- Insulin Do’s and Don’ts
- Do rotate the place where you inject insulin
- Do clean your skin before you inject
- Do check your blood sugar regularly and write down each measurement
- Do count your carbs before using mealtime insulin
- Do know the signs of hypoglycemia
- Do tell friends and family that you’re taking insulin
- Don’t inject the insulin too deep
- Don’t wait more than 15 minutes to eat after taking a mealtime insulin
- Don’t panic if you accidentally take the wrong dose
- Don’t switch your insulin dose or stop taking it without seeing your doctor first
- The bottom line
- Injection 101: How to Properly Take Insulin
- Tips on how to properly administer insulin and considerations to keep in mind when taking the medicine.
- What are the best insulin injection sites?
- Insulin Injection Sites: Where and How to Inject
- Choosing the best body site for an insulin shot
- Insulin treatment for type 2 diabetes: When to start, which to use
Insulin Do’s and Don’ts
Insulin therapy plays a crucial role in managing your blood sugar and can help you prevent diabetes complications.
You may need to take a single type of insulin or a combination of multiple types of insulin throughout the day. This depends on several lifestyle factors, your diet, and how well your blood sugar is controlled between meals.
Using insulin can be tricky sometimes. Here are some do’s and don’ts to pay attention to as you learn how to effectively manage your diabetes with insulin.
Do rotate the place where you inject insulin
Try not to inject your insulin in the same exact place on your body every time. This is to prevent a condition called lipodystrophy. In lipodystrophy, the fat under the skin either breaks down or builds up and forms lumps or indentations that can obstruct insulin absorption.
Instead, rotate injection sites. The best places for injecting insulin are your abdomen, front or side of thighs, upper buttocks, and upper arms due to their higher fat content. Each injection should be at least two inches from the previous site. Try not to inject too close to your belly button (at least two inches away) or into any moles or scars.
For mealtime insulin, it’s best to consistently use the same part of the body for each meal. For example, you can inject in your stomach prior to breakfast, your thigh prior to lunch, and your arm prior to dinner.
Do clean your skin before you inject
Clean your skin with cotton dipped in alcohol or an alcohol pad before you inject yourself. Wait 20 seconds for the area to dry before you inject. This helps avoid infections.
You should also wash your hands thoroughly with soap and warm water before you handle any needles.
Do check your blood sugar regularly and write down each measurement
Your insulin treatment involves much more than injecting insulin. You need to check your blood sugar level regularly using a blood glucose monitor. The constant need to test your blood sugar can feel like a burden, but it’s a crucial part of your diabetes care plan.
Blood sugar measurements can change depending on your stress level, how much exercise you’re getting, illness, changes in your diet, and even hormonal changes during the month. Major changes could mean that you have to adjust your insulin dose.
Write down each measurement or record it in an app on your phone to show to your doctor. Your doctor needs this information to determine how much insulin is right for you.
Do count your carbs before using mealtime insulin
The amount of mealtime insulin you need to inject is based on the number of servings of carbohydrates you plan on eating during a meal. Over time, you’ll get better at figuring out your carb intake. In the meantime, a dietitian can help you come up with a meal plan that works for you.
There are also several smartphone applications and internet-based calculators available to help you figure out your carb intake and your corresponding insulin dosage.
Do know the signs of hypoglycemia
Hypoglycemia (low blood sugar) can happen when you take the wrong insulin dose, don’t eat enough carbs right after taking your insulin, exercise more than usual, or when you’re stressed.
You should take the time to learn the signs and symptoms of hypoglycemia, including:
- being unable to speak or think clearly
- loss of muscle coordination
- pale skin
- loss of consciousness
You should also learn how to manage hypoglycemia if it happens to you. For example, you can eat or drink glucose tablets, juice, soda, or hard candies. You should also be extra cautious after vigorous exercise, as it can lower blood sugar for hours after the workout.
Do tell friends and family that you’re taking insulin
It’s a good idea to teach your friends, colleagues, and family members about insulin and its potential side effects. If you do end up taking too much insulin and having a hypoglycemic episode, they should know how to help.
