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Permalink Reply by Brian (bsc) on September 21, 2011 at 5:09pm

Ralph Defronzo has been critical of sulfonylureas. One can argue about whether they "cause" beta cell destruction or not, but the data seems pretty clear, they don't "preserve" beta cells. Defronzo presents a bunch of data on current (second generation) sulfonylurea's. None of the therapies involving sulfonylureas have any durability. In contrast, Defronzo shows that the TZDs are durable (although their safety may be in question) and further that the GLP-1s may even promote beta cell restoration.

I do not believe that the manufacturers of sulfonylureas can be trusted to give an objective view of whether they destroy or preserve beta cells. I was always clear in my refusal to take sulfonylureas.

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Permalink Reply by AngelaC on September 21, 2011 at 7:02pm

Natalie,

I do agree that people should be informed of their options and allowed to make their own decisions, based on relative risks and benefits. However, people don't always make good decisions. My neighbor's ex-boyfriend, for instance, was diagnosed with stage III-IV bladder cancer earlier this year and the "gold standard" treatment for that stage cancer is a short dose of chemo, surgery to remove the tumor, and then more chemo and radiation. It ensures the best chance of survival, according to most medical experts I read. The doctor recommended surgery and chemo/radiation. What did he choose? He chose chemo and radiation only, which is substantially less effective when cancer is at that stage.

That's not to say that Cathy is not making a reasonable decision. Perhaps she is; I don't know. What I can say is that, based on my experiences, it is likely she will have a difficult time being placed on insulin. Her A1c, while not ideal by AACE standards, is within the standard set by the ADA, which many GPs follow, and it strongly suggests her doctor may be reluctant to change her regimen. One thing working in her favor is the AACE/ACE Diabetes Algorithm for Glycemic Control, which shows a stepwise treatment plan for people with type 2 dm that goes from monotherapy to triple therapy to insulin therapy in a series of steps. Now, she is at triple therapy (Januvia, Metformin, and Amaryl), so if she cannot get her numbers down under 6.5, insulin is the next step and the first insulin docs will prescribe is one of the long-acting insulins, either Lantus or Levemir, one shot per day. If that does not bring down her bgs, then she'll be taken off of the Amaryl and started on Humalog, Novolog, or Apidra.

FWIW, Humalog, Lantus, and the other insulins that are prescribed technically aren't insulins, but are insulin analogs. That is, our lovely injectibles are genetically engineered, or as Wikipedia defines it: An insulin analog is an altered form of insulin, different from any occurring in nature, but still available to the human body for performing the same action as human insulin in terms of glycemic control. They're not as "natural" as people think they are and the impact of injecting something that's not quite insulin into ourselves isn't truly fully known yet. At the same time, I will continue to take my Humalog and Lantus.

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Permalink Reply by Natalie ._c- on September 21, 2011 at 9:38pm

You bring up an interesting question about the analogs. From what I've read, in lispro (Humalog), lysine and proline at positions 28 and 29 are switched, and the reason it still works is because that is an inactive area of the molecule. Apparently, there is something similar in both Novolog and Apidra in the same place. So I wonder if that means that there truly is no biological difference between them and natural human insulin. Obviously we can use insulin that is not identical to our own, or pork and beef wouldn't have worked, and while there were effects like lipodystrophy and hypertrophy, I don't THINK there were any other long-term harmful effects. I could be wrong. But I wonder if that does justify the position that the analogs are safe.

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Permalink Reply by MossDog on September 26, 2011 at 7:44pm

Agree 100% about the GP being VERY unlikely to prescribe insulin at this point. Maybe just a touch of Lantus/Levemir but not enough to even work for most Type 1's (that is what I see GP's do around here anyways)

Re: Insulin Analogs-
Anyone concerned about this certainly has the option of using Regular and NPH. As for me, I do not think it is likely this could be a problem but if it is? Oh well got to die from something...............

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Permalink Reply by Cathy Jacobson on September 21, 2011 at 6:16pm

Unfortunately, Met and my arthritis formula didn't work well together, I didn't mind the met because it did work. But the Janumet is doing it's job.....I just do not want to wait until we are at the door of problems to get an answer. I would rather be a little more proactive with my treatment, that wait and see.

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Permalink Reply by Super_sally on September 22, 2011 at 2:32am

I love being on insulin! It gives so much freedom and makes it very possible to control blood sugars very well, particularly if you still produce a little of your own insulin (as I am also lucky enough to do).

Combine what you are currently doing with some low doses of insulin and your numbers will be able to be perfect.

Insulin generally makes you gain weight if you use it to cover excess carbs. But sounds like your diet is very well controlled.

Do not fear insulin. Go for it. Learn about it, and make it work for you. I can't recommend it more highly.

Moreover, going on insulin while you still have some of your own insulin production left may preserve that function you do have, and you may be able to go for a very long time on low doses of insulin and with your current lifestyle management.

