Читать книгу American Diabetes Association Guide to Insulin and Type 2 Diabetes - Marie McCarren - Страница 7
ОглавлениеIt’s Time for Insulin. And It’s Not Your Fault.
You’re doing everything the same. Diet: same. Exercise: same. Medications: same. Blood glucose … up.
Why? Because type 2 diabetes is a progressive disease. It gets worse with time, and you’ll need more medication to reach your blood glucose goals. Let’s track this downward trend, starting at a time before you had diabetes, when glucose was not a problem.
GLUCOSE: TWO SOURCES
All the talk about controlling blood glucose might lead you to believe that glucose is bad. It’s not. Your muscle and fat cells use glucose for energy.
Glucose can’t just float into those cells. It needs the help of insulin. It’s often said that insulin is the key that opens the door to a cell, allowing glucose inside. Insulin is produced by special cells in your pancreas called beta cells.
You always need some insulin in your bloodstream because your cells always need at least a little glucose coming in. When you have a lot of glucose in your blood, such as after you eat, you need more insulin to move it into cells.
Before you developed diabetes, your pancreas produced just the right amount of insulin. When you ate, your blood glucose level went up. Your beta cells detected this rise and secreted extra insulin (called a bolus) for two to three hours. Your cells responded to the insulin and rapidly took in the glucose from the meal. Your blood glucose levels did not go above 140 mg/dl.
Food is not the only source of glucose in your bloodstream. Your liver stores glucose. If you go without food for a long time, such as when you sleep overnight, your liver releases these emergency stores of glucose. It also does this when your body is under stress, such as when you have an illness or infection.
You don’t want your liver to release these glucose stores until you really need it, so insulin signals the liver to hang on to its glucose. Before you developed diabetes, your liver responded well to insulin. Just a little insulin would be enough to remind the liver not to release glucose. Overnight and between meals, your blood glucose levels stayed in the range of 70–110 mg/dl.
IN THE BEGINNING: INSULIN RESISTANCE
At some point in your life, your body became less sensitive to insulin. Your muscle and fat cells now required more insulin to move glucose inside. Your liver needed more insulin to keep it from releasing glucose. You had become insulin resistant, or, put another way, you had developed insulin resistance.
You may have inherited a tendency toward developing insulin resistance from one or both of your parents. Being overweight and inactive also strongly contributes to developing the condition.
Not everyone who develops insulin resistance goes on to develop diabetes. Some people’s bodies are able to produce huge amounts of insulin, enough to overcome their insulin resistance. But you did develop diabetes, because you have another problem: insulin deficiency.
VOICES OF EXPERIENCE
Your health care team may suggest that you visit a diabetes support group. A typical meeting has a guest speaker, one or more diabetes care professionals, plus people with diabetes. You’ll find it invaluable to talk to people who can tell you with the voice of experience: “You can do this. I did it, and I feel a lot better.”
You can also access a very active support group at any time, day or night. It’s the community that posts on the American Diabetes Association message boards. Go to www.diabetes.org, click on “Message Boards,” and then on “Adults Type 2.” We feel these voices of experience are so valuable that we’ve included excerpts from the message boards throughout this book. (We’ve changed the members’ screen names.) Here’s a sampling:
I don’t know where I would find the time to go to a support group meeting. This board is great because I can monitor it between work calls and stuff, and I also like being able to ask my dumb questions in anonymity! The support I have received here has been wonderful!
I live in a fairly rural area and would have to travel at least an hour each way to get to a diabetes support group.
The boards have had a huge impact in how well I manage this disease. The Boomers (of which I am one) are great users of the ’net. It seems to me the “connection” part is the most important for my generation given that most of our families these days are spread all over the place.
Even folks without computers can go to the public library and use the ones there. I’ve told my doctor about some of the message boards, and he wrote them down to offer to his other patients with diabetes.
I am one of those “old” people (I’m 64) who uses a computer. By the time I had my first appt with my RD, I had found this board and had started reading and learning about diabetes. She knew about the board and was pleased that I was trying to educate myself about it. The people who went through classes with me eagerly listened to things I told them about this board. Having people who have been and still are managing diabetes willing to answer my dumb questions has been a constant source of support.
I’ve learned more from this site than I have from my endo!
Message Board Terms
You’ll see many abbreviations in the message board excepts. The most important is the umbrella caveat YMMV—“your mileage may vary.” It means the person is simply stating what has worked for him or her and is not advising you to do the same because you might get very different results. When reading message boards, assume that “YMMV” is present in every post, whether it’s actually there or not. Also be aware that people may talk about doing things differently than what the insulin or syringe manufacturers—or their own health care teams—recommend. As always, check with your health care team before changing anything about your diabetes routine.
