- With Mayo Clinic diabetes educators
Nancy Klobassa Davidson, R.N., and Peggy Moreland, R.N.
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Nancy Klobassa Davidson, R.N., and Peggy Moreland, R.N.
Nancy Klobassa Davidson and Peggy Moreland
Nancy Klobassa Davidson, R.N., B.S.N, C.D.E
Nancy Klobassa Davidson is a registered nurse who has worked in diabetes education for 17 years. She is a certified diabetes educator (C.D.E.) and is currently in graduate school working on a Master of Science in nursing (M.S.N.) and health care education.Nancy works with adults who have type 1, type 2 and other forms of diabetes. Nancy is coordinator of the Diabetes Unit's intensive insulin therapy program within the Division of Endocrinology, Diabetes, Metabolism, & Nutrition at Mayo Clinic in Rochester, Minn. Nancy has worked extensively with insulin pump therapy and continuous interstitial glucose sensing.
Peggy Moreland, R.N., M.S.N.
Peggy Moreland is a certified diabetes educator (C.D.E.) in the Division of Endocrinology, Diabetes, Metabolism, & Nutrition at Mayo Clinic in Rochester, Minn.Peggy graduated with a Master of Science in Nursing and Health Care Education from the University of Phoenix and is a member of the American Association of Diabetes Educators and the American Diabetes Association. A certified diabetes educator (C.D.E.), Peggy enjoys working with patients to set and achieve diabetes self-management goals.
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Living with diabetes blog
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Feb. 13, 2013
Type 2 diabetes treatments: Why oral meds first?
By Nancy Klobassa Davidson, R.N., and Peggy Moreland, R.N.
One of our readers asked "Why is insulin only considered after oral medications have been found ineffective?" I think this is an excellent question. However, I'm not sure that I have a good answer.
An October 2008 study in Diabetes Care concluded that a six-month course of insulin therapy, compared with oral anti-diabetes drugs (OADs), could more effectively result in adequate glycemic control and improvement of pancreatic insulin producing cells in those who had new-onset type 2 diabetes with severe high blood sugar levels.
Type 2 diabetes is progressive, and the insulin producing cells in the pancreas deteriorate over time. There are an increasing number of children, teens, and young adults who are diagnosed with type 2 diabetes. They'll live longer with diabetes than others before them, and so will be more likely to develop severe insulin-deficiency that requires insulin replacement earlier in life.
Reasons why insulin might not be prescribed sooner if you have type 2 diabetes may include:
- Doctors are concerned about you getting low blood sugar.
- You might not be willing to start insulin or might not have the ability to give yourself injections.
- Primary care providers may perceive that insulin therapy is too complex to manage in their busy practice.
- Prescribing information may be vague, and the provider may be unsure about initial dosing, titration and what kind of insulin to start you on, which may delay making the necessary transition from oral medications to insulin.
According to an April 2005 article in Clinical Diabetes, an A1C level of 9 percent or more signifies the need to take action to lower blood glucose. Numerous studies have shown that early intervention with insulin is more important than was previously believed.
So, I don't have a good answer to this reader's question. However, if your oral medication(s) are no longer helping you control your blood sugar, discuss the option of insulin as a next step with your provider. Taking insulin doesn't mean that you've failed to manage your blood sugar. Type 2 diabetes is a progressive disease, and if you have it long enough, chances are you may eventually need insulin.
Have a good week,
Peggy
11 comments posted
March 28, 2013 10:19 a.m.
Awareness is the first level of defense in the treatment of type 2 diabetes. We must make people aware of what this disease is and how to prevent it. http://dallasnaturaldoctor.com/type-2-diabete
s-plano-chiropractor - Dr J Malay
February 27, 2013 10:10 a.m.
Thomas: Thank you. The diagnosis of type 1 in adults over 30 is often mistaken for type 2 initially as syptoms often present similarly to those with type 2 diabetes.
- Nancy and Peggy
February 27, 2013 10:03 a.m.
Sandra: Occasionally, a physician will add metformin to someone who has been on insulin for a number of years. Metformin actually works on the liver, not the pancreas as the sulfonylureas do. Metformin works to decrease the amount of glucose released by the liver into the bloodstream between meals. Metformin can also help promote weight loss, reduce cholesterol and triglycerides. Some side effects are nausea, upset stomach, or diarrhea. rarely, it may cause a harmful buildup of acid (lactic acidosis). Have a good discussion with your provider as to why you need to take metformin.
