Diabetes Self-Management Blog

Doctors are starting people with Type 2 diabetes on insulin sooner, sometimes at diagnosis. But two recent studies give reason to question this treatment. If you have Type 2, is insulin right for you?

The reason for starting insulin early is simple: Insulin is the quickest way to lower blood glucose levels, and high blood glucose does most of the damage in diabetes. The American Diabetes Association 2014 guidelines say, “In newly diagnosed Type 2 diabetic patients with…elevated blood glucose levels or A1C, consider insulin therapy, with or without additional agents, from the outset.”

Although people with Type 2 make their own insulin, they either do not have enough or are not sensitive enough to it to keep glucose levels down. So the reasoning is, why not help out by injecting more?

But it turns out that in some cases injected insulin may do as much harm as good. Whether it is right for a particular person is an individual decision. A recent study in The Journal of the American Medical Association finds that the negatives may outweigh the positives in many people with Type 2 over the age of 50.

Study coauthor John S. Yudkin said blood sugar levels aren’t everything. Quoted on Diabetes in Control, he said,

The aim of a treatment is not to lower blood sugar for its own sake but to prevent debilitating or deadly complications. If the risk of these complications is suitably correspondingly low and the burden of treatment high, treatment will do more harm than good.

The study followed roughly 5,000 people with Type 2 in the United Kingdom for about 20 years, assessing their quality of life and their rate of complications. They compared the relative risk of complications with the burden and side effects of the treatment.

They found that age makes a big difference. If you begin insulin therapy at age 45 and can lower your A1C by 1%, you may gain 10 months of healthy living. But if you start insulin at age 75, a 1% reduction in A1C could be expected to gain you three weeks of healthy life. In that case you might want to ask if 10–15 years of injections, with their hassles and side effects, would be worth the expected benefit.

“Ultimately,” said Yudkin, “the balance between the two can never be defined by a simple figure like blood sugar level.” It depends on a person’s preferences and abilities. For example, if a person can’t afford glucose monitoring supplies or doesn’t want to monitor, insulin would be a mistake for him.

The researchers caution that their results do not apply to people with an A1C at or over 8.5%. Those with high numbers are at more risk and more likely to benefit from insulin.

Additional research
Another large review, conducted at Vanderbilt University and published in The Journal of the American Medical Association, also takes a dim view of insulin in Type 2. In this study, it was found that lifespan may be reduced when insulin is added to the treatment of people already receiving metformin.

Researchers evaluated the records of more than 178,000 people who were taking metformin. When metformin fails to lower A1C to the target range (usually 7%), a second drug is often added. In this study, 2,948 added insulin and 39,990 added a sulfonylurea drug. Sulfonylureas tell the pancreas to produce more insulin on its own.

Patients’ records were followed for approximately 14 months after they started their second drug. Although the rates of heart attack and stroke were similar, there was a higher death rate among the people receiving insulin.

Why would insulin lead to higher death rates? The authors wrote that weight gain and hypoglycemic episodes (lows) caused by insulin might explain the poorer outcomes.

Hypoglycemia puts tremendous strain on the heart, causing it to pump harder while its own blood supply is reduced. It’s a huge stressor. The strain of hypoglycemic episodes on the heart may cancel out the cardiac benefits of tighter glucose control.

But please note that sulfonylureas can cause lows too. The risks of “tight control” only apply to tight control achieved through certain drugs, not to control achieved by healthier living.

So if you are considering insulin, or if you are on it and have experienced lows, you might ask your doctor if the risk is worth it for you. You might be better off with one of the incretin drugs (Byetta, Bydureon, Victoza, Januvia, Janumet, Janumet XR, Juvisync, Onglyza, Kombiglyze XR, Nesina, Kazano, Oseni, Tradjenta, Jentadueto) or with natural remedies such as a low-carb diet, exercise, vinegar, or bitter melon.

Of course, if insulin is working for you, you should probably keep taking it. As all studies conclude, the right decision is different for each person. Choose what’s right for you.

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Comments
  1. Years back, when I was on a sulfonylurea, I had lows in the 40’s several times a week.