Here is a short glossary to help you get through those abbreviations and terms you’ll find in many message boards, here in the book and out there in the Internet.
A1C: a blood test that shows average blood glucose levels.
AM: morning
appt: appointment
BG or BS: blood glucose, blood sugar
BTW: by the way
Carb: carbohydrate. One “carb” has about 15 grams of carbohydrate.
CDE: certified diabetes educator
D2: type 2 diabetes
Dr: doctor
Dx: diagnosis, diagnosed
Endo: endocrinologist
esp: especially
FBG or FBS: fasting blood glucose/sugar
GP: general practitioner
Hypo: hypoglycemia, blood glucose level that is too low
I: C: ratio of insulin to carbohydrate
IMHO: in my humble opinion
MDI: multiple daily injections
Meds: medications
OMG: oh my gosh
PM: afternoon, evening
Puffers: people who use inhaled dry insulin powder
Pumpers: people who use insulin pumps
RD: registered dietitian
Reg: regular insulin
Rx: prescription
T2: type 2 diabetes; T2s are people with type 2 diabetes
U: units. Insulin doses are measured in units
w/: with
YMMV: your mileage may vary
NEXT: INSULIN DEFICIENCY
Years before your diagnosis, you started to lose beta cell function. Your insulin production dropped. When you were eventually diagnosed with type 2 diabetes, your insulin production was probably about half of what it should be.
If you had not been insulin resistant, then that might have been enough. But because you were insulin resistant, you had “relative” insulin deficiency. This means that relative to your needs, the amount of insulin you were producing was not enough. It wasn’t enough to keep your liver from releasing excess glucose. It wasn’t enough to cover the glucose spikes after meals. Your blood glucose levels were too high all the time.
In contrast, people with type 1 diabetes have absolute insulin deficiency. When they’re diagnosed, they’ve lost about 90% of their beta cell function. Within a year or two of diagnosis, their bodies stop producing any insulin.
MEDICATIONS
You may have been prescribed metformin when you were first diagnosed. This drug keeps the liver from releasing too much glucose. Other diabetes pills make your body more sensitive to insulin. Some diabetes pills stimulate the beta cells to secrete more insulin. These will work for a while. But as you get older, you lose more and more beta cell function. Even with the help of diabetes pills, your body can’t produce enough insulin for your needs. This is not your fault. It’s the nature of type 2 diabetes.
When your body makes too little insulin for your needs, you’ll need to supplement it with injected (or inhaled) insulin. As the years go on, you will become more like a person with type 1 diabetes. Your body will be making little to no insulin. You’ll no longer be simply supplementing with injected insulin; instead you’ll need to supply your body with all of the insulin it needs through injections or inhalation.
SUBJECT: RESISTANCE?
FROM: LK
If most of us are type 2 diabetics with insulin resistance, then why are we injecting more insulin into our bodies? Am I missing something? Why am I pumping more insulin into my body if my body will just reject it?
FROM: LN
When your cells are resistant, it’s as if you have added another lock. Your pancreas produces more and more insulin to break through the resistance, resulting in burnout. Now, even though, hopefully, you have reduced the insulin resistance, your pancreas may no longer be able to produce enough insulin to meet even your now normal needs, which is why T2s sometimes need to inject insulin in addition to what the pancreas produces.
FROM: C
Like in a war, the more bullets you shoot at something the better your chance of getting a hit. Your body initially tries to overcome the cell’s resistance by producing more insulin. This works for a while until your pancreas wears out. At that point, you have to take injections just to feed your cells and stay alive.
FROM: SR
WONDERFUL QUESTION!!! I recently started insulin. My old doctor brushed off my request for an explanation. I have an appt with a new doctor. You asked what I was wondering and was afraid to ask!
IS IT TIME?
How will you know that your diabetes has progressed and that your current diabetes plan is not enough? Look to your blood glucose levels. Diabetes management revolves around blood glucose levels because study after study has proven that the closer your blood glucose levels are to the normal (non-diabetic) range, the lower your risk of developing diabetes complications such as kidney disease, eye problems, and nerve damage. Getting your blood glucose levels down often improves triglyceride levels, too.
There are two types of tests that will tell you what your blood glucose levels are.
Home Monitoring
You can check your blood glucose levels yourself with your home monitor. The goals for most adults are
Before meals: 90–130 mg/dl
1–2 hours after the start of a meal: less than 180 mg/dl
Note: Your doctor might set different goals for you.
