September 25, 2007

EASD: Imbecile Insulin Dosing Schedules Not Much Help for Type 2s

The "DUH" of the Week goes to the geniuses at EASD who reported studies showing that giving "insulin" to a person with Type 2 diabetes and extremely high blood sugars doesn't do much when that "insulin" is ONLY a basal insulin prescribed at the wrong dosage.

Imbecile mistake #1: Prescribing only a basal insulin which has no impact on post-meal blood sugars. What part of "Very high blood sugar spikes after meals damage the body" don't these people get?

Imbecile mistake #2: Giving patients only enough insulin to lower their fasting blood sugar to a level that is still way too high. I have spoken with many Type 2s whose doctors tell them they are doing great if their fasting blood sugar "on insulin" is around 120 mg/dl (6.7 mmol/L). Since this means that every time they eat a few grams of carbs they go over 140 mg/dl (7.8 mmol/L)--the level at which organ damage occurs--and stay there for hours you can see why this is a futile treatment plan.

When you add to the mix that these people are still being told to eat a low fat/very high carb diet, so that they are eating 50-100 grams of carbs at each meal pushing them into the 200s or higher, you can see why their "insulin" regimen is near worthless. Even sadder, these patients with the 120 mg/dl fasting blood sugars are the "good ones" in these doctors' practices. Many type 2s "on insulin" are still getting fasting blood sugars well over 150 mg/dl!

But sadly, this kind of rotten medical treatment is Standard Operating Procedure. Most people with Type 2 are treated by their busy family doctors and most family doctors treating people with diabetics ONLY prescribe basal insulins. And when they do, they almost always prescribe insulin in the generic doses that, out of fear of hypo, are set high enough to guaranteed that the fasting blood sugar level is high enough to damage the organs.

What is so sad here is that the only reason that these people aren't put on "insulin" regimens that give them normal or near normal blood sugars is that their doctors are too busy to bother with the interaction involved and it doesn't occur to them to send Type 2s to the same "Diabetes Educators" that they prescribe for Type 1s. A correctly prescribed basal/bolus regimen-- with insulin for both the fasting and the post-meal state, carefully titrated to match the carb input at mealtimes--can normalize blood sugars.

So because of medical ignorance hundreds of thousands of people are condemned, unnecessarily, to blindness, amputation, kidney failure, and heart attack death.

The fact is, insulin, prescribed right, ALWAYS lowers blood sugar and with some work and education it will produce blood sugars low enough to avoid all the serious diabetic complications. But "insulin prescribed right" means this:

1. Covering the fasting state with a basal insulin titrated to avoid hypos at 3 AM and provide a fasting blood sugar under 100 mg/dl. This may mean using 2 shots of different sizes since none of the basal insulins really lasts exactly 24 hours. One larger shot in the morning, one small at night works well for many people.

2. Covering meals with a faster insulin--Novolog, Humalog, Apidra or R (humulin/novalin), using a carefully computed "insulin/carb" ratio that matchs the dose of meal-time insulin to the estimated amount of carbohydrate in the meal. Ideally, the amount of carb in the meal should be kept low enough that mistakes in guestimating the carb count won't end up causing severe hypos. For many of us this means keeping carbs between 20 - 50 grams per meal.

Getting the correct dose figured out for both basal and bolus insulin involves starting with a low dose and very carefully working up until it's right. This takes time and, for most people, requires the help of a person trained in adjusting insulin doses--a Diabetes Educator.

But the hard work and initial effort involved in learning how to match your insulin dose to the carbohydrate in your meals will pay people with Type 2 diabetes back with decades of improved quality of life.

If you are currently "on insulin" and seeing fasting blood sugars around 120 mg/dl (6.7 mmol/L) and post-meal blood sugars routinely over 160 mg/dl (8.9 mmol/L) 2 or even 3 hours after each meal ask your doctor to send you to see a competent diabetes educator so you can work out an insulin regimen that works. If he or she won't, find a new doctor.

And if you are a person with Type 2--whether or not you are on insulin--who is still eating 100 grams of carbohydrates a meal and wondering why your blood sugar keeps getting worse, check out the web page below and try the strategy described there for two weeks. It may keep you from ever needing insulin!

Jennifer's Advice to Newbies. Don't let the name put you off, this advice has helped people who have had diabetes for decades, too.