If you become unconscious, a friend or family member can give you a shot of glucagon. Talk to your doctor about keeping a supply of glucagon on hand and learning when and how to use it.
Don’t inject the insulin too deep
Insulin is supposed to be injected into the fat layer under the skin using a short needle. This is referred to as a subcutaneous injection.
If you inject the insulin too deep and it enters your muscle, your body may absorb it too quickly. The insulin might not last very long and the injection could be very painful.
Don’t wait more than 15 minutes to eat after taking a mealtime insulin
Rapid-acting (mealtime) insulins were designed to be taken right before you eat to help you control your blood sugar more effectively.
As the name suggests, rapid-acting insulin starts to work rapidly in the bloodstream. If you wait too long to eat, your blood sugar can actually end up getting too low. This puts you at risk for hypoglycemia.
If, for some reason, you can’t eat a meal after you’ve already taken your mealtime insulin, you should carry around glucose tablets, juice, non-diet soda, raisins, or hard candies to avoid hypoglycemia.
Don’t panic if you accidentally take the wrong dose
Calculating the right dose of mealtime insulin can be complicated at first, especially if you don’t know how many carbohydrates you’re going to be eating at your next meal.
Try not to panic if you realize you took too much or too little insulin.
If you think you’ve taken too much insulin, eat some rapidly-absorbed carbs, like juice or glucose tabs. Also, you may want to call your doctor.
If you’ve taken a lot more than you need (like double or triple the correct dose), have a friend or family member get you to a hospital. You may need to be observed for severe low blood sugar.
If you think you’ve taken too little insulin, or you completely forgot to take it at all before your meal, measure your blood sugar. If it gets too high, you may need to take a short or rapid-acting (mealtime) insulin as a corrective measure to lower your blood glucose levels. If you’re at all unsure about the dose, seek advice from your doctor or diabetes care team.
If your glucose is still too high even after a correction dose, give it time. Injecting too soon can lead to dangerously low glucose.
When it comes time to take your next shot, you may be at a higher risk of hypoglycemia. You should monitor your blood glucose levels more than usual for the next 24 hours.
Don’t switch your insulin dose or stop taking it without seeing your doctor first
Switching your insulin medication or changing the dose without asking a doctor can put you at risk for serious side effects and complications.
If you have type 2 diabetes, you should be seeing your doctor or endocrinologist for a checkup roughly every three to four months. At your appointment, your doctor can assess your individual insulin needs and give you proper training on new doses or dosing methods.
Injecting insulin is simple, safe, and effective as long as you learn the right techniques and keep a close record of your blood sugar.
If you have questions or concerns, don’t forget about your diabetes care team, which includes your doctors, nurses, dieticians, pharmacists, and diabetes educators. They are there to walk you through the process and answer any questions that arise.
When should I take my insulin?
There isn’t one simple answer to this question. It depends on things such as:
- The type of insulin you use (fast-acting, premixed, etc.)
- How much and what type of food you eat
- How much exercise you get
- Other health conditions you have
- The type of insulin delivery system (such as shots, pump, or inhaler) you use
Your doctor may want you to take insulin a half-hour before meals, so it’s available when sugar from food enters your bloodstream. Find out exactly when during the day you need to take each of your injections, and what to do if you forget to give yourself an injection.
If I inject insulin, does it need to be in a certain part of my body?
Most people inject it into their lower belly area, since it’s easy to reach. (Be sure to stay at least 2 inches from the belly button.) You can also inject insulin into your arms, thighs, or buttocks.
Ask your doctor or diabetes educator to show you the right way to inject, including how to keep your needle and skin clean to prevent infections. Also learn how to rotate the injection site so you don’t develop hard, fatty deposits under the skin from repeated injections.
Does insulin affect other medicines I take?
Some drugs can intensify low blood sugars caused by insulin. Tell your doctor about all the medicines you take, even those you bought without a prescription.
What can I eat while taking insulin?
Ask your doctor for food recommendations to help your insulin work best. For instance, you’ll want to know how much to eat at each meal, which types of foods are best for you to eat, whether you need to have snacks, and when you should eat. If you drink alcohol, ask your doctor if that’s OK while you’re taking insulin, and what your limit should be.