A1C: An Average
The second way to keep track of your blood glucose levels is with an A1C test. It shows your average blood glucose level over the previous two to three months. It’s like having a hundred glucose checks every day averaged out for you. Here’s how it works.
There’s always some glucose in your blood. The same is true of people who don’t have diabetes. Glucose links up with the hemoglobin in your red blood cells. If you have a lot of glucose in your blood, more of your hemoglobin will have glucose attached to it. Once the glucose is attached, it’s there for the lifespan of that red blood cell, which is 120 days at most.
In a person who doesn’t have diabetes, about 5% of the hemoglobin is glycated (has glucose attached). In people who have diabetes, that percentage is higher. How much higher depends on the person’s average blood glucose levels.
In general, the goal is to have an A1C less than 7%. Your doctor may set a different goal for you.
If you’re a healthy adult, your goal might be less than 6.5%.
If you’re planning to get pregnant, your goal will be to have an A1C close to 6%.
If you’re an older adult with other health problems, you may be advised to keep your blood glucose levels a little higher.
If you’re meeting your blood glucose goals and your control is stable, have an A1C test done every six months. If your treatment plan has changed or you’re not meeting your goals, have an A1C test done every three months. Blood draws for A1C tests are done at a lab or in your doctor’s office. There are home collection kits, too. (For a list of these and other diabetes care products, see the American Diabetes Association’s Resource Guide, published every January in Diabetes Forecast and on www.diabetes.org.)
SUBJECT: A1C
FROM: dd
You know you’re a diabetic when … you’d rather be an “under 7” than a “10.”
STEP IT UP
When should insulin be added to your diabetes plan? The American Diabetes Association, with the European Association for the Study of Diabetes, offers guidelines based on expert opinion in Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy (published in 2006). While this is not a list of rules for how doctors “should” treat every person with type 2 diabetes, it is what works for many people. These guidelines are described on Step 1.
Step 1: Make Lifestyle Changes and Take Metformin
Lifestyle changes are very important at all stages of the disease. Losing some excess weight (even just 10–20 pounds) and being more active will reduce insulin resistance and lower the risks of heart attack and stroke.
Metformin is a good first medication for most people newly diagnosed with diabetes. Metformin doses should be raised to the maximum effective dose over one to two months.
Step 2: Add Another Medication
If A1C is still not at the goal of less than 7%, another medication is needed. But which one?
When Metformin Is Not Enough
Option 1: Add insulin. This is the most effective option. No matter how high your A1C, you can get it down to your goal if you use enough insulin.
Option 2: Add a sulfonylurea. This is the least expensive option but carries the risk of hypoglycemia (low blood glucose level).
Option 3: Add a glitazone. The advantage is that there is no risk of hypoglycemia.
Step 3: Start or Intensify an Insulin Plan
If lifestyle changes, metformin, and a second medication do not get you to your blood glucose goals, these experts recommend using insulin. If you’re already on insulin, you and your health care team should tweak the plan by raising your doses of insulin, using more injections per day, or trying different insulins.
What about adding a third oral medication before moving to insulin? This is not recommended by these experts. If your A1C is more than 8% when you’re on two oral medications, a third oral medication will probably not get you to the goal of less than 7%. If your A1C is less than 8%, a third oral medication may get you to less than 7%, but it will be more expensive than adding insulin.
SUBJECT: WHEN IS IT TIME FOR INSULIN?
FROM: zs
Just curious for those of you who have diabetes and used pills for a while and then were put on insulin. What caused the dr. to put you on insulin? Did you get to a certain number and the dr. felt it was time for insulin?
FROM: VV
I have been diabetic for 18 years now. Over those years I have had to increase doses, change meds, and add meds in order to keep my numbers under control. This past summer I had an episode where my numbers were no longer responsive to the oral meds. I was eating around 15–20 carbs per meal just to keep my numbers down to the high 200s and low 300s. We tried all kinds of new medicines, but you would think I was trying to treat my diabetes with Tylenol for all the good they did. That is when the decision was made to put me on insulin.
Honestly, as much as I did not want to give myself injections several times a day, being put on insulin was a relief. I felt so bad walking around all that time with my numbers so high. How good I feel now far outweighs any inconvenience or the occasional discomfort from a needle. Hope this helps answer your question.
FROM: EB
I have been on Lantus insulin since August. It has made all the difference in the world to my diabetes management. I had never been able to get my numbers under 140, no matter how carefully I ate or how much I exercised (not even when I was teaching backpacking to Girl Scouts). This had become so discouraging that I had really quit trying to manage my diabetes. (I have been diabetic for over 20 years.) I had even quit doing any exercise due to arthritis. When I went on the Lantus, I also went back to eating right, and once I felt better I joined the YMCA and began swimming again. Now my numbers hover around 100, and I find I am much more likely to do the things I should.