AS you are already low carb, I can recommend taking a look at the Bernstein group here. They have excellent advice too!

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Permalink Reply by jims on September 22, 2011 at 8:10am

great response.

fact is we are all on insulin.

when help is needed - boost of insulin; using needle with complete variability beats crap out of pills.

For me needle and insulin really provides extra degree of freedom and timing and abilityt to diet and lose weight.

pills absolute pain in ass like taking hammer to flies.

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Permalink Reply by jims on October 4, 2011 at 7:44am

Super_sally on sept 22/2011 provides ecellent comment and catches the correct response to this mess.

My experience catches the same response and operation.

Why are we taking hammers to hitting flies when liquid injections allows one pancrease to do as much as possible and then add a small boost to keepfinal better control.

Pills for a lot are unhelpful

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Permalink Reply by neilin on September 28, 2011 at 11:56am

My feeling is if you are doing as well as you describe, I would think for a very long time before going on insulin. Especially, since you are the one thinking about asking the doctor to put you on it, and not the other way around. I have not yet had to be on insulin, and my doctors have always suggested to me to avoid taking insulin for as long as possible.

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Permalink Reply by MossDog on September 28, 2011 at 12:20pm

Hi neilin,
Did your doctors ever give you a reason for avoiding insulin as long as possible?

I have noticed in my limited experience that people who still produce small but significant amounts of insulin have an easier ( I REALLY hesitate to use this word because none of it is easy) time with highs and lows than someone who produces little to none. If you think about it, the body then is able to help some when you have screwed up, which even the most controlled of us does on occasion. The thought is also that by using insulin earler you may be able to extend the amount of time your body can produce insulin.

In the end this is a personal decision as is most of diabetes management but I would hate for a Doc's preconceived notions about waiting to start insulin paint a bad picture of needing insulin for you. There are likely good theories on why to delay insulin (although honestly any reason escapes me right now) but just like my paragraph above, these are only theories.

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Permalink Reply by jims on September 28, 2011 at 3:00pm

As one who has a pancreas adding lots of insulin and I am on a CGMS due to all the fracas of an overdumping liver, use of the correc t insulin has been rewarding and saved a lot of grieft with following comments:

a) oral pills simply cause pancreas to boot up pancreas output. One is still on insulin.
b) oral pills are a slege hammer approach and my worst lows where on starlix plus my pancreas.
c) liquid insulin allows for the finest garularity to boost one's pancreas and injust injection time for best
d) since one has body insulin still working, I watch body bolus after eating lunch or dinner and only inject after gut/intestine starts putting out its glucose and bg has lifted above 140. Based on carbs eaten. I add a 2 to 4 unit
dose. If I inject before meal, dose adds to body bolus and takes bg down further before digestion completes.

As my liver wakes up with a vengence after waking up and any metformin has been exhausted, I insert dose of 4 units and this is sufficient for breakfast and keep liver under control. Wake up bg is usually 122 to 133 and after 4 unit dose in am, BG rises to 140 and sometimes peaks at 150. I eat breakfast shortly and bg stays pretty stable.

Until I had CGMS, I was unaware of any pancreatic action after 30 years on the dam oral drugs which I think are inappropriate for a type 2 trying to maintain diet unless ones pancreas is nearly exausted or at bottom.

I originally ended up on insulin due to a dam liver dawn effect that would shoot BG to 238 every morning reliably.

I was put on 26 units of 75/25 that was terrible. AFter shutting down liver dawn effect with 500mg does of metformin at 10:00pm and 12:00 am; bg was 122 to 133 at midnight and remained same at wakeup.

After fixing liver on metformin and now using hunalog lispro - 4 units in am; 3 units at lunch and 2 to 3 at dinner; bg now moves like slow waves on a placid lake and predictable. Previous 30 years - all over the map and unpredictable.

A1c went from 13.3 to 6.4 today.

On the other side of this mess one wants to control carbs closely and get heratyexercise - equivalent of 1 to 2 miles walking a day.

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Permalink Reply by Brian (bsc) on October 4, 2011 at 4:39am

I was always told that insulin would make me gain weight and that hypos posed a serious health risk. I just had an appointment with my endo last week. She has only known me as an insulin dependent patient. She looked at my A1C and said maybe I don't need insulin and that maybe medications would work. So we went through my discussion of how I was on three medications and could not reach target. And the truth is that my targets have always been more aggressive than the ADA and hence more aggressive than many doctors. She was concerned about hypos. She might have general concerns about weight, but I am not overweight and I have lost weight since starting insulin.

But my experience with insulin is as MossDog describes. I actually am blessed with easyy control since I have remaining insulin production. And having blood sugars that are almost always < 140 mg/dl means that I am doing everything to preserve my remaining insulin production. I take a long-term view and I'm very happy with my move to insulin.

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