Diabetes Forecast

What's Behind a Switch to Insulin?

How do health care providers decide when it is time to place their patients with type 2 diabetes on insulin? Shelley Burlison, Soldotna, Alaska

Belinda Childs, MN, ARNP, BC-ADM, CDE, responds: When you are not reaching the blood glucose goals that you have set with your diabetes care provider, then a change in treatment is needed. For most people with diabetes, the A1C goal is 7 percent or less (or estimated average glucose of 154 mg/dl or below). The goal for fasting blood glucose is generally less than 130 mg/dl, and after meals, blood glucose levels should be less than 180. If oral medications are no longer working to help keep your blood glucose levels within the target range, then it may be time to go on insulin. Sometimes, other options like Byetta or Victoza (both incretin mimetics that are injected) may be used before going on insulin.

Even with the new classes of oral medications and injectables, most people with type 2 diabetes will need insulin at some point. Some patients may start on nighttime insulin to control fasting blood glucose and then add insulin before eating to control the post-meal blood glucose levels.
It is difficult to predict how long someone can use oral meds alone to manage blood glucose. When type 2 is diagnosed, elevated blood glucose levels are a result of insulin resistance and insulin deficiency. That is, the insulin being made by the body isn't being used properly (resistance), nor is there enough insulin being made to control the blood glucose (deficiency). Diabetes is a progressive disease; by the time you're diagnosed, your body is making only 20 to 50 percent of the amount of insulin it should be. The longer you have diabetes, the more likely it is that you will need to go on insulin. Controlling your blood glucose is what is most important. Whether you take insulin or not, it is a matter of finding the right combination of healthy food choices, exercise (which helps our bodies use insulin better), and medication to reach good glucose control.



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