Type 2 Diabetes and Insulin: When and Why Is It Prescribed? Type 2 diabetes is a chronic condition affecting millions worldwide. While lifestyle modif...

Type 2 Diabetes and Insulin: When and Why Is It Prescribed?

Type 2 diabetes is a chronic condition affecting millions worldwide. While lifestyle modifications and oral medications are often the first line of defense, insulin can become a necessary treatment option at various stages of the disease. This article explores the role of insulin in Type 2 diabetes management, detailing when and why it is prescribed, different types of insulin, and what to expect when starting insulin therapy. Understanding this critical aspect of diabetes care empowers individuals to make informed decisions in partnership with their healthcare providers.

Insulin is not a sign of failure but a potentially life-changing treatment to help achieve optimal blood sugar control and prevent long-term complications. It's a natural hormone that everyone produces, and sometimes the body simply needs help regulating it effectively.

Understanding Type 2 Diabetes and Insulin Resistance

In Type 2 diabetes, the body either doesn't produce enough insulin or becomes resistant to its effects. Insulin resistance means that cells don't respond properly to insulin, preventing glucose (sugar) from entering cells to be used for energy. This leads to a buildup of glucose in the bloodstream, resulting in high blood sugar levels (hyperglycemia).

Key Factors Leading to Insulin Resistance:

Genetics: A family history of diabetes increases the risk.
Obesity: Excess weight, especially abdominal fat, is strongly linked to insulin resistance.
Physical Inactivity: Lack of exercise contributes to decreased insulin sensitivity.
Age: Insulin resistance tends to increase with age.
Certain Medical Conditions: Polycystic ovary syndrome (PCOS) and non-alcoholic fatty liver disease (NAFLD) are associated with insulin resistance.

The Progression of Type 2 Diabetes:

Initially, the pancreas tries to compensate for insulin resistance by producing more insulin. This can maintain normal blood sugar levels for a period, but eventually, the pancreas may become exhausted and unable to keep up. This leads to a decline in insulin production and a gradual increase in blood sugar levels, ultimately resulting in a Type 2 diabetes diagnosis.

The following table highlights the typical progression:

| Stage | Insulin Production | Insulin Resistance | Blood Sugar Levels | | -------------------------- | ------------------ | ------------------- | ------------------ | | Pre-Diabetes | Increased | Present | Slightly Elevated | | Early Type 2 Diabetes | High to Normal | Significant | Elevated | | Later Type 2 Diabetes | Decreased | Significant | Significantly Elevated |

When is Insulin Prescribed for Type 2 Diabetes?

Insulin is usually considered after other treatments, such as lifestyle changes and oral medications, have not achieved adequate blood sugar control. Several factors can lead to an insulin prescription in Type 2 diabetes, including:

A1C levels remaining above target: If the hemoglobin A1c (A1C) level, which reflects average blood sugar levels over the past 2-3 months, consistently remains above the target range (typically 7% or lower) despite other treatments, insulin may be recommended.
Symptoms of high blood sugar: Persistent symptoms of hyperglycemia, such as excessive thirst, frequent urination, unexplained weight loss, and fatigue, may indicate that blood sugar control is inadequate, and insulin may be necessary.
Certain medical conditions or situations: Insulin may be the preferred treatment during pregnancy (gestational diabetes or pre-existing Type 2 diabetes), after surgery, during illness, or if certain kidney or liver problems prevent the use of other diabetes medications.
Oral medications are not enough: As Type 2 diabetes progresses, the pancreas naturally produces less insulin. In some cases, the oral medications that help the body use insulin more efficiently or stimulate the pancreas to release more insulin are no longer enough to keep blood sugar levels in the target range.

The American Diabetes Association (ADA) recommends that healthcare providers consider adding insulin if non-insulin therapies fail to achieve or maintain glycemic targets. They emphasize individualizing treatment plans based on patient-specific factors.

Types of Insulin Used in Type 2 Diabetes

Various types of insulin are available, each with different onset, peak, and duration of action. This allows for individualized treatment regimens to best match a person's eating habits and lifestyle. The main categories include:

Rapid-acting insulin: Starts working within 15 minutes, peaks in 1-2 hours, and lasts for 2-4 hours. Taken before meals to cover food intake. Examples include lispro (Humalog), aspart (Novolog), and glulisine (Apidra).
Short-acting insulin (Regular insulin): Starts working within 30 minutes, peaks in 2-3 hours, and lasts for 3-6 hours. Also taken before meals, but needs to be administered further in advance compared to rapid-acting. Example: Humulin R, Novolin R.
Intermediate-acting insulin (NPH insulin): Starts working in 1-2 hours, peaks in 4-12 hours, and lasts for 12-18 hours. Provides background insulin coverage and is often taken twice daily. Examples: Humulin N, Novolin N.
Long-acting insulin: Starts working in a few hours and provides a steady level of insulin for 24 hours or longer. Provides basal (background) insulin coverage and is typically taken once daily. Examples: glargine (Lantus, Basaglar, Toujeo), detemir (Levemir), and degludec (Tresiba).
Ultra-long-acting insulin: Degludec (Tresiba) can last up to 42 hours, offering extended basal coverage.
Premixed insulin: Combinations of different insulins (e.g., rapid-acting and intermediate-acting) in a single injection to provide both mealtime and background coverage. Examples: Humalog Mix 75/25, Novolog Mix 70/30, Humulin 70/30, Novolin 70/30.

