Bringing high sugar levels down to normal levels rapidly is increasingly found to confer long-term benefits for people with diabetes.
AFTER a year on medication, Amir*, 50, was taken aback when his endocrinologist suggested insulin injections to control his blood sugar. Anxiety crept in as he remembered, “wasn’t insulin only for those with very serious cases of diabetes?”
Anticipating his reaction, the endocrinologist then explained that the insulin is used to make up for the insufficient production of insulin in his body, which is not enough to bring his blood glucose levels down.
“With the doctors explanation I felt more assured. Now I’m happy my blood glucose level is under control after about a year on insulin,” says Amir.
With adjustable dials and micro-fine needles, reusablee and disposable insulin pens today are less painful and easier to use than the good old needle and syringe method of insulin administration in the past. In the past decade, the treatment and management of diabetes have evolved. From just reaching lower blood glucose targets to recommended screening for cardiovascular diseases in people with diabetes, a more aggressive management of diabetes is advocated as the numbers ballooned in Malaysia over the years.
One of the latest developments is the increasing use of insulin earlier after the diagnosis of diabetes. “Insulin used to be the last resort in treating type 2 diabetes, but now it has changed,” says consultant endocrinologist Prof Datuk Dr Anuar Zaini.
The rationale behind this can be traced to the pancreas, an insulin-producing gland shaped like a thin pear lying behind our stomach.
A landmark study, the UK Prospective Diabetes Study (PDS), reveals that when diagnosed, a lot of the patients with type 2 diabetes show high insulin levels. This indicates insulin resistance, where the body needs to produce more insulin to maintain blood glucose at the same level.
In the same study, most patients had high blood glucose even before diagnosis, but it is not high enough to cause symptoms typical to diabetes patients. Hence it is not easily detected because most people are not even aware of it.
“This is the dangerous part, when people do not know that they have diabetes because their blood glucose levels are still not providing symptoms although they are abnormal,” says Dr Anuar.
Because the insulin levels are already high, the pancreas is working very hard to maintain the glucose levels at normal levels. But there is a limit to how much insulin a pancreas can produce, Dr Anuar explains.
As it is estimated that a person’s pancreas has already lost 50% of its function upon diagnosis, it is important to identify diabetes early so that a higher percentage of pancreatic function can be preserved.
So, if you identify diabetes when your pancreatic function is still 80%, chances are you can preserve the function by lifestyle changes and treatments better than people who are diagnosed when their pancreatic function is 50%. “Even with treatment, the pancreatic function will still continue its steady decline,” says Dr Anuar.
“If the pancreatic function decreases to a dangerous level (10 - 20%), a person may require full-time insulin to help control his or her sugar levels,” says Dr Anuar. “So what we have to do is to bring down the glucose levels fast to let the pancreas rest and recover,” he adds.
Introducing insulin
The management of the patient depends on the status of the patient when he comes to see the doctor. If the diabetes is detected late and the blood glucose level is very high, insulin is often used as a temporary measure to bring down the glucose level, says Dr Anuar.
Otherwise, doctors follow the clinical practise guidelines for diabetes management, which starts with continuous lifestyle intervention followed by oral drugs to get blood glucose levels under control.
“But if they do not reach glucose targets with those interventions, we have no choice but to use insulin and bring the glucose down to normal levels,” says Dr Anuar.
Animal studies have been done to show that when the blood glucose is brought down fast, the pancreas is also allowed to recover fast. That is the reason why there are doctors who advocate the rapid control of blood glucose with insulin, says Dr Anuar.
“By doing that, you try to reverse the injury to the pancreatic cells,” he adds.
However, the recommendation of insulin use is often perceived by patients and their family members as the progression of diabetes to a serious stage.
“We tell our patients that insulin is not the end of the road. We are using insulin now because your pancreas is already halfway ‘gone’, so we want to make sure the better survival of the pancreas,” says Dr Anuar.
Although we need more data to prove that by using insulin we can prolong pancreas survival, what we are saying is if we can get the patient to achieve their glucose targets, so be it, he adds.
While some may need insulin for a long period of time to control their blood glucose levels, some may only need it for a short duration to get their glucose levels down and stabilised within acceptable targets.
Studies have revealed that people who achieved good blood glucose control early in their diabetes are conferred benefits in preventing complications longer compared to people who did not.
So, there is incentive for us to get patients’ blood glucose under control earlier so the effects of the early control could be felt longer,” says Dr Anuar.
Pens in treatment
With the advent of disposable insulin pens and micro-fine needles, injection pain is no longer a hindrance to the use of insulin.
Amir, for instance, injects insulin every night before he goes to sleep without much trouble. “It is not that painful as the pen comes with one of the smallest needles,” he says.
Shaped like a large marker, insulin pens are also easy to carry around for those who are constantly on the move.
One of the problems with insulin injections is the risk of hypoglycaemia (low blood glucose), which may cause seizures, loss of consciousness and even death in severe cases.
There have been studies that report higher morbidity and mortality when higher doses of insulin is administered, but those communities are from the higher age group and they may be more prone to hypoglycaemia, says Dr Anuar.
“Our community involves a younger age group, and they may be a little more resistant to insulin. The incidence and complications of hypoglycaemia may be less (in this community) when you start insulin early, but we need more data to find out.
“That is why (in this community), hypoglycaemia should not be a disincentive to start insulin,” he adds.
He concludes that lifestyle intervention is still the cheapest and most effective, it needs to be sustained, which is easier said than done. So, when that fails, early diagnosis and appropriate treatment – insulin included – saves lives. – By Lim Wei Wen
