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Meet the Author Archive, Thursday, March 25, 2008
Our guest was Marie McCarren author of "ADA Guide to Insulin & Type 2 Diabetes" published by the American Diabetes Association. Marie is a medical writer who has specialized in diabetes for 15 years. Several years ago, ADA held a series of workshops on insulin therapy for primary care providers across the country. ADA wanted to make this information available to people with type 2 diabetes. Geri Spollett, MSN, C-ANP, CDE, said, "[Guide to Insulin] contains information that is usually learned after years of clinical practice." Jason Iltz, PharmD, CDM, said, "[It] is thorough yet concise. The answers and explanations often come from people who know best: those with diabetes who have lived it, learned it, and are willing to share firsthand experiences." Marie's other books include "Carb Counting Made Easy for People with Diabetes" and "A Field Guide to Type 2 Diabetes." Forum_Moderator: Our guest today is Marie McCarren, author of "ADA Guide to Insulin & Type 2 Diabetes." The book was written for people with diabetes, but health care professionals are buying it too. Here is the table of contents: 1. It's Time for Insulin. And It’s Not Your Fault Marie: Thanks. It's great to be here. Forum_Moderator: Marie, you’re not a health care professional, correct? Marie: That's right. I'm a medical writer. I take what the researchers and diabetes care professionals report and write it in regular language. For this book, we also took excerpts from ADA's Adults with Type 2 Message Board. Forum_Moderator: Can you tell us about the evolution of "Guide to Insulin"?
Marie: Years ago, I was on staff at Diabetes Forecast. We ran an article about insulin therapy for type 2 diabetes and asked readers to share their experiences. We got a ton of letters. They all vividly described much the same story: The person resisted going on insulin, felt worse and worse, finally agreed to insulin, and then thought, "That wasn’t so hard," followed by "I’m feeling better," followed by "Why did I wait so long?" Here are two excerpts: "I couldn't function before I started the insulin regimen. I couldn't process information or remember anything and was morosely depressed. When people asked how I felt on insulin, I could only describe it as though I was no longer walking through molasses." - KHS // “I tested almost 300 mg/dl every morning. I could sleep standing up because the fatigue was overwhelming. I suffered this way for a few years until I became so worried about the terrible way I felt that I just decided to give up and take insulin shots. I started on two injections of 70/30 per day. The change was miraculous." —CS
Forum_Moderator: OK, we've got some questions coming in. Marie: Great maryann: My Doctor wants my fasting bs to be 100 and after meals 140. I'm type two on insulin and oral medications. Is this possible? Marie: Yes. If you use enough insulin, your blood glucose levels will come down. You may need two types of insulin: a basal (long-acting) insulin to control fasting blood glucose, and a mealtime insulin to control after-meal spikes. sweetness: How does a doctor decide to take you off oral meds and put you on insulin? Marie: Your doctor may not take you off your oral meds, he/she may just add insulin to your treatment plan. For example, studies show that staying on metformin allows better A1C (average blood glucose level) with lower doses of insulin, often with no weight gain. On the other hand, let’s say a person is on metformin and a sulfonylurea. The person starts with basal (long-acting) insulin and gets his fasting numbers to his goal but his after-meal blood glucose levels are still going too high. That means that even with the help of the sulfonylurea, which should spur the pancreas to produce insulin, his pancreas is not able to make enough insulin. His doctor would probably stop the sulfonylurea because it’s not doing any good, and add mealtime insulin. Marie: The other part of the question is “When/How does the doctor decide to add insulin?" You can tell if your diabetes plan is working by looking at your blood glucose levels. The ADA recommends for most adults: an A1C less than 7%, before-meal (this includes fasting BG) levels of 70-130 mg/dl, and peak after-meal levels (usually 1-2 hours after eating) less than 180 mg/dl. Type 2 diabetes is a progressive disease. You’ll need more medication as the years go on to meet these goals. The American Diabetes Association, with the European Association for the Study of Diabetes, offers guidelines in Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy, published in 2006. It isn’t a list of rules for how doctors should treat every person with type 2 diabetes, it is what works for many people. In brief: Step 1: Make lifestyle changes and take metformin. If that doesn’t do enough, or as diabetes progresses over the years, go to Step 2: Add another medication: insulin, a sulfonylurea, or a glitazone. If/when that plan no longer works, go to Step 3: Start or intensify the insulin plan. Marie: What about adding a third oral medication before moving to insulin? This is not recommended by these experts. If your A1C is more than 8% when you’re