Can my first "med" just be insulin?

Hi folks: I was diagnosed T2 about 4 years ago, and while my doc wanted to put me on Metformin the same day, I told him I wanted 6 months to see what diet/exercise would do, and I got my A1C of 10.5 down to 5.6 in that time. Fast forward to now, i’d had a few ups and down, depending on how good i was about low carb and exercise, but my recent sedentary COVID lifestyle has sent my A1C to 11. I know i can get that down again w diet and exercise, but think i need help. I did try Metformin last year and quit after 2 weeks of gastro hell. My Mom and bro are both T2 and take meds plus insulin. But reading so much about all these drugs and side effects, etc. i frankly just want to take insulin. I’m anticipating push back from my Kaiser doctor. Any good strategies for making the case to skip all the trial and error of the various meds?

I’m all for advocating for yourself to get the treatment options you feel are best, even if it’s not the typical course…

But as someone who’s taken insulin most of her life, I want to seriously stress that insulin in a scary and dangerous game. The potential side effects of insulin are WAY worse than you’ll find with oral medications. I seriously doubt you’ll find a single type 1 among us who has never had a life-threatening hypo. Given the insulin-resistance of type 2, you’ll likely need unusually large amounts of insulin, increasing the inherent danger. It’s not something i would wish on anyone unless you absolutely need it.

I feel like you’re making this decision much too lightly if you’re making it just to avoid nausea and/or diarrhea. Aside from hypoglycemia, potential adverse reactions to the DRUG insulin (it’s still a pharmaceutically manufactured drug, don’t be misled because it mimics a natural hormone. The drugs are different) include: allergic
reactions, local injection site reactions, lipodystrophy, rash, pruritus, Onychomycosis, sensory disturbance, urinary tract infection, chest pain, headache, skin disorder, abdominal pain, sinusitis, DEATH, etc… Does insulin still sound like your first treatment choice??? This is precisely why you SHOULD expect pushback from your doctor. It’s not the safer nor easier option you seem to think it is.

Myself, and a lot of other Type 1s, have started taking Metformin in addition to insulin, because it reduces the amount of basal (background/long-acting) insulin I need. So I speak from experience when I tell you that Metformin does get better. The first month undeniably and absolutely sucks, but then I never experienced the GI distress again. And honestly, even if the side effects never faded, I would take them any day in lieu of insulin, if I could.

Thankfully there are other options if you don’t want the Metformin. Every prescription drug comes with a scary list of potential side effects, but that doesn’t mean they are common or that you’ll experience any of them. I STRONGLY urge you to reconsider your desire to skip the oral meds altogether.

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The issue with only taking insulin if you’re T2 with a family history of T2 is whether you have significant insulin resistance at play. You might need a very large amount of insulin, which wouldn’t be the end of the world, but could result in weight gain etc., if you don’t also treat the insulin resistance so your body is able to utilize insulin better. That’s what the metformin does. But you may as well ask your doctor.

Did you take the extended release form of metformin?

Whether or not your doctor is willing to “risk” putting you directly on insulin most likely depends on his/her impression of you. Are you responsible enough to manage using insulin safely? If you are given insulin and things go “casters up”, can the decision be justified to his/her peers?

Truth be told, most if not all doctors are likely to view your request from the frightful perspective expressed in Robyn’s earlier post. So I’m not optimistic about your chances of being prescribed insulin, if that is what you still believe you actually want. But the only way to find out is to discuss it with your doctor and find out how that goes.

For what it’s worth, here’s what happened with me back in mid 1978.

I was an enlisted man in the Navy in my mid 20s going to language school in Monterey, CA. My fasting blood glucose was extremely high and I was down about 40 lbs to a noticeably skinny 160, so I was diagnosed as an adult-onset (i.e. T2) diabetic and put on whatever oral medication they prescribed back then.

While I was home on leave in December, I saw a civilian physician in Milwaukee who gave me a glucose tolerance test. The test showed I was producing 1/2 of the insulin expected so he recommended I take supplemental insulin. In today’s terms, I was not a T2 but a LADA T1, a distinction the medical community was only starting to recognize at that time.

