Many people with diabetes are afraid of insulin and would like to avoid it at all costs. We are gaining new allies in the treatment of this chronic disease. It even turns out that insulin administration can be stopped and replaced with other preparations. When is insulin needed, and when are tablets enough?
When the pancreas does not produce insulin - this is the case in type 1 diabetes - patients must take this hormone. Indiabetes treatmenttype 2 begins with drugs taken by mouth or immediately with insulin. How exactly the treatment looks like, what effect of antidiabetic medications, when we needinsulin , and when we needtabletsexplains the diabetologist, Assoc. dr hab. n. med. Grzegorz Rosiński from the Medical Center of the Medical University of Warsaw.
What's new about insulin-tablets?
Doc. dr hab. n. med. Grzegorz Rosiński: In patients with preserved residual pancreatic ß-cells function, it is possible to switch from insulin therapy to oral therapy, by administering together with metformin a modern incretin drug - saxagliptin.
What drugs besides insulin can be administered in type 2 diabetes?
G.R.: In Poland, most patients use - in various combinations - drugs derived from biguanide (metformin), sulfonylurea (PSM) and acarbose. Metformin reduces insulin resistance and facilitates the conversion of glucose into energy. Usually, treatment begins with it, especially diabetics with concomitant obesity. Metformin can be administered alone or together with other preparations that lower blood sugar or with insulin. Drugs from the PSM group increase the production and release of insulin from the ß-cells of the pancreas, and increase insulin sensitivity. They are given especially when metformin alone is producing effects. Acarbose reduces the intestinal absorption of glucose, and thus the postprandial glucose increase. It is used on its own or in combination with metformin and other medicines.
What medications are available to diabetics abroad?
G.R.: In the early stage of type 2 diabetes, in combating postprandial hyperglycemia, aluminides in combination with metformin, which are not available in Poland, are good. Like sulfonylureas, they affect the early release of insulin from ß-cells, increase it, and act briefly and quickly. InUnlike sulfonylureas, alinides do not cause sugar drops between meals or on an empty stomach. There are also glitazones, also unavailable in Poland, which increase the action of insulin in muscle and adipose tissue, improve glucose transport to cells and lipid metabolism, thanks to which insulin resistance is reduced, sugar drops, and the parameters of lipid metabolism are also improved. However, possible contraindications are always assessed, as studies have shown that this group of drugs has an adverse effect on the risk of a heart attack, as well as exacerbation of symptoms of heart failure or osteoporosis. Glitazones are indicated in combination with metformin or other drugs, but not with insulin. The incretin drugs mentioned at the beginning (available from us, but not reimbursed), acting similarly to intestinal hormones, are very promising. They have a low risk of hypoglycaemia and have a protective effect on the ß-cells of the pancreas. The latest research shows that some type 2 diabetics who have already started using insulin can switch to a combination of two oral drugs - metformin and the new drug saxagliptin, just from the group of the so-called incretin drugs.
Can diabetes be treated well with pills alone?
G.R.: In the treatment of this disease, lifestyle modification is the first priority: changes in diet and regular physical activity, followed by pharmacological treatment. Diet and exercise are often overlooked by both diabetologists and patients. Therefore, it must be constantly emphasized that there is no other possibility of good diabetes control, than the combined use of an appropriate diet, exercise and pharmacology. This applies to type 2 diabetes, which is 80 percent. cases of this disease. It seems that after some time of treatment with tablets - shorter, if the therapy is not well managed - the patient switches to insulin. Usually permanently, when, as a result of improper treatment, the insulin-producing cells "burned out". In the complete absence of endogenous insulin, tablets are not sufficient and must be supplied externally. But there are also temporary shifts to insulin, e.g. in preparation for surgery, severe disease, e.g. pneumonia, heart attack, and the associated great stress for the body. Insulin must then be given as sugars are rising rapidly. Also, if an orally medicated diabetic becomes pregnant, she switches to insulin.
At what blood glucose level should I switch from tablets to insulin?
G.R.: With poor diabetes control, which is manifested by poor sugar levels for some time or an increase in the percentage of the long-term compensation index - which is glycated hemoglobinHbA1c - or if complications arise. The limit is HbA1c - 7 percent. Formerly, the Polish Diabetes Society considered 6.1 percent the norm, but today we know that screwing up this result often leads to hypoglycaemia. In many countries, it is believed that there is no point in reducing this ratio too much, because this - due to hypoglycaemia - brings more harm than gains. But when HbA1c remains above 7%, insulin is required.
Are younger people offered to switch to insulin faster?