FROM: jj
I am 49, and have been a type 2 diabetic for over 10 years. I maintained it with diet and exercise and lost over 75 pounds. I had to add oral medications within 5 years. Then last September came along
No matter what I did, my sugar levels did not want to come down in the normal range. Everyone’s blood chemistry is different, but eventually your body quits producing insulin to the point of requiring that you add insulin to your regime along with the oral meds. It really has made a huge difference in the way I feel and act. I use an insulin pen with the new micro needles—it is SOOO easy.
FROM: CN
I was diagnosed type 2 about 17 years ago. Started controlling it with diet and exercise, then as time progressed, went to oral medication. About two years ago, my fasting was getting close to 150, and my doctor seemed to think that was OK. I didn’t. We had a heart to heart talk and I started Lantus. One year later, I added Humalog before meals. I brought up the subject of an insulin pump with my doctor and September of last year, became a pumper.
“BUT I FEEL FINE!”
Not having enough insulin in your system is like having termites. You don’t notice when termites first infest your house. You don’t see piles of sawdust. The corner of your house doesn’t sag. It’s only when they’ve been there a long time that you see a sign. In a panic, you call a termite inspector. His probe sinks right into a stud. “Too bad you didn’t call us 5 or 10 years ago,” he says. “We could have treated your house and saved you all this damage.”
When you don’t have enough insulin, your blood glucose levels are too high. That causes damage that is unseen and goes unnoticed. Over time, you’ll begin to notice the damage. Years of high blood glucose can lead to vision loss, kidney problems, and amputation.
Don’t go by how you feel. Look to your blood glucose levels.
Blood glucose levels: Normal, nondiabetic (A1C less than 6%).
How you feel: No symptoms.
What’s happening in your body: No ill effects.
Blood glucose levels: A bit above normal.
How you feel: No symptoms.
What’s happening in your body: Some damage to cells and blood vessels.
Blood glucose levels: Well above normal.
How you feel: Mild symptoms that you might not realize are from high glucose levels. You lack energy. You’re irritable. You might think, “It’s just age” or “It’s stress.”
What’s happening in your body: More damage. It takes fewer years to develop the signs of eye, kidney, and nerve damage.
Blood glucose levels: Very high.
How you feel: More obvious symptoms. You’re getting up at night to urinate. You may be so tired and moody that your family is thinking, “Mid-life crisis? Depression?”
What’s happening in your body: Laying the groundwork for major complications and shorter lifespan.
SUBJECT: INSULIN MAKES ME FEEL GOOD
FROM: Hml
I have been dealing with diabetes for about 20 years now. After trying and trying to keep control with oral medications, diet, and exercise, and failing again and again, I can tell you that insulin therapy (for me, in conjunction with oral medications), makes me FEEL GOOD. I can’t imagine going back to feeling like crap again. And without the minor inconvenience of dealing with insulin, I would feel like crap all the time. Fighting it when the time comes simply isn’t worth it.
I just got my lab results yesterday from my most recent doctor visit. A1C 6.5, FBG 96, cholesterol 96 (yes 96!), and triglycerides 72. Before insulin? A1C 11+, FBG 240+, cholesterol 190, and triglycerides 600.
Insulin is not a bad thing. When you achieve good control, you will feel better than you have in a long time. Give it a chance; you’ll see. Good luck.
FROM: TH8
When you said you used to feel like crap, what do you mean?
FROM: Hml
All of those symptoms of high or low BS that really drag you down over time. I would get severe headaches with a BS spike, also tired all of the time. I could hardly get out of bed whether I had 6 or 10 hours of sleep. I had no energy. It goes on and on. Once you get this thing under control, it is amazing how much different you will feel. I know I am not tired anymore. I can wake up in the morning and get right out of bed etc.
INSULIN AT DIAGNOSIS?
Some people have very high blood glucose levels when they are diagnosed. It might seem that their diabetes is very advanced and that they have very few beta cells left. But that’s not always the case. High blood glucose has a snowball effect. The beta cells are there, but they’re suffocated by the high levels of glucose and stop working. In addition, the high glucose levels make muscle and fat cells become even more insulin resistant. Then blood glucose levels go even higher.
Treatment that brings blood glucose levels back to a healthier level will relieve this glucose toxicity, which will improve insulin sensitivity and allow the beta cells to work again.