    Now I am on an insulin pump, I get a low in the 50’s 2 or 3 times a YEAR. Adjusting the dosage is up to me, rather than a doctor who sees me for 15 minutes every 3 months.

    I think these studies are flawed.

    -Lloyd

    Posted by Lloyd |
  2. At age 73 and taking Metforim, I thank you so much. This supports the common sense, patient life style centered approach of my MD and me.

    Posted by joan |
  3. I am 85 and have been on metiformin, acthos, and now Januvia or Onglyza… had been also on glimepride, but have dropped that, and only use it once a day if my tests show above 130. I have been averaging 110 with daily fasting tests in the a.m. Watching my diet, and doing regular daily around the house activities. No special exercise program. I fee pretty good, and my Dr. had wanted to put me on insulin perhaps 10 years ago, but I didn’t like to use needles, nor work with the ups and downs that sometimes comes with insulin… so he put me on metiformin and some of the others.. and I feel I am managing well. My problem is weight gain over the past 10 years of about 20 to 25 pounds which I can not shake.. any help would be appreciated. I am careful with my diet, and eat half or less portions of everything when we go out.

    Posted by Donna Johnston |
  4. My sister had a co-worker who got sick and tired of taking drugs for his Type 2 Diabetes, so he asked his doctor if he could switch to insulin. He gained a ton of weight and died suddenly of a heart attack at age 60. He left a wife, children, and grandchildren who depended on him. Insulin is not for everyone for sure.

    Posted by Mary G |
  5. I’ve always considered my A1c of secondary importance to the narrow range of blood sugar levels in healthy non-diabetics. It takes considerable effort and education to achieve this. Even a fairly good A1c can be a result of some really low and many way too high readings… especially eating a high carb diet. Insulin is rather necessary for optimal results. Your test meter is your best friend too.

    What are the chances that most of this type of research involves diabetics who eat the normal low fat, high carbohydrate diet? Pretty good I’ll bet and the results they produce are completely predictable, as your findings show David.

    Posted by JohnC |
  6. David, unless you can provide some scientific reason for including vinegar and bitter melon, such as large studies done by disinterested parties, i would appreciate you leaving this voodoo junk out of this magazine.Diabetes is hard enough without all the BS….A

    Posted by airblade |
  7. Dear Airblade,

    There is good evidence for vinegar’s value, which we have frequently cited, like here and here. This research was done by “disinterested parties” at universities.

    They were not “large studies.” There will NEVER be “large” studies, because there is no money in vinegar. That doesn’t make it “voodoo”. With bitter melon, there are fewer studies in humans, but much anecdotal evidence and some animal studies, which I cited here.

    Again, there’s virtually no money in it, so there likely will never be large studies of bitter melon.

    I’m not going to stop mentioning these treatments. They are safe, affordable, and have worked for millions of people.

    Posted by David Spero RN |
  8. Dear David, Your numbers are a bit off, since when do 10 subjects equal millions of people. If this stuff was the greatest thing since sliced bread, every Dr would be handing their diabetes patients gallons of vinegar with a bitter melon chaser. This kind of voodoo info has helped to bring back measles and other childhood diseases, from the novac crowd, who are sure that they have the right info. Everyday i get lots of D2 cures in my inbox, including both of your suggestions, its called spam….A

    Posted by airblade |
  9. I am type 2 for several yrs and presently monitor on rising in the morning taking insulin only if reading is over 140. also taking 1000 mg metformin but have semtoms of vision bluring, but swim 2/3 of a mile a dayand try to cut down on carbs. My problems is with different opions from all the experts.Frankly I am confused. Am pretty healthy for 81 but don,t want to become a victom of htis terrible curse of Dibeties.

    Posted by James C. Porter |
  10. I posted a reply to Davids magic thinking post and its gone. I would like to know who is in charge of censoring these posts…A

    Posted by airblade |
  11. Thank you, David for posting information about vinegar and bitter melon. I have found all your posts to be intelligent, well informed and sensible.

    Posted by Consuelo |

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