. If concerns about pain are keeping you from trying insulin, talk to your doctor about testing a needle during a visit. You may be pleasantly surprised.

7. Insulin will lead to weight gain (NOT NECESSARILY)

Insulin helps the body absorb the calories from the foods you eat, so weight gain is a risk. When starting insulin, you can take steps to avoid packing on pounds. The obvious strategy is to eat less and exercise more. Yet there are other approaches to preventing weight gain. For example, “there is evidence that if you take insulin with metformin, then there is less weight gain,” says John Buse, MD, PhD, of the University of North Carolina–Chapel Hill School of Medicine. Some studies have also shown that using an injectable incretin mimetic, such as exenatide (Byetta) or liraglutide (Victoza), and insulin may also prevent weight gain.

8. Insulin can cause hypoglycemia (FACT)

The occasional low may be hard to avoid when taking insulin, but people with type 2 diabetes who take only long-acting insulin are less likely to have hypoglycemia than those taking multiple daily shots of mealtime insulin. “That first episode may be scary,” says Meneghini, but he tries to get patients to come around to the idea that the unpleasant symptoms are actually a good thing. “That’s your body telling you that your blood glucose is too low and you need to eat something,” he says. Before you start a new exercise routine or change your eating plan or if you experience lows, talk to your doctor about a dose adjustment.

9. Taking insulin is hard (NOT NECESSARILY)

You may associate insulin with testing blood glucose, carbohydrate counting, and other tasks. Some insulin users do benefit from these activities, but not everyone will need to do the extra work. For example, most people with type 2 diabetes who take insulin use a fixed dose of long-acting insulin, so they may not need to count carbohydrate grams, which is a strategy for adjusting mealtime insulin doses. Whether blood glucose testing is needed is more complicated. The jury is still out on who benefits from blood glucose monitoring, says Meneghini, though he encourages self-checks by people changing or adjusting medications, food, or exercise. Blood glucose measurements tend to be useless, however, without instructions on how to use the information, he says: “The frequency of testing and when you test are dependent on what you are going to do with that result.”

Types of Insulin

The body makes just one type of insulin, but scientists have developed a variety of insulins that can be taken as medication. The goal with insulin given as medication is to mimic how the body adjusts insulin levels automatically. In the absence of diabetes, the body produces low, steady insulin levels between meals and produces rapid, high peaks of insulin at meals to “match” how much food is eaten.

Long-acting insulin

begins to work several hours after injection and lowers blood glucose levels somewhat evenly over a 24-hour period.
Types: Insulin detemir (Levemir) and insulin glargine (Lantus)

Rapid-acting insulin

begins to work 15 minutes after injection, peaks in one hour, and is effective for two to four hours. It’s used in insulin pumps and for mealtime injections.
Types: Insulin glulisine (Apidra), insulin lispro (Humalog), and insulin aspart (NovoLog)

Other insulins
include regular or short-acting insulin (Humulin R, Novolin R); intermediate-acting insulin, or NPH (Humulin N, Novolin N); and premixed insulins, which combine fast-acting and longer-acting insulin.



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