Selecting the appropriate insulin type and regimen requires careful consideration of individual needs, blood sugar patterns, lifestyle, and preferences. Healthcare providers work closely with patients to develop personalized treatment plans.

The table below summarises the different insulins, providing details on their onset, peak and duration:

| Insulin Type | Onset | Peak | Duration | | ------------------- | ----------------- | -------------------- | ----------------- | | Rapid-Acting | 15 minutes | 1-2 hours | 2-4 hours | | Short-Acting | 30 minutes | 2-3 hours | 3-6 hours | | Intermediate-Acting | 1-2 hours | 4-12 hours | 12-18 hours | | Long-Acting | Several hours | No pronounced peak | 24 hours or more | | Ultra-Long-Acting | Several hours | No pronounced peak | Up to 42 hours |

Administering Insulin: Methods and Techniques

Insulin is typically administered via subcutaneous injection, meaning it's injected into the layer of fat just beneath the skin. Common injection sites include the abdomen, thigh, upper arm, and buttocks. Rotating injection sites is important to prevent lipohypertrophy (fatty lumps) or lipoatrophy (loss of fat tissue) at the injection sites, which can affect insulin absorption.

Methods of Insulin Administration:

Syringes and vials: Traditional method involving drawing insulin from a vial into a syringe and injecting it.
Insulin pens: Convenient, pre-filled devices that deliver a precise dose of insulin with each injection. The pen needles are very fine and usually make the injection almost painless.
Insulin pumps: Small, computerized devices that deliver a continuous basal dose of insulin throughout the day and bolus doses (mealtime insulin) at the touch of a button. Insulin pumps can improve blood sugar control and reduce the frequency of injections but require training and commitment.

Essential Injection Techniques:

Wash hands: Before each injection, wash your hands thoroughly with soap and water.
Prepare the injection site: Clean the injection site with an alcohol swab and allow it to dry.
Pinch the skin: Gently pinch up a fold of skin at the injection site.
Insert the needle: Insert the needle at a 90-degree angle (or 45-degree angle if using a shorter needle) into the pinched skin.
Inject the insulin: Push the plunger of the syringe or pen slowly and steadily until the dose is delivered.
Hold for a few seconds: Keep the needle in place for a few seconds after injecting the insulin to prevent leakage.
Release the skin and remove the needle: Release the pinched skin and carefully remove the needle.
Dispose of the needle properly: Dispose of used needles and syringes in a sharps container to prevent accidental needle sticks.

Your healthcare team, including a certified diabetes educator (CDE), can provide comprehensive training on proper insulin administration techniques.

Monitoring Blood Sugar and Adjusting Insulin Doses

Regular blood sugar monitoring is crucial when taking insulin. Monitoring helps determine how the insulin is working and whether dose adjustments are needed. This is usually done with a blood glucose meter that measures the glucose level in a small drop of blood, typically obtained by pricking a finger. Continuous glucose monitors (CGMs) are also becoming increasingly popular, which track blood sugar levels continuously throughout the day and night, providing valuable insights into glucose trends and patterns.

Frequency of Blood Sugar Monitoring:

The frequency of blood sugar monitoring varies depending on the individual's insulin regimen, blood sugar control, and overall health. Your healthcare provider will recommend a personalized monitoring schedule, but generally, people taking insulin need to check their blood sugar:

Before meals
2 hours after meals
Before bedtime
Occasionally in the middle of the night (especially when starting insulin or adjusting doses)
Before, during, and after exercise
When feeling symptoms of low or high blood sugar

Adjusting Insulin Doses:

Insulin doses should be adjusted based on blood sugar readings, carbohydrate intake, activity levels, and other factors. Your healthcare provider will provide specific instructions on how to adjust your insulin doses. The common rule is to start with low doses, gradually increase the doses to meet the target level and minimise side effects. It's important to keep a log of blood sugar readings, insulin doses, food intake, and activity levels to help identify patterns and make informed adjustments. Never adjust your insulin doses without consulting with your healthcare provider.

Potential Side Effects and How to Manage Them

Insulin therapy is generally safe and effective, but potential side effects can occur. The most common side effects include:

Hypoglycemia (low blood sugar): The most concerning side effect of insulin is hypoglycemia, which occurs when blood sugar levels drop too low (typically below 70 mg/dL). Symptoms of hypoglycemia can include shakiness, sweating, dizziness, confusion, and, in severe cases, loss of consciousness.