What is my target blood sugar level?
Your doctor should tell you how often you need to check your blood sugar using your blood glucose meter. Find out your target blood sugar range before and after meals, as well as at bedtime. For most people with diabetes, the targets are:
- 70 to 130 milligrams per deciliter (mg/dL) before meals
- Less than 180 mg/dL 2 hours after a meal
Injection 101: How to Properly Take Insulin
Tips on how to properly administer insulin and considerations to keep in mind when taking the medicine.
By Susan B. Sloane, BS, RPh, CDE
Probably the most well-known fact about diabetes is that those living with the disease frequently have to prick their fingers and inject themselves with insulin to maintain healthy glucose levels. For those that have been diagnosed with diabetes, they know that injecting insulin can be a daily task that, if not done correctly, can lead to more problems than solutions.
Insulin is not the only injectable medication that exists for diabetes patients; there are other medications, known as GLP-1, that are also injected. The use of these medications is increasingly common, and therefore it is extremely important to be aware of proper injection techniques in order to reduce the risk of problems associated with medication injection.
Injecting insulin can be done with a vial and syringe or an insulin pen. Studies have shown that insulin pens make the injection process easier for many patients. Needle length is an important factor to consider. New clinical evidence recommends using shorter needles that are 4 mm long. Similarly, the needle gauge is a factor that needs contemplation. Ideally, a short, thin needle works best for most individuals.
Insulin and other diabetes medicines are injected subcutaneously, or just below the skin. Research has shown that despite its short length, the 4 mm needle is long enough to adequately reach under the skin. For patients that are heavier, longer needle length may be required.
Anyone living with diabetes knows that the whole insulin process is not a pain-free endeavor, which is another reason why thinner and shorter needles are recommended. These compact needles are less painful than traditional needles. Your own health care team will decide what type of needle is best for your body type.
Insulin pens are generally easier for patients to use, especially for those with limited dexterity such as children and elderly patients. It is also helpful to use insulin pens if your eyesight is not good since the use of syringes is a complicated two-step process.
With syringes, you must draw the proper dose of insulin into the syringe from a vial, which could lead to dosing errors for those who have limited vision. Not only could dosing errors cause complications to those living with diabetes, but they can also be extremely frustrating for patients.
The area of your body where you inject insulin is also a factor in the absorption of the insulin product. You have most likely been told to inject insulin into your upper arm, abdomen, buttocks, or thigh. Each patient has a “favorite” spot to inject, based on individual preference.
The following information from the Joslin Diabetes Center gives a rundown on injecting insulin in different areas of the body.
- Stomach: Stay at least two inches away from the belly button or any scars you may already have when using the abdomen for injections.
- Thigh: Inject at least 4 inches or about one hand’s width above the knee and at least 4 inches down from the top of the leg. The best area on the leg is the top and outer area of the thigh. Do not inject insulin into your inner thigh because of the number of blood vessels and nerves in this area.
- Arm: Inject into fatty tissue in the back of the arm between the shoulder and the elbow.
- Buttock: Inject into the hip or “wallet area” and not into the lower buttock area.
- When rotating sites within one injection area, keep injections about an inch (or two finger widths) apart.
- Do not inject into scar tissue or areas with broken vessels or varicose veins. Scar tissue may interfere with absorption.
- Massage or exercise that occurs immediately after the injection may speed up absorption because of the increased circulation to the injection site. If you plan on strenuous physical activity shortly after injecting insulin, don’t inject in an area affected by the exercise. For example, if you plan to play tennis, don’t inject into your racquet arm. If you plan to jog or run, don’t inject into your thighs.
- When injecting with an insulin pen, inject straight in and be sure to hold the pen in place for a few seconds after the insulin is delivered to ensure that no insulin leaks out.
My sons generally use their thigh or upper arm. When they were younger, I did most of their injection in their buttocks because there was more “padding” there and they felt less pain. With the newer needles available now, pain upon injection remains minimal, although each patient is different.