In one study, 126 people newly diagnosed with type 2 diabetes were put on insulin pumps for two weeks. Then they controlled their diabetes with diet and exercise only. Half were still able to control their diabetes with diet and exercise after six months, and some were able to for up to two years.
SUBJECT: STARTED WITH INSULIN
FROM: D
My Dr started me on insulin right away. He later mentioned that he might possibly change me to oral meds. I said “NO.” While I wasn’t crazy about the idea of daily shots (an understatement!) in the beginning, the fact that I had my fasting from 312 down to consistently under 120 within 5 DAYS by using insulin made me like it a lot more. I take one shot of Lantus every morning and keep the NovoLog around for whenever I need it. If I control my carbs, I don’t need the extra shot.
FROM: Ll
I actually requested insulin. I had a bad experience with an oral medication when I was first dx, and I was off medication for about a year. Then last winter I got a really bad liver infection that sent my numbers through the roof. I started doing research on all of my options and decided that insulin was the best option. It has a long and proven track record and fewer side effects than most medications.
I had all my facts lined up and started talking with the Dr about why I wanted insulin and she got this big smile on her face and said “I’m so happy you said that because insulin is the best thing for you. Most people freak out when I mention it.” I’m still happy with my choice.
FROM: LN
Totally agreed that insulin may be the best choice for many, including newly diagnosed people. Doctors assume that people are scared of injections, and so usually they keep it a later possibility, but insulin has some real advantages over oral meds—it works faster, the dosage can be controlled with greater specificity, unknown side effects don’t exist, and depending on the type of insulin it can be a cost-effective solution compared to brand-name meds that can cost $150–250 per month.
FROM: ENO
Using drugs to modify how food is digested, how the liver reacts to hormones, or forcing the beta cells to produce more insulin are a far more radical change than replacing missing insulin or providing enough insulin to overcome resistance. That’s just my take on it. Sorta like I’d rather eat the natural carrot actually grown in dirt over the carrot-flavored, vitaminized, mineral-added, nutritional analog. The latter might actually be better for me but I’ll take my chances on the dirt version. It’s been around a lot longer.
SUBJECT: PILLS VS. INSULIN
FROM: Gm2
I have been doing the T2 diet/exercise/pills and now Byetta routine for over 30 years. And at first it was really easy and now almost easy if I stay on the plan. But I gotta tell you that staying on the plan continuously is almost impossible after the first year or two. So, I’ve got these “gaps” of bad readings—grandma’s lasagna, orchard fresh peach pie, vacations, conference meetings, pizza anytime, fried foods, celebrations—you know the pattern. I’ve never had a “bad” A1C, always about 6.4, but that may be helped because of the “what goes up big comes down big” syndrome.
My point, after all this rambling, is that I’m not sure why the endos just don’t stick us on insulin and teach us to manage that way instead of taking a wild guess about what will happen with the pills, because the pills are not a scientific certainty. In fact, I have always found the pills’ predictability to be greatly lacking. Do they just think we’re scared of needles and can’t count carbs?
Anyway, I’m thinking of voluntarily asking for insulin next month when I see the endo. I think that would actually be easier and more reliable. Just gathering thoughts, opinions, and info before I make a decision. Thanks.
FROM: BA
I asked my CDE today about why insulin is usually a last resort choice for type 2 diabetics. (This was my third visit with this educator who is also an RD and has type 2 herself, and I’ve been very impressed with her.) I think her response was very interesting.
She attributes the reluctance in the U.S. to use more insulin to two things: 1) patient resistance and 2) physician resistance. Patients aren’t keen on dealing with needles, storing insulin, and carrying it around. They know about bad reactions to earlier generations of insulin and don’t know about newer developments. They equate going on insulin to failing. We talk about “insulin dependent” diabetics but not “drug dependent” diabetics.
Doctors aren’t keen on all the education that has to accompany getting people to use insulin appropriately and all the follow-up visits. Until recently there were no diabetes educators to call on to shoulder some of this burden, and the majority of diabetic patients still have no access to this service. Patients (out of ignorance and/or fear) don’t want it and doctors (out of convenience) don’t try hard to change their minds. This is all just her opinion, of course, but I thought it was interesting.
She told me about a new patient she saw recently, a woman in her 70s who has had type 2 for 40 years and has had absolutely no complications. She just moved here from Canada and has been on insulin from the beginning. This made the CDE wonder whether U.S. patients really get on insulin soon enough in many cases.
BTW, she doesn’t think I should be on insulin, but she thinks I’m an excellent candidate for Byetta. Best wishes to you, whatever plan you decide to follow.
