The odds of coming off insulin   (December 4, 2008)

I recently received a question by e-mail, and thought I'd share the question and my reply with readers. The writer asked:

Wondering what the odds are of coming off insulin once you are on it? I am now on Byetta, Avandia and Glucotrol and my endocrinologist is trying to start a small dose of insulin. She says "maybe your pancreas needs a rest." I'm afraid I would be on it forever.

I replied:

Before answering your question, I'd respond with a question of my own: what's so awful about being on insulin therapy long-term? I know there are lots of reasons for people to be concerned about insulin therapy, some of which are valid (the possibility of hypoglycemia, and the chance for weight gain), and some of which are not -- see my previous essay about the Top Ten Reasons not to start insulin therapy.

You seem to have type 2 diabetes, based on your taking several standard diabetes medications. If your A1C remains elevated (or, worse, is going up), something else needs to be done. First on the list: be sure you are on the best possible meal plan, to lose any excess weight and control glucose and lipid levels optimally. If you haven't spent time with a diabetes dietitian recently, you should. Second, if possible, increase your exercise level. If your meal plan and exercise program are already the best that you can possible handle, then insulin is definitely needed. Adding or switching pills would only be procrastinating, in my opinion.

The main point for me to make is that taking insulin shots does not mean that you've somehow "failed" at controlling your diabetes. Type 2 diabetes is a progressive disorder, and eventually the beta cells of the pancreas will no longer be able to make sufficient insulin, no matter how hard you've worked at managing your diabetes.

In your case, most physicians would probably recommend adding a single injection of insulin and staying on your present diabetes medications. The shot, either Lantus, Levemir, or NPH, is usually recommended to be given in the evening hours. Any of these should improve your morning pre-meal BG level and your A1C.

The nice thing about insulin is that there's no upper limit to the dose for insulin, except for the possibility of hypoglycemia, so as time goes by, and you get used to insulin shots, it would probably be a good idea to increase the insulin dose, and slowly lower the doses of one or more of the partially effective and very expensive medications you are now taking.

To go back to your question about the odds of discontinuing insulin: if you are already on maximal meal planning, exercise, and doses of your present medications, you will need insulin supplementation indefinitely. If by some chance you can later improve your meal planning or exercise, or reduce any other stressors that are kicking up your glucose level (if for example, you are taking steroid medications for some other medical condition), then sure, it'd be worth a trial later to discontinue insulin.

But remember, insulin is life-saving. For folks with type 1 diabetes, it's needed every day, and that's all there is to it. And for people with type 2 diabetes, if your pancreas plus your medications plus your meal plan plus exercise can't control your blood glucose level, it's time for insulin.