Different areas of the body also have unique insulin absorption rates. Injecting insulin into the abdomen will afford the quickest absorption, and the buttocks and thighs will allow the slowest absorption. It’s not generally recommended to exercise after an injection, but if you do, you should be aware that the medicine will be more quickly absorbed into the body.
Here are some general tips and tricks for injecting insulin or other diabetes medications:
- As a rule, you can insert short needles at 90 degrees without pinching the skin. Slimmer individuals may need to “pinch” up the skin to inject.
- Leave the needle in the skin after injecting the medication for 10 seconds to ensure proper delivery of the medicine.
- When using longer needles, inject at a 45-degree angle to ensure you get the medication just under the skin.
- Make sure not to use needles more than once, and dispose of your needles/syringes safely according to your local government regulations. A sharps container can be purchased at most pharmacies and is the safest way to dispose of needles.
You can get more information on how to safely dispose of needles on the FDA’s website by clicking here.
Lastly, you can keep track of your insulin injections with the Dario app. You can track the exact dose of insulin you are taking, the type (whether it be bolus or basal insulin), and you can even include the area of your body where you’re injecting via the “Note” tag.
Overall, properly injecting insulin and other diabetes medications is an important part of an effective diabetes management routine. If you have to inject insulin on a daily basis, follow the preceding tips to make it an easier process, spend less time dealing with your diabetes, and more time living your life!
About Susan Sloane
Susan B. Sloane, BS, RPh, CDE, has been a registered pharmacist for more than 29 years and a Certified Diabetes Educator for most of her career. Her two sons were diagnosed with diabetes, and since then, she has been dedicated to promoting wellness and optimal outcomes as a patient advocate, information expert, educator, and corporate partner.
Susan has published numerous articles on the topic of diabetes for patients and health care professionals. She has committed her career goals to helping patients with diabetes stay well through education.
The articles provided on this website are for informational purposes only. In addition, it is written for a generic audience and not a specific case; therefore, this information should not be used for diagnostic or medical treatment. This site does not attempt to replace the patient-physician relationship and fully recommends the reader to seek out the best care from his/her physician and/or diabetes educator.
Marso SP, Daniels GH, Brown-Frandsen K, et al. Liraglutide and cardiovascular outcomes in type 2 diabetes . N Engl J Med. 2016; doi: 10.1056/NEJMoa603827 Frid A, Hirsch L, Gaspar R, et al. ., and the Scientific Advisory Board for the Third Injection Technique Workshop. New injection recommendations for patients with diabetes. Diabetes Metab 2010;36(Suppl. 2):S3–S18 Joslin.org. (2017). Tips for Injecting Insulin | Joslin Diabetes Center. Available at: http://www.joslin.org/info/tips_for_injecting_insulin.html.
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What are the best insulin injection sites?
Image credit: Stephen Kelly, 2019
A person needs to inject insulin into the layer of fat directly under the skin, known as subcutaneous tissue, with a small needle or a device that looks like a pen.
Several different sites can support an insulin injection.
The abdomen is a common site for insulin injections that many people with diabetes choose. It is easy to access and often less painful than other sites due to protection by fat, greater surface area, and less muscle.
To give an injection into the abdomen, pinch a section of fatty abdominal tissue, with fingers either side.
The site should be between the waist and the hipbones about 2 inches away from the belly button.
Avoid injecting near any scar tissue on the abdomen.
The upper arm is another possible site for insulin injection.
Place the needle into the tricep area at the back of the arm, about halfway between the elbow and the shoulder.
Difficult self-administration is the main disadvantage of this site. Getting enough of a pinch to administer the insulin can be tricky. A person might need assistance for an injection into the upper arm. They might also experience greater comfort while injecting into the non-dominant arm.
This means injecting into the left arm of a right-handed person or the right arm of a left-handed person.
The thigh is a simple area for self-injection.
When choosing the thigh as an injection site, insert the needle into the front of the thigh, halfway between the knee and the hip. It should be slightly off center towards the outside of the leg.
The injection should take place around 4 inches, or about the width of a hand, above the knee and the same distance from the top of the leg. Avoid the inner thigh due to the denser network of blood vessels in that area.
Inject the medicine into a pinch of at least 1–2 inches of skin.
