50-60% of people with Type 2 Diabetes are treated with insulin: Why?

an Insulin pen from Diabetes Insight, Cork, Ireland

So can a person with Type 2 diabetes, develop Type 1 diabetes?

Over 50-60% of people with Type 2 diabetes are treated with insulin. So does that make them a Type 1 insulin dependent diabetic? I get asked this quite alot, not just by people with diabetes, but by health care professionals!! And the answer would be definitely not. Once a person develops Type 2 diabetes they will always have Type 2 diabetes and likewise for Type 1 diabetes. I would refer to someone with Type 2 diabetes, who is treated with insulin as  ‘Type 2 insulin requiring’ diabetes. Maybe this term may not be recognised by the WHO in its classifications, but its easy to understand. Again it is one of the common myths that are associated with diabetes. Many people when they are diagnosed with Type 2 diabetes never realise that insulin therapy is a possibility as part of their treatment regime, as it is normally associated with Type 1 diabetes. So when the conversation eventually will steer to prescribing insulin &/or GLP hormone injectable therapy, people are naturally very upset.

Progression of Type 2 Diabetes

So why does someone with Type 2 diabetes end up on insulin? Type 2 diabetes is a chronic progressive condition. There is much debate as to at what stage progression can be delayed, prevented or even reversed. That is a debate for another day and one which brings about interesting opinions, research and treatment options. We know from the UKPDS (United Kingdom Prospective Diabetes Study) that beta cell function declined and insulin resistance increased in people with type 2 diabetes by 7% a year¹. At the end of the 11 year study, over half of all participants in the trial needed additional therapies. So in order to gain good long term glycaemic control in people with type 2 diabetes, this study showed us that just one treatment option is not enough, additional medication over time will be needed and a multi-drug approach adopted.

Eventually insulin resistance and beta cell function (these are the cells that produce insulin, which in turn keeps your blood sugar levels under control) decline, which will result in persistent hyperglycaemia and an increased risk of developing complications associated with high blood sugar levels. This leads to what we call ‘secondary failure’ in type 2 diabetes. At this stage insulin therapy is required.

The Research

I always explain this approach to people with Type 2 diabetes and the reasons behind it. Good glycaemic control is not just about making the doctor look good when you achieve your targets, its so much more than this. The UKPDS study, along with the DCCT(Diabetes Control and Complications Trial) categorically showed us that achieving good glycaemic control prevents or delays the complications associated with both types of diabetes². It is important to highlight this to people as I previously stated, as I always have found it increases compliance to treatment regimes. I wouldn’t fancy taking extra medication if I did not understand why, so I expect the same from my clients.

Insulin Regimes in Type 2 Diabetes

There is a number of factors to consider when people with Type 2 diabetes start on insulin therapy and what type of therapy they will go on and this will be decided by your diabetes team in collaboration with you. Many people will start with just a once a day long acting insulin and maintain much of their oral medications albeit with a few changes. Many will go to a twice a day insulin, and eventually may progress to a long acting insulin with rapid acting insulin during the day with meals, the same as for many people with Type 1 diabetes.

GLP-1 Hormones

There is a new wave of injectable drug therapies called GLP 1 hormones, commonly known as Byetta, Bydureon (Exenatide) by Lily Manufacturers and Victoza (Liraglutide) by Novo Nordisk that are used for Type 2 diabetes. Byetta and Bydureon are the same medical drug. The only difference is that Bydureon is long-lasting, requiring only one injection per week, whereas Byetta is taken twice-daily due to its much shorter-term effects.

They work by copying, or mimicking, the functions of the natural incretin hormones in your body that help lower post-meal blood sugar levels. They also work by:

  • Stimulating the release of insulin by the pancreas after eating, even before blood sugars start to rise.
  • Inhibiting the release of glucagon by the pancreas. Glucagon is a hormone that causes the liver to release its stored sugar into the bloodstream.
  • Slowing glucose absorption into the bloodstream by reducing the speed at which the stomach empties after eating, thus making you feel more satisfied after a meal.

These effects are in direct response to the presence of carbohydrate in the gut and therefore the chance of significant hypoglycemia occurring is unlikely, unless used in combination with other hypoglycemic drugs. They maybe used as a stepping stone between oral medication and insulin in Type 2 diabetes, especially in people who are overweight/obese.

Support & Information Vital

It is vital for anyone with Type 2 diabetes who is starting injectable therapy to get the right support going forward. Many people with Type 2 diabetes see insulin therapy as a failure and the negative associations can lead to poor compliance and control. Previously I ran a diabetes support group, which was a mixture of people with type 1 & 2 diabetes and it proved very successful. People with Type 1 diabetes provided great support and advice to those with Type 2 diabetes who were starting on insulin therapy and for many people with Type 1 diabetes they did not realise that many people with Type 2 diabetes are on the same insulin regimes as them.

Seeking advice, support & information from your diabetes team is a must and additional sources like the services of Diabetes Insight can be accessed if required.

Breaking down Barriers and Dispelling Myths

It is unfair to say that people with Type 2 diabetes brought it on themselves and especially when it comes to commencing insulin therapy. There can be a terrible stigma associated with commencing insulin therapy in Type 2 diabetes, and this is not helped sometimes by the diabetes community itself. There are many factors to consider, and just as many people with Type 1 diabetes feel very angry by being labelled the same as Type 2 diabetes, many people with Type 2 diabetes are tired of being blamed for ‘bringing it on themselves’. We cannot ignore and must acknowledge that many of the risk factors for developing Type 2 diabetes are associated with lifestyle and being overweight, but no one can change their age, family history and ethnicity which have as much if not more of a causative factor than lifestyle alone.

We all need to dig deep, get our facts straight and support one another when it comes to diabetes, no matter what type. Because whether you have Type 1 or Type 2 diabetes, the fact of the matter is, if it is not controlled, the complications and outcomes are the same for both types.

References:

1. UK Prospective Diabetes Study Group: Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 352:837-53, 1998

2.  The Diabetes Control and Complications Trial Research Group. (1993). “The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus”. N Engl J Med. 329 (14): 977–86

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