- Nancy and Peggy
February 27, 2013 9:54 a.m.
Sharon: Excellent points! Thank you.
- Nancy and Peggy
February 27, 2013 9:51 a.m.
Bonnie: Both Nancy and I have read Dr. Richard Bernstein's book, "Diabetes Solution". If his program is working for you that is great!
- Nancy and Peggy
February 26, 2013 4:22 p.m.
If you read Dr. Richard K. Bernstein's book, "Diabetes Solution", you would be able to write a better article about the use of medication and insulin for diabetes type 2 patients who want to normalize their blood sugars. You totally misrepresented his views on the protocol he uses for meal planning to help normalize blood sugar and avoid complications.See http://www.mayoclinic.com/health/comments/MY0
1817_comments#post Perhaps you could actually call his office for the 2011 book and revise your article to actually add a paragraph explaining the use of insulin and diet versus medication and diet that has worked successfully for thousands of people who have benefited from not Richard Bernstein (the Canadian doctor recommending dangerous calorie levels) and Dr. Richard K. Bernstein (the diabetes doctor who is himself a type 1 doctor and expert in diabetes wound care and prevention of diabetes complications with a clinic in New York) My A1c went from 9 to below 6 in 3 months just following what I read and free monthly pod casts and my understanding endocrinologist. What worked for me was initially counting carbs of 12-24-24 to avoid sharp drops in glucose levels, a GLP1, and Glucophage. Then we dropped the count to 6-12-12. My hope is that in 2 months time when I see the endo again, I will be at normal glucose levels. You say that I have a progressive disease. Well, already my little toes have feeling again and peripheral double vision from nerve palsy is gone. There's - Bonnie
February 26, 2013 3:01 p.m.
Am 74 been diagnosed Type 2 since I was 45(probably had it for years before discovered accidently) & had various pills (which made no difference )gave me bad dysentry.I have been on act rapid & protophane for a number of years & am a different person.before I had cystitis, tonsilitis ,pyelitis & cintinually on antbiotics.22 protophane @ night ,8 in the morning & 15 units act rapid per meal or according to what blood test is i have a chart made by diabetic Dr.
- Joyce
February 26, 2013 2:58 p.m.
Part of the issue may also be a hold-over from decades of previous practice where the golden rule was oral meds first, until they don't work any more, then Insulin as a last resort. Years ago cost and Insulin availability were issues; cost is still a factor. Though supplies like Insulin pens and easier-to-use glucose machines have made Insulin therapy easier, it is still more complex than oral meds, especially when people have decreased eye sight, memory issues, or a poor understanding of diabetes and glucose control.
- Sharon
February 26, 2013 12:15 p.m.
I hope someone answers Sandra's question. Here's a different take on why insulin might be prescribed instead of oral meds. I was able to control blood sugars for 8 years by a combination of diet and exercise. My A1C crept up to the point that I needed to do more, and started taking metformin, which didn't seem effective, and then metformin plus glipizide, which also didn't work. I went to an endocrinologist and had some blood work done, and was told that the probable reason for ineffectiveness of the meds was that I didn't have Type 2 to begin with, but rather Type 1 that in some cases progresses very gradually and is often misdiagnosed as Type 2. I now take humalog as needed with food and lantus (12 units) at night.
- Thomas
February 23, 2013 8:29 a.m.
Should you be put on metformin if you have been taking insulin for over 25 years? Currently taking humalog on a sliding scale three times a day and lantus (17 units) at night. Doctor has recently added metformin - I think it is useless as the pancreas is no longer functioning so it cannot be stimulated. Will it do more harm than good? I fear heart damage as I already have congestive heart failure. Should I be concerned? I am a Type 1 diabetic.
- Sandra
February 20, 2013 12:16 p.m.
Interesting article! I am T2. Although I would not want to be tied down with an insulin regimen, it seems healthier than dealing with drug side effects. My doctor prescribed Actos, which I took for about three months until I got my lifestyle under control. Now it's said to cause breast cancer! I think lifestyle options should be given to new patients as well as drug options. I realize some people aren't motivated, but those who are deserve the chance. My A1c was 13 or so at diagnosis almost 20 years ago and now it's 5.1 - 5.3 consistently.
- Carol
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