Though easy to access, regular injections in the thigh can sometimes cause discomfort when walking or running afterward.
Lower back, hips, or buttocks
The final site for administering an insulin injection is the lower back or hip.
To administer an injection here, draw an imaginary line across the top of the buttocks between the hips.
Place the needle above this line but below the waist, about halfway between the spine and the side.
As with the upper arm, this site is very difficult to use for self-injection and may require another person for administration. When injecting into the buttocks, avoid the lower part.
Insulin Injection Sites: Where and How to Inject
Before injecting insulin, be sure to check its quality. If it was refrigerated, allow your insulin to come to room temperature. If the insulin is cloudy, mix the contents by rolling the vial between your hands for a few seconds. Be careful not to shake the vial. Short-acting insulin that isn’t mixed with other insulin shouldn’t be cloudy. Don’t use insulin that is grainy, thickened, or discolored.
Follow these steps for safe and proper injection:
Gather the supplies:
- medication vial
- needles and syringes
- alcohol pads
- puncture-resistant sharps container for proper needle and syringe disposal
Wash your hands thoroughly with soap and warm water. Be sure to wash the backs of your hands, between your fingers, and under your fingernails. The Centers for Disease Control and Prevention (CDC) recommends lathering for 20 seconds, about the time it takes to sing the “Happy Birthday” song twice.
Hold the syringe upright (with the needle on top) and pull the plunger down until the tip of the plunger reaches the measurement equal to the dose you plan to inject.
Remove the caps from the insulin vial and needle. If you’ve used this vial before, wipe the stopper on top with an alcohol swab.
Push the needle into the stopper and push the plunger down so that the air in syringe goes into the bottle. The air replaces the amount of insulin you will withdraw.
Keeping the needle in the vial, turn the vial upside down. Pull the plunger down until the top of the black plunger reaches the correct dosage on the syringe.
If there are bubbles in the syringe, tap it gently so the bubbles rise to the top. Push the syringe to release the bubbles back into the vial. Pull the plunger down again until you reach the correct dose.
Set the insulin vial down and hold the syringe as you would a dart, with your finger off of the plunger.
Swab the injection site with an alcohol pad. Allow it to air dry for a few minutes before inserting the needle.
To avoid injecting into muscle, gently pinch a 1- to 2-inch portion of skin. Insert the needle at a 90-degree angle. Push the plunger all the way down and wait for 10 seconds. With smaller needles, the pinching process may not be needed.
Release the pinched skin immediately after you’ve pushed the plunger down and removed the needle. Don’t rub the injection site. You may notice minor bleeding after the injection. If so, apply light pressure to the area with gauze and cover it with a bandage if necessary.
Place the used needle and syringe in the puncture-resistant sharp’s container.
Choosing the best body site for an insulin shot
In the past, doctors and nurses told patients to rotate their insulin shots to different sites on their bodies. Now we know that it’s best to take insulin shots in the part of the body that matches the insulin action a person wants.
See Illustration: Sites for Injecting Insulin
Injection areas and action
Insulin enters the bloodstream faster from some areas of the body than from others. Where you take your shot can affect your blood sugar levels.
Generally, insulin enters the blood:
- Fastest from the abdomen (stomach area).
- A little slower from the arms.
- Even more slowly from the legs.
- Slowest from the buttocks.
Exercising can also speed up the amount of time it takes for the insulin to enter your blood. You can figure out where to take your shot based on how quickly or slowly you want the insulin to enter your bloodstream.
For example, if you’re going to be exercising, such as walking or doing any kind of lifting, you probably don’t want to take your shot in your leg or arm. Exercising those areas quickens the amount of time it takes for the insulin to get into your blood stream. This can cause your blood sugar to drop suddenly during or right after you exercise. If you plan to eat right after taking your shot, you might use a site on your stomach. That way the insulin will be available faster to handle the rise in your blood sugar after the meal.
Rotate sites in the same area
Follow these guidelines when you choose a site to take your shot.
- Try to be consistent in where you take your shots. Always take your shot of fast-acting insulin in the stomach or arm. Take slower-acting insulin in the leg or buttocks.
