Insulin and Other Diabetes Medications: The Benefits of Early Treatment
Starting Blood Glucose-Lowering Meds Early Can Help
It's human nature to delay unwanted tasks—especially ones that involve pricey prescription drugs and multiday blood glucose (also known as blood sugar) checks. But when people with type 2 diabetes (PWDs type 2) delay their start on a blood glucose-lowering medication, it's not good medicine.
"We now know that type 2 is a serious and progressive disease that requires serious attention from day one," says Virginia Valentine, R.N., CDE, PWD type 2, a clinical nurse specialist in Albuquerque, New Mexico, and coauthor of Diabetes: The New Type 2 (Tarcher, 2008).
Mounting evidence shows that early, aggressive management of blood sugar, along with control of blood lipids (good and bad cholesterol) and blood pressure can make controlling type 2 diabetes easier down the road. Too often, however, people with type 2 and their health care providers are too slow to act when it comes to adding and changing medications. Some health care providers tend to delay adding insulin to treatment plans for people with type 2 diabetes.
Don't Avoid or Delay Starting Blood Glucose-Lowering Medications
The typical wait-and-see approach to treating type 2 diabetes can lead to years of living with blood sugar levels that are too high. Both the person with type 2 and their health care provider can contribute to the treatment inertia, Valentine says.
She and other providers commonly hear justifications and rationalizations from people with diabetes, including:
• "If I don’t have to take diabetes medications, then it must not be the serious kind of diabetes.”
• “Metformin will damage my kidneys."
• "Insulin will cause me to lose a foot."
There are valid concerns to consider, including drug costs, possible weight gain, and the risk of hypoglycemia, which is associated with a shrinking number of categories of blood glucose-lowering medications.
When people with type 2 ask for one more chance to lose weight or promise to watch what they eat, health care providers often hold off prescribing blood glucose-lowering medication or adding another. If blood sugar remains too high for a few more months, that risks continuous damage to organs and tissues from head to toe.
"It's not the insulin or side effects of oral glucose-lowering medicines that cause damage to the body's organs," says Claudia Shwide-Slavin, R.D., CDE, a dietitian and certified diabetes educator in New York City. "It's the out-of-control blood glucose levels for years at a stretch."
Consider Lifestyle Changes, Plus Medication
In the past, treatment for type 2 diabetes (particularly at diagnosis) focused mainly on changing lifestyle behaviors to more healthful eating, regular exercise, and weight loss. But research has led to greater understanding of the progressive nature of type 2 diabetes. The availability of several new categories of blood glucose-lowering medications introduced since 1995 has increased the push for earlier and more aggressive blood glucose control over time.
Research shows that five to 10 years before type 2 diabetes is diagnosed, and as people gain weight, insulin resistance sets in. Initially, the body is able to produce more insulin in response to rising blood sugar levels, but eventually the pancreatic beta cells are no longer able to keep up and blood glucose becomes elevated. By the time most people are diagnosed with diabetes, they have lost 50-80 percent of their beta cell function.
Less and less insulin and continued insulin resistance lead to ever-higher blood sugar levels if untreated. In addition, several other damaging health problems can occur, including high blood pressure and elevated blood lipids (such as low HDL [good] cholesterol, high LDL [bad] cholesterol, and elevated triglycerides), which are associated with insulin resistance. In fact, these problems often occur prior to the rise of blood sugar levels.
Weight loss usually improves insulin sensitivity, but weight loss is not always possible. If a person loses weight soon after being diagnosed with type 2 (or, better yet, when they have prediabetes), insulin sensitivity usually improves. "Losing even 10-20 pounds from one’s starting weight with a healthy eating and physical-activity plan can improve insulin resistance, the centerpiece of the type 2 storm. This amount of weight loss can also lower blood pressure and improve blood lipids," Shwide-Slavin says.
However, for too many people, weight loss doesn't happen, and elevated blood sugar levels progress into the diabetes range.
To Diagnose Prediabetes and Type 2 Diabetes:
Healthy Non-Diabetes <100
Healthy Non-Diabetes <140
A1C (done in a lab, not
a home test)
Healthy Non-Diabetes <5.6%
*Lower glucose levels are used to diagnose gestational diabetes (during pregnancy).
Start Blood Glucose-Lowering Medication Earlier
Today, the push is to treat type 2 diabetes aggressively from day one.
The American Diabetes Association and the European Association for the Study of Diabetes recommend: Most adults diagnosed with type 2 diabetes, in addition to losing weight, eating healthfully, and being more physically active, should immediately start on a medication to lower glucose levels. The medication most often prescribed is metformin, which combats insulin resistance and improves insulin sensitivity. However, these organizations suggest that people whose A1C is 7.5 percent or below and are highly motivated to make lifestyle changes could be given the opportunity to do so for three to six months prior to starting medication.
The goal: To improve insulin sensitivity and in turn lower blood sugar levels. Metformin does not cause weight gain and in some people may help them lose a few pounds.
Why it's important: Mounting evidence shows that aggressively lowering blood sugar levels in people newly diagnosed with type 2 diabetes can slow the dwindling of beta-cell function (insulin is made in the beta cells) and the disease progression.
Another reason to get an early start: Research shows that people with early-onset diabetes who target tight control early in the diagnosis can more easily control their blood sugar with less medication for a longer time. People who have years of inadequately controlled blood sugar have more difficulty gaining control and might need more blood glucose-lowering medicines over the years.