on two oral medications, a third oral medication will probably not get you to the goal of less than 7%. If your A1C is less than 8%, a third oral medication may get you to less than 7%, but it will be more expensive than adding insulin. Marie: Here’s an exchange, originally from the Type 2 Message Board, that also addresses this common question: From ZS: "Just curious for those of you who have diabetes and used pills for a while and then were put on insulin. What caused the dr. to put you on insulin? Did you get to a certain number and the dr. felt it was time for insulin?" // From VV: "This past summer, my numbers were no longer responsive to the oral meds. We tried all kinds of new medicines, but you would think I was trying to treat my diabetes with Tylenol for all the good they did. Honestly, as much as I did not want to give myself injections several times a day, being put on insulin was a relief. I felt so bad walking around Harry: I started Lantus last month and am going up [increasing the dose] every 3 days but I’m still not getting the fasting numbers my doctor said I would get to. Is there something wrong? Marie: Don't get discouraged if your fasting glucose doesn't change much in the first few weeks. In the Treat-to-Target Trial ("Randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients"), it took an average of 10 weeks to get fasting glucose levels near the goal. Joe_in_Detroit: does insulin have any side effects like cramping? Marie: I have never seen cramping listed as a side effect of insulin. Philadelphia: I started with 10 units (of basal insulin) and I'm up to 28. How high will it go? Marie: Keep following your doctor's instructions about how often and how much to increase your dose. If you want to predict what your final dose will be, you can do some calculations. The final dose of basal insulin—glargine (brand name Lantus) and detemir (brand name Levemir) are basal insulins—is typically 0.3–0.4 units per kilogram of body weight per day (U/kg/day). (There are 2.2 pounds to 1 kg, so divide your weight in pounds by 2.2.) Leaner people may need only 0.2 U/kg/day. People who are very overweight (more insulin resistant) may need 0.5 U/kg/day. So a person who weighs 165 pounds may need 15 units per day (165 ÷ 2.2 × 0.2 = 15). Someone who weighs 330 pounds may need 75 units per day (330 ÷ 2.2 × 0.5 = 75). Your final dose also depends on how many other diabetes medications you take. Rebecca: If you start insulin can you ever get off of it? Marie: Most people who start insulin will need to stay on insulin to meet their blood glucose goals. Their bodies simply don't make enough. A few people are able to stop using insulin. For example, a person might be very insulin resistant because he is very overweight. If he loses a lot of weight, he might be able to keep his blood glucose levels in his goal range without insulin for a time. Some people have very high glucose levels when they are first diagnosed. Their beta cells (the cells in the pancreas that make insulin), are suffocated by the high glucose levels and have shut down. This is called glucose toxicity. These people may need insulin at first. This will relieve the glucose toxicity. The beta cells then come coughing back to life and start making insulin again. Then these people may able to control their diabetes without using insulin for a time. Forum_Moderator: Great questions today. Marie, in closing, who will find "Guide to Insulin" helpful?
Marie: In the introduction, we have hypothetical situations. If one of these describes you, you'll find this book helpful: "My doctor told me I need to go on insulin, and I'm freaked out." "My blood sugars are always too high. My doctor just keeps saying, 'Eat less. Exercise more. Take your pills. See you in six months.' I think we should be trying something else." "I have crummy health insurance. I see a different doctor every time, and the appointments are always rush, rush, rush. They gave me a prescription for insulin, but I don't know what I'm doing, so I haven't had it filled yet." "I’m not the kind of person who just takes the prescription, no questions asked. I want to know: Why do I need insulin? Why am I being prescribed this type of insulin? Would another work better for me?" "My diabetes educator suggested I go to a diabetes support group. It would be nice to hear from people who have done this, but I can't find the time." Forum_Moderator: That's it for today. Thanks so much for taking the time to be here Marie. Thanks to all of you who joined us by asking great questions or by just tuning in. If you wish to continue any of today's discussions please feel free to visit the ADA Message Boards. Keep up to date with all the ADA Live events and reference the archives here. We hope you found this interesting and informative and that you'll join us again next time here at ADA Live. Our guest will be Rite Aid Pharmacists and diabetes experts, will discuss and answer your questions on all aspects of diabetes at 1:00 p.m. EDT Thursday, April 3, 2008. See you then. Marie: Thanks, it was a pleasure to be here. |
The American Diabetes Association is pleased to present ADA Live! - a series of live Q&A sessions on topics related to diabetes and healthy living. 