However that doctor didn’t (couldn’t?) prescribe insulin for me. Instead, I brought it up with an Air Force doctor I saw when I returned from leave to my next training school in Texas. After consulting with the civilian doctor, I was prescribed the supplemental regular insulin the civilian doctor recommended.

So I picked up that the insulin and syringes from the base pharmacy and then went back to my room and proceeded to use it as prescribed. Yes, I had episodes of hypoglycemia. Did it kill me? Not that I recall. Still, I doubt that this is unlikely to be the experience anyone else would have. :man_shrugging:

Note: The introduction of glucometers made a big difference in terms of using insulin to treat diabetes.

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I appreciate your response and perspective, Robyn. I probably do have an oversimplified view of insulin. My mother and bro have had no reactions or hypo/low incidents, but i know it’s no walk in the park, and the margin of error can have ugly consequences. I will keep an open mind towards meds first.

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thanks. i did take the extended release. but it’s a good point about treating insulin resistance. I may need to suck it up and try metformin again, or maybe an alternative.

Yeah, good reminder about doctor’s POV. we don’t have a strong connection – he’s a busy guy and i’ve only seem him 4 or 5 times. so i could see why he might not be into an insulin first approach.

I wonder if Trulicity would be an option, instead of mealtime insulin. My endo told me if I wasn’t on this you would be taking meal time insulin. Just a thought. Nancy50

Do you see a CDE, might be a good advocate. She/he also has more time to go over things. Nancy50

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Just want to amplify @Nancy50’s remark, as “insulin” means a lot of different things. Basal insulins, like Lantus, are very different from fast acting meal insulins like Novolog, which are all different from the old-school insulins like R and NPH. My understanding is that it’s pretty common to put T2s on Lantus alone if insulin therapy is indicated. It’s a much flatter effect curve, and much less likely to cause hypos. That may be what your mother and brother are taking. It would worth finding out. It basically just kind of boosts your overall insulin availability without the peaks.

And welcome to the forum, btw—its a great place to learn and people are generally well informed and supportive. Hope you stick around!

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I missed this is you first post,welcome to the group. D Life can be a puzzle, even after 28 years. Nancy50

I’m not disputing what @Robyn_H says here but I do want to temper it a little bit. I do so out of experience. Being Type 2 and very insulin resistance I am the perfect example of what she says, I can do some industrial size boluses. I am human and I can make mistakes that would make me susceptible to crushing lows considering the size of my boluses.

I have had some low, my worse ever were in the mid forties and I was functional, I have never felt I had a low that I felt was life threatening. I credit my good fortune to the remaining amount of natural insulin production I have left. I believe it acts as a buffer to extreme lows.

Even with what I just said I cannot and do not discount what @Robyn_H said. A failing pancreas can be a fickled thing, I do not try to out think it.

I did not start with insulin, I went thru the whole oral meds routine, I did not ask for insulin, I avoided it, but once I started it I realized it was the best treatment for me. That was me after 15years on orals, insulin was finally something that really worked.

I have no love affair with insulin, it is a love/hate thing. I am past the point of no return. I couldn’t go back to oral meds if I wanted to but if I could I would consider it. Using insulin is no walk in the park. It takes constant attention, and constant preparation. It involves itself in every decision and every aspect of your life. When you are insulin dependent diabetic there are no time outs, or days off, or minutes off, or even seconds. It may not consume 100% of your thoughts but it and all that goes with it consumes at least a small percentage 100% of the time.

Although I had no choice in the matter but to start insulin I realize that when I chose insulin I chose the best thing and the worst thing at the same time. I also gave up something that I can never regain, a sense of freedom, never again can I leave my house without thinking, am I OK on the insulin front.

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Thanks @DrBB, @Nancy50 and @Stemwinder_Gary. This is all great perspective for me right now. I’ve been an occasional lurker on this forum, and you’re right @DrBB, it’s a great source w great peeps – but can also be information overload – and may have contributed a bit to my skepticism around various meds. While i’ve read about how careful you have to be with insulin, i also feel like I’ve heard a lot of the “finally something that works” theme from so many posters. so i think my brain went to the shortcut of “why bother with all these confusing meds”. But the “put off insulin until you really need it” approach seems smart too.

