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Insulin Therapy for Type 2 Diabetes

by Virginia Peragallo-Dittko, RN, BC-ADM, MA, CDE

If you feel defeated, remember that perfection is not the goal of diabetes self-management. Even if you chose not to make healthy food choices or to exercise in the past, insulin therapy is not a punishment. But it can be an opportunity to reevaluate your choices and get involved in managing your health. Once you know the facts about Type 2 diabetes, you’ll see that you didn’t fail; your pancreas did.

Insulin therapy as threat. For years, your doctor threatened you with insulin therapy if you didn’t stop overeating. Unfortunately, this practice continues. Some well-intentioned health-care providers use insulin injections as a threat to motivate people. However, this only serves to send the message that insulin injections are something to be avoided, not that insulin is one of many effective treatments for diabetes. Health-care providers need to learn other methods for helping people who struggle with managing their diabetes.

Insulin inconvenience. It’s true; it is easier to take pills. However, newer insulin delivery devices minimize the inconvenience of taking injections, and insulin regimens can be tailored to your needs and your routines to make it easier.

Permanent or temporary?
In the treatment of Type 2 diabetes, insulin therapy may be prescribed for a variety of reasons and may be permanent or temporary. For example, some people require short-term, or temporary, insulin therapy when they take certain drugs such as steroids to treat other medical conditions. Because steroids such as prednisone can cause extremely elevated blood glucose levels, insulin may be used to lower blood glucose levels during steroid use. Generally, when the steroids are discontinued, the person no longer requires insulin therapy.

Infection or long periods of untreated diabetes may cause a condition called glucotoxicity. When someone is glucotoxic, elevated blood glucose levels interfere with the body’s ability to lower blood glucose. Short-term insulin therapy is used to lower blood glucose levels, eliminating the glucotoxicity and restoring the body’s normal glucose regulation.

Effective treatments for insulin resistance include weight loss, exercise, and insulin-sensitizing medicines such as pioglitazone (Actos), rosiglitazone (Avandia), and metformin (Glucophage). But some people may also require large doses of injected insulin, at least initially, to get past the barrier of insulin resistance and keep their blood glucose within range. Once these people have lost weight and begun exercising, they may be able to discontinue insulin therapy—as long as their pancreas continues to produce insulin. But people who have both insulin resistance and a pancreas that cannot secrete enough insulin require permanent insulin replacement.

Insulin replacement strategies
Just as there are different reasons to use insulin therapy, there are different formulations of insulin that are prescribed based on what your body needs. To get past the barrier of insulin resistance or to combat glucotoxicity, long-acting or intermediate-acting formulations of insulin may be prescribed. Long-acting insulins, which include Ultralente and the insulin analog glargine (Lantus), are typically injected at bedtime and are usually effective for up to 24 hours. Intermediate-acting insulins, which include NPH and Lente, are also often injected at bedtime but are effective for only 12 to 16 hours.

When both insulin resistance and inadequate secretion of insulin by the pancreas are the problem, two different insulin formulations are needed: one long-acting, or basal, insulin and one short-acting, or bolus, insulin. The long-acting insulin supplies the low-level, background insulin needed by the body at all times; the short-acting insulin supplies the insulin your body needs at mealtimes to handle the glucose from food. So-called “mealtime” insulins include Regular and the rapid-acting insulin analogs lispro (Humalog) and aspart (NovoLog).

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