- Try to avoid using the exact spot you used for your last shot. For example, space your next shot just an inch or so from your last previous shot. If you use the same place over and over, you can build up scar tissue which will make it harder for insulin to enter the bloodstream.
- Many people like to pick one area and rotate around it, like a small clock.
Ask your doctor or a member of your health care team to help you plan the best places to take your insulin shots based on your lifestyle and insulin needs.
Clinical review by Meredith Cotton, RN
By: Sue Cotey and Andrea Harris, RNs
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When you have type 1 diabetes, your doctor will prescribe insulin therapy for you. That’s because your body produces little or none of this critical hormone. (In contrast, if you have type 2 diabetes, insulin therapy typically comes into play only when other treatments aren’t effective.)
You may feel some fear about starting insulin therapy. It’s perfectly natural to worry about starting injections. But they’re key to your treatment. Insulin will keep you from feeling fatigued and will help you prevent complications, including heart disease and organ damage.
So doing your best to take your insulin as your doctor directs is important. Educating yourself about diabetes and about the injection process is a good first step. It will help you gain the confidence you need to follow through with your treatment plan.
Here’s a primer on insulin, why you might need it and how to use it correctly.
1. Why do you have to inject insulin?
Insulin injections are your most effective way to keep your blood glucose levels in a healthy range when lifestyle changes and other medications cannot.
Because of the way your body breaks insulin down, you can’t take it in pill form. So insulin must be injected into the fatty layer of your skin. Although giving yourself shots poses a challenge at first, you will grow used to it.
Depending on your needs, your doctor will prescribe insulin in either short-term or long-term doses:
- Short-term insulin: You will take this several times a day to manage blood sugar spikes when you eat.
- Long-term insulin: You will take this once daily to cover blood sugar spikes over 24 hours.
Studies show that, once they start insulin injections, many patients intentionally skip doses. It’s important to view insulin injections not as a punishment, but as your key to good health.
2. What is the proper injection technique?
Learning to give yourself a shot is sometimes daunting. Many people opt to use the newer insulin pens or inhalers to avoid shots. But if you need injections, you can make the process more comfortable by remembering to:
- Throw away any needle that touches any surface before you inject to avoid contamination. Start over with a new one.
- Insert the needle at a 90-degree angle.
- Insert it into a skin fold if you’re of normal weight or slim.
- Keep the needle in the skin for 5 seconds (10 seconds for a pen) after it’s fully depressed.
- Place each injection at least one half-inch away from the previous one.
- Rotate injection sites. You can use the abdomen (best absorption site), buttocks (slowest absorption site), and the front and side of your thighs, and upper and outer arms.
3. How do you care for the injection site?
Remember these tips to avoid pain and/or infection at your injection sites:
- Start with clean hands before each injection.
- Make sure your skin is dry before each injection.
- You don’t need to swab your skin with alcohol before the injection if you bathe at least once a week and aren’t visibly dirty.
- Use each needle only once.
4. Which complications should you watch for?
It’s normal to see some slight bleeding or bruising at the injection site. However, if this occurs consistently or you experience unusual pain with injections, your doctor can help you improve your technique.
You shouldn’t have other complications if you follow our tips on caring for your injection site.
However, if you reuse needles or don’t rotate injection sites, you may experience lipohypertrophy. This inflammation or breakdown of fatty tissue creates lumps or thickens the skin. It can reduce insulin absorption and make it harder for you to manage your blood sugar.
5. How can you overcome fear of injections?
If fear is keeping you from starting injections or giving them to yourself regularly, these tips can ease you through the process:
- Ask your doctor to schedule a visit with a diabetes educator. Diabetes educators are specially trained to teach people how to take insulin and will have more time to provide support as you learn.
- Practice with dry injections first. This can make it easier when you’re first learning to take insulin.
- Let the insulin reach room temperature before injecting it. This can make injections less painful.
- Ask your doctor about changing your dosage if the volume of insulin in each injection is causing pain.
- Ask your doctor if you might be able to use a port, which only requires a needle stick every two or three days.
- Enlist the help of family members, caregivers or friends in giving you injections or reminding you to do so.