G.R.: It is known that the best medicine for young people in addition to diet and exercise, there is insulin. If correction is not achieved with oral treatment, it should not be continued until complications develop. We need to determine how much of the patient's own insulin production is. Sometimes you have to take into account insulin resistance, because with it, despite high production, insulin is not enough; with a weight of 70 kg, the given amount of own insulin would be sufficient, but with a weight of 120 kg, additional insulin should be given. As for age - older people often have complications, the most dangerous of which is renal failure. This is an indication for a switch to insulin. There has recently been some debate about whether you can take metformin in kidney failure. Currently, it is believed that it cannot be taken - any damage to the kidneys, a decrease in glomerular filtration should be an indication for patients with diabetes to switch to insulin.
If there are complications, it means that the patient was treated poorly?
G.R.: The patient often thinks that the doctor is responsible for the complications, but the doctor is only his advisor. Whatever the patient eats or takes medications regularly, he regularly exercises - it is his business. Unfortunately, complications are common. And that is why it is necessary to check very carefully whether it is allowed to give the drug by mouth or insulin immediately. It may not be enough to treat diabetes with diet, exercise and the pill alone. But the most common is the late failure of the sulfonylurea drugs and then external insulin has to be added.
And then you switch from pills to insulin?
G.R.: I do it as follows. I convince the patient to use insulin, I give him a long-acting insulin once a day before going to bed - a long-acting analog or NPH insulin. There are different regimens - depending on the fasting blood glucose level - methods of setting the evening insulin dose, I do not give more than 10-14 units at the beginning. I look at the sugars and adjust the dose accordingly. If I judge that in the presence of existing complications, treatment with oral medications is no longer possible, I switch to treatment with insulin alone. I'm labeling glycated hemoglobin a hundreddays - if there is no improvement, I adjust the dose.
How long does oral treatment take on average?
G.R.: This was assessed in the POLDIAB study, which found that this period is 10-12 years. But I have patients treated orally for 20 years.
What do you think about the trend towards insulin treatment as early as possible?
G.R.:This is the result of glucotoxicity - if your sugar level is high, you need to reduce it as soon as possible. When prof. Berger was the head of the European Society for the Study of Diabetes, believed that diabetes should only be treated with insulin. The tendency was this - let's switch to insulin as early as possible, let's not wait for complications, but get ahead of them. Let's start with insulin treatment to reduce sugar rapidly, so that this high level does not damage the body as much as possible. And then, when blood glucose levels have leveled off, consider what to do next and switch to tablets or insulin right away.
Insulin is a boon, but patients defend themselves against it. Why is this happening?
G.R.: Research among patients and my own experience shows that many of them are afraid of using insulin, including . for fear of hypoglycaemia. An international study (GAPP, 2010) showed that as many as 67% of people fear hypoglycaemia. patients. This is one of the most important reasons for skipping insulin doses or not using it as prescribed by your doctor. Often, when I tell the patient: we're switching to insulin, he defends himself. Then I give him a prescription for a white cane, and he asks: why do I need this cane? I say: without insulin, you will go blind. Then he agrees to take it. But only for two weeks, on a trial basis. It comes after two weeks and announces: I don't want pills, I'm finally feeling fine. Before that, I got up five times a night to urinate, I had no strength for anything, I was losing weight. Now I have no thirst, I don't have frequent urination, I am strong. It bothers me a little bit, stinging, keeping track of the hours, but overall my quality of life has improved, so I'm not going back to the pills. So the attempt to take insulin for a test so that the patient can see that he feels well after it is successful.
The patient is afraid of hypoglycaemia, but also stinging and discomfort. What is the doctor afraid of?
G.R.: We are more afraid of hypoglycaemia with oral medications than with insulin. Hypoglycemia with long-acting drugs is very dangerous and often fatal. After insulin, hypoglycaemia passes quickly. This is especially important in the case of kidney failure. If we then administer, for example, a sulfonylurea, then a few days have to be administered intravenously with glucose so that the patient does not die. Almost every sick person will give it to insulinI can cope with low sugar. Hospitalization is necessary with oral medications, especially in an elderly person.
doc. dr hab. n. med. Grzegorz Rosiński is the founder of the Diabetic Foot Diabetes Clinic. This supra-regional
and multidisciplinary office operates at the Independent Public Central Teaching Hospital in Warsaw at ul. Banach (block F).
Therapy depends on the type of diabetes
- In type 1 diabetes,treatment consists in following a special diabetic diet, skilfully dosed physical effort and injecting insulin multiple times a day. Any oral medications, which are in line with the product characteristics on the leaflet, are contraindicated.
- In the treatment of type 2 diabetes,oral anti-diabetic drugs (hypoglycaemic drugs) reduce insulin resistance and glucose absorption from the gastrointestinal tract, and increase insulin secretion.
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