Monday, June 27, 2011

How Should Insulin Be Used? Take it the way you would make it!

A study presented at the American Diabetes Association (ADA) meeting in the last few days confirmed what I have been arguing and teaching for years about how insulin is best taken.

But first a warning: this post is not simple but it  is really important. 

Sadly, most people with diabetes do not understand how best to use insulin. And, what’s worse, very few doctors, who prescribe insulin prescribe the best insulin in the best way for people with diabetes. This includes endocrinologists who are doctors who specialize in diabetes!

Two concerns with insulin treatment include: problems with low blood sugar (glucose) and difficulty with weight control. By the way, hypoglycemia is the medical term for low blood glucose, usually considered to be below 70.

Have hypoglycemia and weight control been issues for you on insulin therapy?

The key point of this post is that these issues, risk of hypoglycemia and weight control can be kept to a minimum when you take insulin like the way a person without diabetes would make insulin. Take it the way you would make it!

First is a fact you need to know. Glucose comes from two places: the food you eat (and liquids you drink if they have calories) and from what your liver makes.

A person without diabetes makes a little bit of insulin around the clock even when they don’t eat. That’s called “basal” insulin. It’s like a slow-release insulin. This basal insulin tells the liver to not make too much glucose.

Normal people, without diabetes, also make a bunch or “bolus” of insulin that prevents the glucose level from zooming up after food. That’s like quick-release insulin. Let’s call it mealtime insulin since it’s for food.

This mealtime insulin is meant to match the meal. It’s gone when the effect of the meal on the sugar level is gone, at around 4-5 hours.

Of course, not all meals or drinks will tend to increase the blood glucose. Meals and drinks that contain carbohydrates do that. But that’s another subject.  Don’t get distracted now.

So in order to mimic, reproduce or simulate how insulin is made normally, we need basal insulin and mealtime insulin; that’s both slow- release and quick-release insulins.

Lantus  also called insulin glargine is the long acting basal insulin for which we have the most experience. Levemir (insulin detemir) is another good basal insulin.

Lantus takes 2-3 hours to start working and lasts 24 hours. It’s like a slow-release type of insulin; it releases a little around the clock.

The amount (the dose) of Lantus the person should take is the same everyday but that dose (measured in units) needs to be figured out so that a meal can be skipped and no low blood glucoses (hypoglycemia) will occur. The person taking Lantus should not have to eat to prevent a low blood sugar.

In fact, in general, a person with diabetes who is on the right dose of Lantus should have a stable blood sugar overnight and during the day without food.

Lots of people who see us as new patients are taking way too much Lantus insulin. Most of them need far less Lantus and more mealtime insulin. Lantus is not for the meals; it is the between-meals-around-the clock- even-when-not-eating insulin.

Then there is the mealtime insulin. Mealtime insulin is also called rapid acting insulin. Rapid acting insulins work quickly and are gone after roughly 4-5 hours. They are quick-release and short-acting.

Rapid acting insulins include Humalog

and Apidra

So how can you get the best sugar control using insulin therapy?

Take a rapid acting insulin before 1 or more meals and 1 injection of Lantus (long acting, basal) insulin. In general, patients take the rapid acting insulin only when they eat.

And with this basal bolus approach, you can eat when you want to as long as you take the rapid acting insulin at the time you eat. 

Of course, getting the doses right for each patient is really important and takes expertise.

Now, unlike the basal bolus type approach, there are insulins that make you eat at the same time even when you can’t or might not want to eat. These are the pre-mixed insulins like: Novolog Mix, Humalog Mix, the 70/30, 75/25, 50/50 insulins and N or NPH insulin.

These insulins all look cloudy, not clear like those insulins for basal bolus therapy. And all these cloudy insulins do not allow flexibility with meals. With those cloudy insulins, you better eat or else, you’ll get hypoglycemic. 

So, as you can imagine, an important benefit of basal bolus insulin treatment is that weight control is easier. Many people who switch from other insulins to the basal bolus approach lose weight. And, after the switch, they almost always have fewer problems with hypoglycemia.

There are other advantages of the basal bolus insulin treatment. For example, good blood sugar control is easier to achieve.

I teach doctors in the use of basal bolus insulin treatment. And most of our patients prefer it. The recent study presented at the ADA confirmed all of these reasons to use basal bolus therapy and not to use the cloudy insulins mentioned above.

In fact, less than 5% of the patients in our practice are on  cloudy insulins like 70/30. If you are on one of those insulins, you might consider a change.

Remember, regarding insulin: take it the way you would make it.

In many ways, you will see your way clear to better glucose control and easier weight control. 


  1. I'm on an insulin pump. I am very active(I have run 40,000+ miles over the last 25 years) and do eperience hypoglycemia more often than I like. I have also experienced a very rapid weight gain after going on the pump about 1.5 years ago. It also seems to me the type of insulin I used depends on which company won the bid with my insurance company.

  2. First, congratulations on your astounding commitment to running and staying active over the years!

    Second, I also understand that insurance companies select the rapid acting insulin based upon costs to them.

    Lastly, there are many reasons for weight gain in pumpers including: too much insulin, eating too much, much improved control and not making amylin. Amylin is a hormone that reduces appetite and improves after meal control of glucose. It is available as a medicine (injected) called Symlin. Careful use of Symlin often helps pumpers with control of both weight and glucose.

  3. I definitely will investigate Symlin. It seems like I gained 25 pounds over just 2-3 months after getting the pump and then my weight remained steady but I know I am carrying too much abdominal fat. Recently, I have dropped weight but not the recommended way. I broke 6 vertebrae and a few facial bones in a bicycle accident and my appetite has dropped a few notches. I'm walking everyday but am looking forward to running again. I appreciate the blog- another way to keep informed and be responsible for my own wellness. Thank you.

  4. Erun: Yes, check out Symlin although many endocrinologists have not had much experience with it. It's been available for about 6 years.
    Thanks for your feedback and stay tuned.