Insulin: second line or last resort?

If you had diabetes, treated with oral medicines for many years, would you be afraid to start insulin? That was the question in my mind as I spoke to Lorraine today and tried to allay her fears about starting insulin. With fasting blood glucose levels above what we want to see 2 hours after a meal and a hemoglobin A1c above 10, there was no question she was overdue.

Last year we started seeing new information about when patients should start insulin in the course of their disease progression. Patients seem to think it means you're nearly in the grave, and starting insulin is a "last resort." Well, now we're finding out that preserving pancreatic insulin secretion by supporting the patient's current level of functioning with exogenous (injected) insulin helps improve the long-term glucose control patients are able to achieve.

We are basically using certain oral medicines (not all, metformin and others excepted) to "flog" the pancreas into producing insulin at its maximum capacity. By adding insulin and removing these drugs, perhaps the pancreas won't completely lose its ability to produce insulin as quickly.

Like I told Lorraine, believe me, you want insulin--it's the best diabetes medicine we have. With this new insight, she could easily accept the role of insulin in slowing her disease progression. Given a few days to let it sink in, and some training about using insulin, she will benefit. For today, the decision to start insulin was basically turned into a "no-brainer." I'm optimistic that she will be able to embrace the challenge and have many more highly functional years to enjoy her grandchildren as a result.