Additional Medications Might Be Needed
After years with type 2 diabetes, the ability to make sufficient insulin to control blood sugar is likely to decrease. Keeping blood sugar in control often requires an increased dose of one or more medications and the possible addition of other blood glucose-lowering medications over time. With more categories of these medications now available, this is possible. It wasn’t years ago. The best mix of blood glucose-lowering medications for you depends on several factors:
For starters: Your blood sugar numbers and A1C results can determine how much an additional medicine is likely to lower blood glucose.
Next: Your tolerance for the medicine, other health problems, and medical concerns impacting whether you can take certain medicines should be taken into account.
Make sure: Your provider considers whether your schedule fits with the desired regimen and that you can handle the cost of medicines.
There's no one right answer to which medications you should take and when. The same applies to when to raise the dose or add a new drug to the mix as blood glucose creeps up and insulin production declines. The American Diabetes Association and European Association for the Study of Diabetes suggest that you keep your eye on the A1C level that you and your health care provider agree is best for you. Many younger and healthier people should shoot for an A1C of 7 percent or lower. However, older individuals may not need to aim quite so low; an A1C of 7.5 percent or 8 percent may be sufficient to keep them healthy. If you're not hitting your target, work with your provider to increase or add medicines as quickly as possible to reach your A1C goal. For example, the process of starting metformin (you want to start with a low dose, like most medications) to reaching the maximum dose should occur over just one to two months.
"Way too often people and their providers wait too long to start, increase, or add medicines to the mix," says diabetes educator Virginia Valentine. Contact your provider to get the necessary changes made between office visits, if necessary.
Starting on Insulin
Many people who have had type 2 diabetes for 10 or more years no longer make enough of their own insulin to meet their body's needs.
What is insulin? Insulin is the oldest and most widely used blood glucose-lowering medicine to manage diabetes. It's very effective at lowering blood sugar, and there's no maximum effective dose. If you live long enough with type 2 diabetes, you will likely need to take insulin because your beta-cell function simply wears out over time. A C-peptide lab test can reveal how much of your beta-cell function remains. "If it's time for you to start taking insulin, don't delay," Valentine says. "Keep in mind, your beta cells have failed; you haven't."
Unfortunately, insulin has been mistakenly considered the treatment of last resort. That's in part because it must be injected, it can cause hypoglycemia, and if people are not careful about their calorie intake, it can cause weight gain.
"Insulin carries an outdated stigma that you must have a 'bad case' of diabetes if you need it," says Richard Ruth, who has had type 2 diabetes for several decades. Richard began taking insulin nearly 10 years ago. He started with long-acting insulin before bed, and over several months he and his provider realized Richard also needed to take insulin before each meal.
Other Helpful Blood Glucose-Lowering Medications
Insulin isn't the only blood glucose-lowering medication available today. Since 1995, with the approval of metformin in the United States, several new blood glucose-lowering medications have been approved by the U.S. Food and Drug Administration. And there are more on the way.
Another group of hormones that doesn’t get as much attention as insulin but also diminishes in supply is incretins.
Incretins are hormones made in and secreted from the small intestine. They enhance the release of insulin made in the pancreatic beta cells after eating and help keep blood sugar in control.
The ABCs of Diabetes
Once you start on a blood glucose-lowering medication, your healthful eating and physical activity plan remains critically important.
Diabetes control is about more than just blood sugar numbers—it's also managing blood pressure and blood lipids (cholesterol) to prevent or delay damage to your heart, eyes, nerves, and kidneys. Control of your blood pressure and cholesterol may require one or more medications to achieve your target goals.
ABCs of diabetes, according to the American Diabetes Association:
A is for ... A1C or Blood Glucose
• A1C goal: <7 percent
• Fasting and before-meals blood glucose: 80-130 mg/dl
• 1-2 hours after the start of a meal: <180 mg/dl
B is for ... Blood Pressure
• Goal: <140/90 mmHg
C is for ... Cholesterol
• Total cholesterol: <200 mg/dl
• Triglycerides: <150 mg/dl
• LDL cholesterol: <100 mg/dl
• LDL cholesterol with heart disease: <70 mg/dl
• HDL cholesterol for men: >40 mg/dl
• HDL cholesterol for women: >50 mg/dl
"Eating healthy and being physically active always help make the job of getting and keeping your ABCs in control easier, perhaps with fewer medicines to take," says diabetes educator Claudia Shwide-Slavin.
Get Your A1C on Target
During the last decade, three important studies looked at intensive glucose control (A1Cs between 6 and 7 percent) in certain diabetes populations and raised cautions about heart attacks and strokes. The National Institutes of Health ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial, the ADVANCE trial, and the Veterans Affairs Diabetes Trial investigated tight blood glucose control in people with advanced type 2 already at high risk for heart attack and stroke.
"The results of these studies have caused me to less-aggressively manage people with type 2 diabetes who are older and have had many years of diabetes," says one of the principal ACCORD investigators, Faramarz Ismail-Beigi, M.D., Ph.D., professor of medicine at Case Western Reserve School of Medicine in Cleveland. "I may strive for an A1C of 7.5 percent in these people, whereas in people with recently recognized type 2 diabetes without heart and blood vessel disease, I'll shoot for an A1C of 7 percent (or lower), if it can be done safely."
The 2015 American Diabetes Association Standards of Medical Care in Diabetes continues to promote the general A1C goal of 7 percent or less for most people. A less-stringent A1C goal, however, may be used for people with a history of severe hypoglycemia, limited life expectancy, advanced small or large vessel diseases, or people who have had diabetes for many years and can't attain an A1C of 7 percent or less.
What You Can Do:
• Discuss with your health care provider what your A1C goal should be. Think about whether this A1C goal is right for you.
• If your A1C is above the 7 percent mark or doesn’t meet the goal that you have set for yourself, talk to your provider about how you can work together to progress your therapy to gain control.