Because I was controlling my numbers fairly well without meds as recently as a year ago, i feel like i’m still hanging on to that mindset. However, I’ve had a bit of numbness in my big toes in the last week or two, which is the wake up call that sent me to the lab. I’m worried my blood sugar is starting to wreak havoc, and it’s time to get serious. So to your point @Nancy50, an endocrinologist may be a better partner for me to sort all this out. Just emailed my GP about my labs. Will see how that convo goes.

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Please don’t think of me as trying to dissuade you, I want you to be more aware of the facts.

If you were here because your doctor was pressuring you I would be right up front trying to assure you that it is a good choice. I would be trying to convince you that what most people absolutely fear about insulin, the needle, is not really a concern. I would be telling you that it is the most effective treatment. It is the big gun.

The most effective is not always necessary, If you have a choice, chose what best fits you and your lifestyle.

I haven’t seen it as much in the last few years but it used to be kind of a theme around here that people encouraged T2’s not to be so apprehensive about going to insulin. Dr’s tend to use it as a threat—“Do your exercise and diet stuff or insulin injections are in your future!”—which a lot of us think is nonsense and even rather unethical.

But it is non-trivial because it is potentially dangerous stuff and you need to know what you’re doing. It may be useful to see it from the Dr’s p.o.v. It’s a very unusual situation to prescribe this stuff: a drug that can put your patient into a coma or worse, but you have to let them administer it to themselves with no medical supervision, multiple times a day, in dosages that can vary all over the place and that they have to figure out themselves. That just goes against the grain of every medical instinct. So they tend to be very conservative about it.

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I have always been conflicted about pushing insulin on T2 and I try not to. I am always eager to help someone thru the transition to insulin if it is what their doctor is recommending.

Insulin has been the best treatment for me and I will tell the curious T2 of my mostly positive insulin experience with the qualifier that you must make this decision with your doctor.

This theme began with a couple of members that took it upon themselves to start insulin without doctors approval. Both were very informed members with the knowledge to pull it off. It worked out well for both of them. There are advantages for a T2 to start insulin treatment earlier.

The real question is when the advantages become great enough to justify the risk associated with insulin therapy. I would hope a person would not make that decision without the benefit of a doctors training.

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I was diagnosed as T2 about 20 years ago when I was 30. The meds I hated, and they really never worked that great anyway. My wife was/is a T1 and was on insulin. So after a few months of feeling crappy from the meds and still not being able to eat I told my doctor I wanted to just go on insulin and I’m glad I did. Now I’m seeing all these pharmaceutical companies are being sued over some of the same meds I was on. I was never overweight, and the thought of never being able to enjoy any type of snack or food bothered me. I would choose insulin over meds any day of the week, but thats just me.

There are a lot of tools in the toolbox for a person with the situation you describe. It would be silly to think only one could work, or that you wouldn’t need a mix of tools, maybe different ones at different times.

If you are vigilant of your condition throughout the day, there shouldn’t be any reason you can’t consider insulin as well, whether basal or bolus or both. Insulin works really well for what it does!

My other piece of advice for insulin users no matter their “type” is to consider a cgm (or lots of daily finger tests). This can also really help in your discussions with your endo about what meds are best suited.

First, many older people who develop Type 1 are misdiagnosed as Type 2, and insulin works GREAT!!!
Second, a true Type 2 (as identified by a proper Glucose Tolerance Test that measures both insulin and blood glucose over a 3 hour period, starting fasting then a glucose challenge, then checking how the body responds) has plenty of insulin but glucose stays high even with higher than normal insulin. I knew a lady about 35 years ago whose GP prescribed only insulin for diabetes of either type, and she said she could take an entire bottle and her sugar would not go down.
Third, the standard treatment for Type 2 is initially Glucophage, which eventually stops working, and must be supplemented. Since we still do not understand the best treatment for Type 2, the best treatment after Glucophage stops working is not clear: some say to switch to a different oral medication, others say add another oral medication to Glucophage, some say add insulin to Glucophage, while some say add both another oral medication and insulin to Glucophage.
Fourth, if you are a true Type 2, insulin alone will not work very well. If you are a misdiagnosed Type 1, nothing will work better than insulin.

This statement is too broad. For many type2 insulin alone works quite nicely. Type 2 diabetes is so variable, with many factors. How far along in the disease and/or how much insulin resistance one has are two of the major factors. There are also several different subtypes of T2.