Who needs insulin?
By Renate Drousch
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| Diabetes Mellitus: Who needs insulin? |
• Everyone with type 1 diabetes—such patients will die
without insulin treatment (Table )
• Type 2 patients with hyperglycaemia uncontrolled on
non-insulin treatments
• Patients with acute onset of severe symptoms
Intense thirst and polyuria can be devastating.
Insulin cures these symptoms by reliably reducing the blood glucose towards
normal levels. Thus, all such patients should be considered for insulin
therapy, at least initially, to make them feel better. If the symptoms have
arisen within weeks, or have progressed rapidly, it is likely that the patient
requires long-term insulin therapy. If these symptoms are combined with ketosis
and weight loss, insulin is mandatory.
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| Diabetes Mellitus: Who needs insulin? |
Ketone producers
In someone with diabetes whose blood glucose
concentration is > 11 mmol/l, moderate to high ketonuria or blood ketone
levels > 1 mmol/l suggests the need for insulin therapy unless they are on
strict weight-reducing or an ‘Atkins style’ diet. (Lower ketone levels do not
definitely exclude the need for insulin.)
Insulin treatment is life-saving in acute DKA. Any
patient who has had an episode of proven DKA in the past is likely to need
lifelong insulin treatment. Rarely, patients subsequently produce enough of
their own insulin to return to oral hypoglycaemic therapy. This decision should
be made by a consultant diabetologist; however, patients should be encouraged
to test their blood glucose particularly assiduously during intercurrent
illness or stress. They should keep insulin in the refrigerator for immediate
use if the blood glucose concentration rises to avert a further episode of
ketoacidosis.
People who
have lost weight unintentionally
Marked weight loss (e.g. > 3 kg) in anyone with
newly diagnosed diabetes, especially those who have lost weight despite eating
well, may indicate the need for insulin treatment.
Ill people
Insulin should be given to new or established patients
with acute myocardial infarction if glucose control is required. People with
diabetes who have an infection, an accident, or a surgical illness often need
insulin until the additional illness is under control. The necessity of insulin
treatment
should be assessed in all diabetic patients urgently admitted
to hospital.
Children and young people
The majority of people whose diabetes develops at <
30 yrs of age have type 1 diabetes with an absolute insulin requirement. Type 2diabetes is increasing in this age group, but the decision not to use insulin
should be taken very carefully by a consultant diabetologist or paediatric
diabetologist.
Pregnant women
It is usual to give insulin to pregnant women with
diabetes who cannot control their blood glucose by diet and metformin.
Type 2 patients who are hyperglycaemic despite non-insulin hypoglycaemic drugs, diet, and exercise
Consider insulin treatment in patients whose HbA1c is
persistently > 48 mmol/mol (6.5 %). In obese people or those who eat a lot
of sugar it may be possible to improve matters by re-evaluation of the diet and
exercise pattern.
Many patients who have declined insulin for years are
astonished at how much better they feel on insulin and wish they had agreed to
have it years before.
Patients with complicated diabetes
Insulin may help patients with severe painful diabetic
neuropathy, even if their glycaemic balance is reasonably controlled on
non-insulin therapy. The rationale is that aggressive normalization of the
blood glucose with insulin
may relieve the symptoms. Patients with other tissue
damage may benefit. Patients with severe hypertriglyceridaemia (i.e. ≥ 10
mmol/l) and diabetes
are sometimes treated with insulin to achieve normoglycaemia
and normotriglyceridaemia.
A very low-fat diet and carefully balanced
carbohydrate intake are needed, and lipid-lowering drugs may also be required.
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