Management:

Carry a source of fast-acting glucose (e.g., glucose tablets, juice, hard candy) at all times to treat hypoglycemia.
Follow the "15/15 rule": If blood sugar is low, consume 15 grams of carbohydrates, wait 15 minutes, and recheck blood sugar. Repeat if necessary.
Wear a medical ID bracelet or necklace to alert others in case of severe hypoglycemia.
Ensure family, friends, and coworkers know how to recognize and treat hypoglycemia.
Weight gain: Insulin can promote weight gain, as it helps glucose enter cells, where it can be stored as energy.

Management:

Work with a registered dietitian to develop a healthy eating plan that is low in calories and carbohydrates.
Engage in regular physical activity to burn calories and improve insulin sensitivity.
Discuss weight management strategies with your healthcare provider.
Injection site reactions: Redness, swelling, itching, or pain at the injection site can occur.

Management:

Rotate injection sites regularly to prevent lipohypertrophy.
Use proper injection techniques.
Apply ice or a topical corticosteroid cream to the injection site if needed.
Lipohypertrophy (fatty lumps): Repeated injections at the same site can cause fatty lumps to form under the skin, which can affect insulin absorption.

Management:

Rotate injection sites regularly.
Avoid injecting into areas where lipohypertrophy has developed.
Other possible side effects: These include oedema and allergic reactions.

It's important to promptly report any side effects to your healthcare provider so they can be addressed appropriately.

The Psychological Aspects of Starting Insulin

Starting insulin can be emotionally challenging for some people with Type 2 diabetes. Concerns about injections, the stigma associated with insulin, and the perceived failure of other treatments can lead to feelings of anxiety, fear, or depression. It's important to acknowledge and address these emotions.

Coping Strategies:

Education and support: Learning about insulin therapy and connecting with others who are on insulin can alleviate anxiety and provide valuable support.
Open communication: Talk openly with your healthcare provider about your concerns and fears.
Support groups: Join a diabetes support group to share experiences and learn from others.
Mental health professional: If feelings of anxiety or depression are overwhelming, consider seeking help from a mental health professional.
Focus on the benefits: Remind yourself that insulin can improve blood sugar control, reduce the risk of complications, and enhance your overall quality of life.

Lifestyle Adjustments Alongside Insulin Therapy

Insulin therapy is most effective when combined with a healthy lifestyle. The treatment works best when you're also looking after other things. In particular you should be aware of your eating habits and also taking some exercise.

Dietary Recommendations:

Follow a balanced eating plan that is low in processed foods, sugary drinks, and saturated fats.
Work with a registered dietitian to develop a personalized meal plan that fits your individual needs and preferences.
Pay attention to carbohydrate intake and adjust insulin doses accordingly.
Eat regular meals and snacks to prevent hypoglycemia.

Exercise Guidelines:

Aim for at least 150 minutes of moderate-intensity aerobic exercise per week.
Engage in strength training exercises at least twice per week.
Check blood sugar levels before, during, and after exercise and adjust insulin doses or carbohydrate intake as needed.
Carry a source of fast-acting glucose during exercise in case of hypoglycemia.

Advances in Insulin Technology and Delivery Systems

The field of diabetes technology is constantly evolving, with new advances in insulin and delivery systems. These innovations aim to improve blood sugar control, reduce the burden of diabetes management, and enhance the quality of life for people with diabetes. Some of the latest advances include:

Smart insulin pens: These pens connect to smartphone apps to track insulin doses, blood sugar levels, and other data.
Automated insulin delivery systems (artificial pancreas): These systems combine a continuous glucose monitor (CGM) with an insulin pump and a sophisticated algorithm to automatically adjust insulin doses based on real-time blood sugar levels.
Faster-acting insulins: Newer insulin formulations are designed to be absorbed more quickly, providing better mealtime coverage and reducing the risk of postprandial hyperglycemia.
Inhaled insulin: Afrezza is a rapid-acting inhaled insulin that is absorbed through the lungs, providing a convenient alternative to injections for some people.

It's crucial to discuss with your healthcare provider whether new technologies and systems are appropriate for your situation.

Conclusion: Embracing Insulin as a Tool for Better Health

Insulin is a powerful tool for managing Type 2 diabetes and achieving optimal blood sugar control when lifestyle modifications and oral medications are no longer sufficient. Understanding the different types of insulin, proper administration techniques, and potential side effects is essential for safe and effective use. Insulin is not a sign of failure but rather a means to improve overall health and prevent long-term complications. The key to success lies in close collaboration with your healthcare team, regular blood sugar monitoring, healthy lifestyle choices, and a positive attitude. Embracing insulin as a tool for better health empowers individuals with Type 2 diabetes to live full and active lives.