Tools To Help You Manage Your Diabetes When Insulin Is Prescribed

By Dace Trence, MD, FACE

It is estimated that one third of the U.S. population will be diagnosed with diabetes mellitus by the mid part of this century...perhaps even sooner if the rising trend in newly diagnosed diabetes cases continues. The vast majority of these diabetes cases will be type 2, the diabetes that results from the body’s own insulin not working as it should (what is referred to as “insulin resistance”), plus progressively less insulin being produced by the body’s pancreas.

In the early stages of diabetes type 2, medication might not be necessary. Dietary changes, combined with increased physical activity, can be very effective in controlling blood sugar. Recommended dietary changes typically include an emphasis on decreasing sugary liquid and food intake and often also decreasing total calories to lose weight. Physical activity should be increased–which does not mean having to swim the ocean to China and back every night–but making an effort to routinely (daily) walk, garden, bike. The goal is to make muscles work, as this makes the body more sensitive to insulin...and more likely to make the insulin that is being made more efficient in its work in helping keep blood sugars within normal levels.

As time progresses, medication will usually be needed to bring the blood sugar level down to normal levels. There are a variety of pills that work in different ways to help the body regulate sugar levels. Although typically one pill is prescribed, with doses adjusted depending on how well it works to get the blood sugar to goal levels. However, there is now a major, long-term study that is trying to answer a very important question: would it be better to start on a combination of two drugs?

Funded by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health (NIH), The GRADE (Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness) Study is looking at a combination of metformin and one of four other drugs. More information can be found at https://grade.bsc.gwu.edu. The results of this study, however, will not be known for some years. So, for now, the usual treatment approach is to add another pill if control of the blood sugar is not obtained at full dose of your first prescribed medication. This dual pill approach might even require a third pill. But at some point, even if pills have worked, they might not work as they did when first prescribed. Experts in the field know from a study done in the past, the UKPDS (United Kingdom Prospective Diabetes Study), that when used to control blood sugars to as normal a level as possible, pills failed for 50 percent of patients within three years and for 75 percent of patients within nine years. When this happens, there is a choice of injectable medicine: a GLP-1 (glucagonlike polypeptide-1) agonist or insulin.

THIS IS NOT A TIME TO PANIC!

Although a discussion about the need to start insulin can come as an unwelcome surprise, it does not mean that there has been a failure on your part to manage your diabetes. Remember that earlier in this article it was mentioned that part of the problem of type 2 diabetes is the progressive inability of the pancreas to make insulin. So, for many people with type 2 diabetes, there will come a need to start the use of insulin. And great progress has been made in the tools that are made for insulin use.

First, syringes have become shorter and thinner and are now 6 millimeters (about ¼ inch) in length and 31 gauge thickness (for comparison, as a measure of thinness, a safety pin is typically 17-18 gauge, and the larger the gauge, the thinner the needle). Many lancets used for doing fingerstick blood sugar checks are in the 28-30 gauge range, so they are thicker than insulin syringes!

Second, insulin can also be given through pen devices. These are either pens that are disposable after the contained insulin is used up or beyond recommended duration of use, or pens that are metal and designed to hold cartridges containing insulin–the cartridge being the disposable part–once the contained insulin has been used or has gone beyond the recommended duration of use. Needle tips that are put on the pen for insulin injection are available even in shorter sizes: 4 millimeters (about 1/6 inch), 5 millimeters (about 1/5 inch) and 8 millimeters (1/3 inch). Proper technique should be reviewed with your diabetes team, but studies show that learning how to use a pen is much easier than learning how to use an insulin syringe.

Some pens even come with a memory feature that records what your last injected insulin amount was and when it was given. But pens can be more expensive than insulin given through syringes, and health insurance coverage varies. Some insurance policies do not cover pens, some only under very specific conditions. Yet it makes sense to do some investigation into your costs for pens versus insulin bottles and syringes.

Insulin bottles should be discarded at 30 days from opening due to concerns over changes in insulin efficacy (potency), which could mean a lot of insulin having to be discarded if the doses you are using are small. As one pen contains 300 units of insulin, and typically there are 5 pens to a box, it might be more economical to use a pen if your daily insulin dose need is a small one. Your one box of pens might last you longer with less insulin having to be tossed. This is something that you should definitely review with your diabetes team!

Third, insulin can be given through reservoirs, commonly known as pumps. The American Association of Clinical Endocrinologists (AACE) has just updated a review of the status of insulin pumps in the U.S., under the guidance of diabetes specialist Dr. George Grunberger in collaboration with other experts in diabetes care. Insulin pumps are not new tools in diabetes. They have been used for more than 35 years. But the technology has improved dramatically over the years, and use also has increased dramatically. In the U.S. in 2005, an estimated 20 to 30 percent of individuals with type 1 diabetes (the diabetes that results from lack of insulin being produced by the pancreas) and less than one percent in those individuals with type 2 diabetes on insulin therapy, were using insulin pumps. The U.S. Food and Drug Administration (FDA) estimated that 375,000 pumps were in use in the U.S. in 2007, up from approximately 130,000 in 2002. And the numbers are increasing!

Several different pumps are available on the market. Some have insulin in a contained pod, put on the skin, that is controlled by a separate device, much like a PDA. Other pumps have the capacity to be linked to a continuous blood sugar sensor that can shut the pump down for a period of time if a pre-determined low blood sugar level is sensed. Some pumps have the capacity to receive glucose (blood sugar) data from your glucose meter, allowing the use of computer-based programs located in the pump that can help decide how much of an insulin dose might be required for a meal, or to bring down a high blood sugar to more normal levels. But pumps require much skill in preparation to ensure optimal operation. Education in how best to use the pump to help you with your diabetes is a critical part of preparing for pump use. And pumps are very expensive.

A possible alternative is the recently available “patch pump”–a disposable reservoir of insulin designed to work for 24 hours and then disposed of. It delivers one of three different constant rates of insulin over 24 hours and also allows a variable amount of insulin to be given before meals. This is a less-costly alternative to typical insulin pumps, but is limited in the amount of daily total insulin that can be delivered in this manner.

The bottom line: if you hear insulin mentioned, don’t despair. You DO have options!

Dr. Dace Trence is Director of the Diabetes Care Center and Professor of Medicine at the University of Washington Medical Center in Seattle. She is also the University of Washington Endocrine Fellowship Program Director and Director of Endocrine Days, a medical education program for endocrinologists practicing in the Pacific Northwest. She is on the American College of Endocrinology Board of Trustees and chairs the CME Committee and is also chair of the AACE Publications Committee.