Taking insulin as your doctor prescribes will help keep your blood glucose on target. Talking to your doctor about your fears and concerns can help ease this process.
Insulin treatment for type 2 diabetes: When to start, which to use
Many patients with type 2 diabetes eventually need insulin, as their ability to produce their own insulin from pancreatic beta cells declines progressively.1 The questions remain as to when insulin therapy should be started, and which regimen is the most appropriate.
Guidelines from professional societies differ on these points,2,3 as do individual clinicians. Moreover, antidiabetic treatment is an evolving topic. Many new drugs—oral agents as well as injectable analogues of glucagon-like peptide-1 (GLP1) and insulin formulations—have become available in the last 15 years.
In this paper, I advocate an individualized approach and review the indications for insulin treatment, the available preparations, the pros and cons of each regimen, and how the properties of each type of insulin influence attempts to intensify the regimen.
Coexisting physiologic and medical conditions such as pregnancy and chronic renal failure and drugs such as glucocorticoids may alter insulin requirements. I will not cover these special situations, as they deserve separate, detailed discussions.
WHEN SHOULD INSULIN BE STARTED? TWO VIEWS
Early on, patients can be adequately managed with lifestyle modifications and oral hypoglycemic agents or injections of a GLP1 analogue, either alone or in combination with oral medication. Later, some patients reach a point at which insulin therapy becomes the main treatment, similar to patients with type 1 diabetes.
The American Diabetes Association (ADA), in a consensus statement,2 has called for using insulin early in the disease if lifestyle management and monotherapy with metformin (Glucophage) fail to control glucose or if lifestyle management is not adequate and metformin is contraindicated. The ADA’s goal hemoglobin A1c level is less than 7% for most patients.
The American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE), in another consensus statement, use an algorithm stratified by hemoglobin A1c level, in which insulin is mostly reserved for when combination therapy fails.3 Their goal hemoglobin A1c level is 6.5% or less for most patients.
Comment. Both consensus statements make exceptions for patients presenting with very high blood glucose and hemoglobin A1c levels and those who have contraindications to drugs other than insulin. These patients should start insulin immediately, along with lifestyle management.2,3
Both consensus statements give priority to safety. The AACE/ACE statement gives more weight to the risk of hypoglycemia with insulin treatment, whereas the ADA gives more weight to the risk of edema and congestive heart failure with thiazolidinedione drugs (although both insulin and thiazolidinediones cause weight gain) and to adequate validation of treatments in clinical trials.
Ongoing clinical trials may add insight to this issue. For example, the Outcome Reduction With Initial Glargine Intervention (ORIGIN) study is investigating the effects of the long-acting insulin glargine (Lantus) in early diabetes with regard to glycemic control, safety, and cardiovascular outcomes.4 This study is expected to end this year (2011). The safety of alternative treatment options is also under investigation and scrutiny. In the interim, individualized treatment should be considered, as we will see below.
MY VIEW: AN INDIVIDUALIZED APPROACH
The decision to start insulin therapy should be made individually, based on several factors:
- Whether the patient is willing to try it
- The degree of hyperglycemia
- How relevant the potential side effects of insulin are to the patient compared with those of other hypoglycemic agents
- Whether oral hypoglycemic agents with or without GLP1 analogues are expected to provide the desired benefit
- The patient’s work schedule and lifestyle factors
- The availability of nurses, diabetes educators, and others to implement and follow the insulin treatment.
Will patients accept insulin?
Factors that affect whether patients comply with a treatment include the number of pills or injections they must take per day, how often they must check their blood glucose, adverse effects, lifestyle limitations caused by the treatment (especially insulin), and cost. Most patients feel better when their glucose levels are under good control, which is a major motivation for initiating and adhering to insulin. The anticipated reduction of diabetic complications further enhances compliance.
Education promotes compliance. Patients need to know that type 2 diabetes tends to progress and that in time their treatment will have to be intensified, with higher doses of their current drugs and new drugs added or substituted, possibly including insulin. This information is best given early, ie, when the diagnosis is made, even if hyperglycemia is mild at that time.
With newer insulin preparations and delivery devices available, more patients are finding insulin treatment acceptable.