Question
Why is insulin often considered a last resort in the treatment of type 2 diabetes?

Response from Teresa L. Pearson, MS, RN, CDE Director, Diabetes Care, Fairview Health Services, Minneapolis, Minnesota

Even though the United Kingdom Prospective Diabetes Study showed that as many as 60% of people with type 2 diabetes eventually will need insulin to manage their blood glucose to target, insulin is not used to its maximum benefit. Time, fear, lack of knowledge, and psychological resistance on the part of both the patient and the provider all play a part.

For providers, when the need to add another agent to manage blood glucose arises, the time involved in teaching the patient about the new medication and the time to titrate the agent are issues. It takes longer to teach self-administration of insulin compared with self-administration of a pill. However, the new insulin pens have made teaching insulin administration much easier, as have the simple algorithms, such as Treat-to-Target,^[1] 1-2-3,^[2] and the once-daily titration schedule for long-acting insulins.

Concerns also arise about hypoglycemia and weight gain in patients who may already be overweight. Although these are valid concerns, the new insulin analogs have significantly reduced the likelihood of hypoglycemia – especially nocturnal hypoglycemia -- as well as weight gain. Patients should be educated about hypoglycemia and should also meet with a nutritionist to adjust food intake to reduce the likelihood of weight gain.

Psychological resistance to insulin is another reason for viewing insulin as a last resort. In psychological insulin resistance, the patient’s wish to "stay off the needle" is combined with provider concerns, as described above. Often, provider and patient never even talk about these issues, and the result is a delay in initiating insulin to the detriment of the patient’s health. Lack of knowledge on the part of both the patient and the provider contributes to the delay. This is a conversation that needs to be had early on in the diagnosis of diabetes, emphasizing that diabetes is a progressive disease. The goal is not to stay off insulin, but rather to control the blood glucose in an effort to prevent or delay the complications associated with diabetes.