Stanley Schwartz, MD, FACP, FACE, shares his views on early insulin initiation.
Insulin is the most effective agent available for lowering glycemia. If given in appropriate doses, insulin may decrease any elevated HbA1c to, or close to, the therapeutic goal.
However, insulin therapy is associated with weight gain of 2 to 4 kg (e.g. 4 kg in ~10 years in UKPDS), which is proportional to the patient’s caloric intake and reduction of glycosuria, that is, "storing the calories that otherwise would be excreted with the urine when they are hyperglycemic"….
Insulin therapy is also associated with hypoglycemia. In clinical trials, aimed at normoglycemia and achieving a mean HbA1c of 7%, severe hypoglycemic episodes (defined as requiring help from another person to overcome the problem) occurred at a rate between one and three per 100 patient‑years (that is the use of agent by anyone for 1 year), compared with 61 per 100 patient‑years in the Diabetes Control and Complication Trial (DCCT) intensive therapy group.
Moreover, while trying to achieve good blood glucose control in patients who are eating "too much of the right stuff" or eating "the wrong stuff" (simple carbohydrates), insulin doses are often increased. Then, when patients try to eat better, they may experience an increase in appetite prior to meals, and in their effort to avoid hypoglycemia may typically consume excess calories to prevent hypoglycemia, thus gain weight. Additionally, the patient may be unaware of hypoglycemia during sleep, which may result in rebound fasting hyperglycemia which is then inappropriately treated by increasing their basal doses. This engenders a vicious cycle, typified by marked increases in weight and recurrent, significant hypoglycemia, and overall poor control.
Thus, for the benefit of avoiding undue weight gain and hypoglycemia, we use 2-4 non-hypoglycemic agents and expect a patient to follow a eucaloric diet, having eliminated simple carbohydrates and instead consuming a calorie‑controlled diet with moderate amounts of high‑fiber, complex carbohydrates, lean proteins and heart‑healthy fats.
If they do not follow such a diet, we will not start insulin even if they are persistently hyperglycemic, (even if they are not at ADA or AACE glycemic or HbA1c goals) as long as they are asymptomatic- without polyuria, polydipsis, polyphagia-, as we believe the vicious cycle above is more dangerous to the patient acutely, than persistent asymptomatic hyperglycemia.
Thus, we delay starting insulin therapy until the patient and team (Physician, Registered Dietitian‑Nutritionist, Certified Diabetes Educator) is confident that the patient is compliant with a eucaloric diet, having eliminated simple carbohydrates and instead consuming a calorie‑controlled diet with moderate amounts of high‑fiber, complex carbohydrates, lean proteins and heart‑healthy fats, and having failed 2-4 non-hypoglycemic, agents.
We have no hesitation in starting insulin with patients who have persistent hyperglycemia after 2-4 non-hypoglycemic agents if they are on the correct diet. We will keep non-insulin therapies (except sulfonylureas/glinides], when we start basal analogue insulin, as we find total insulin doses required for control, need for bolus insulin, and glycemic variability through the day are all reduced if this is done, especially if an incretin is used/kept (on label-sitagliptin, the other incretins off-label). If, post-prandial sugars are still elevated after achieving good control of fasting sugars, we will then start bolus analogue insulin therapy. We use analogue insulins for clinical experience in seeing less hypoglycemia and weight gain, which is confirmed by at least some of the data in the literature.
It has been much easier to obtain compliance with injectables in our patients since the advent of availability of 30-32 gauge needles , especially if we ‘poke’ patients with one in the office proving to them that these needles don’t hurt! In fact we find more ‘injectable-resistance’ in physicians and care-givers, and find the same advice (poking themselves with these needles) engenders more passion on the part of these care-givers in recommending injectable therapies when needed.
Dr. Schwartz has been awarded the honor of being a TOP DOC by Philadelphia Magazine many times over the years, including 2009, 2010 and 2011 for the treatment of diabetes and metabolic syndrome. For over 30 years, Dr. Schwartz was an Associate Professor at the University of Pennsylvania, most recently directing the Diabetes Program at the Philadelphia Heart Institute.
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