Insulin vs Expensive Orals: Higher Satisfaction, Less Weight Gain

Doctors have been so brainwashed by the drug companies as to the superiority of their oral drugs to insulin that it is rare to find anyone newly diagnosed with Type 2 diabetes who was put on insulin at diagnosis except for those whose diagnosis occurred during a hospital admission where blood sugars were found to be over 500 mg/dl.

This is true, even though there is compelling evidence that putting people with Type 2 on insulin immediately after diagnosis provides long term benefits, even if the patients stop the insulin a month or two after they start it.

There are three reasons why doctors fight against putting the newly diagnosed person with Type 2 diabetes on insulin: Fear that the patient will not comply with the treatment because it involves shots, fear that insulin will cause dangerous hypos, and fear that the patient, already battling a weight problem will gain more weight.

It does not take a new study to debunk all these fears. The patients who supposedly refused needles rushed to adopt Byetta as soon as they were told it would cause weight loss or rejuvenate beta cells--claims that in many cases were untrue. Patients taking the sulfonylurea drugs Amaryl or Glyburide routinely experience dangerous hypos if they neglect to eat high carb meals throughout the day. Actos and Avandia cause dramatic and permanent weight gain in many of those who take them, because the drugs' mechanism of action lowers blood sugar by creating new fat cells and clearing glucose by transforming it to fat and storing it in the new cells, but doctors prescribe them anyway.

Nonetheless, for those of us who consider insulin the best of all the diabetes drugs, a new study published in Diabetes Care confirms our belief that insulin should be the first, not the last, drug prescribed to people with Type 2 who cannot normalize their blood sugar with diet alone. Insulin, rather than the obscenely expensive oral drug cocktails doctors prefer.

Here's the study:

Insulin-Based versus Triple Oral Therapy for Newly-Diagnosed Type 2 Diabetes: Which is Better? Ildiko Lingvay, et al. Diabetes Care July 10, 2009, doi: 10.2337/dc09-0653

This was a three year study. One group of patients were put on insulin plus metformin. The abstract does not specify whether the insulin was basal insulin (Lantus or Levemir) or a combination of basal and fast acting insulin. Given what I hear from my correspondents, my guess is it was basal insulin alone.

The other group of people with Type 2 diabetes in this study were put on a typical drug cocktail regimen consisting of metformin, glyburide, and Actos.

Blood sugars as measured by A1c were very similar in both groups, however there was less weight gain in the insulin/metformin group" than in the drug cocktail group. Not only that, but as reported in Diabetes in Control the researchers said,

"... while the weight gain persisted over time in the group treated with oral hypoglycemic agents, the weight gain in the insulin-treated group leveled off after 18 months and even regressed towards baseline.

Fewer people dropped out of the insulin arm of the study than the oral drug arm, too, suggesting that it was easier to comply with.

There is a reason why early insulin might be so helpful for people with Type 2 diabetes and it is, that, when prescribed properly, insulin is much more likely to lower blood sugar below the level that produces secondary insulin resistance,.

Secondary insulin resistance is a phenomenon doctors are often unaware of. It turns out that when blood sugars rise to a certain point--somewhere around 180 mg/dl--this rise causes an increase in insulin resistance, so that once blood sugars are high they stay high, because it takes more insulin to lower blood sugar than it does when blood sugars are below the threshold. This secondary insulin resistance also makes weight gain more likely.

This is why so many people with Type 2 see a dramatic drop in their blood sugar when they cut carbs out of their diets. Their insulin sensitivity improves as soon as the blood sugar drops under that threshold and their remaining insulin is far more effective. In addition, the drop in secondary insulin resistance often makes it easier to lose or maintain weight on the same calorie intake.

Giving people insulin in doses that drop blood sugar below that same threshold has a similar effect and makes it much easier to control blood sugar, too.

Injecting insulin does something else--it gives the battered beta cell a chance to recover. Alternative drugs like Byetta, Januvia, Prandin, Starlix, Glyburide and Amaryl all force the exhausted beta cells to secrete insulin, stressing the already stressed cells. Injected insulin replaces beta cell insulin, giving the beta cells a chance to rest.

Many people with newly diagnosed Type 2 diabetes don't need any drug at all. I hear daily from people who have adopted the strategy described HERE and lowered A1cs from well over 8% to the 5% range that prevents complications.

But if like me, you have something going on in your own, unique metabolism that means that you can't get normal blood sugars eating under 100 grams of carbohydrate a day, don't be shy about asking your doctor for insulin.

Insulin works. Combined with a low carb diet it won't pack on the pounds--especially if you use Levemir rather than Lantus. Fears that use of insulin might increase cancer appear to be unfounded, at least for people who combine insulin with metformin. You can read more about the insulin/cancer scare HERE.

In contrast to the unsupported fears about insulin, the known side effects of Actos are ugly, and getting uglier by the month. The sulfonylurea drugs, Amaryl and Glyburide, are sold with an FDA warning that they may increase the risk of heart attack. Januvia and Onglyza lower blood sugar using a mechanism that turns off a cancer suppressor gene.

If you worry about the confusing data about Lantus and cancer (which is far from conclusive) ask your doctor about using R insulin which is identical to the insulin your own beta cells produce. Many people find that R insulin is the ideal insulin to use along with a low carb diet as it is slower in action than the much more expensive analog insulins and matches the digestion curve of a higher protein/higher fat meal far better.