Insulin, Orals, and Your Options

If you have diabetes, you know that the right medication can be vital to how well you feel. Sometimes, to achieve the best results, that may mean more than one "right" medication. Research shows your best choice may be a combination of drugs.

The reason? Diabetes isn't just about regulating insulin, says Cynthia Payonk, R.N., patient educator at Lehigh Valley Hospital and Health Network's Helwig Center for Diabetes and Nutrition Education.

Insulin is the substance your pancreas makes to help convert blood sugar into energy, a process that goes awry if you have diabetes. "We used to think of insulin regulation in type 2 (adult onset) diabetes as a single problem," Payonk says. "Now we know there are three distinct problem areas."

The most obvious is insulin deficiency—the pancreas isn't producing enough. But your liver also may be secreting too much sugar into the bloodstream, instead of regulating the flow to keep it constant. Finally, you may have insulin resistance. "Muscle tissue takes in sugar as fuel, but some people's muscles lock it out, leaving high levels in the bloodstream," Payonk says. "Insulin is the key that opens the lock and lets the sugar in."

Each condition responds best to a different drug. Sulfonylureas (such as Glucotrol) boost insulin production; metformin (Glucophage) improve liver function; and glitazones (such as Avandia) fight insulin resistance. "Now we can target the specific problems," Payonk says, "and use the right drug combination to address them."

Despite these advances, many people with type 2 diabetes will have to take insulin eventually, says Payonk's colleague, endocrinologist Larry Merkle, M.D. "The natural progression of the disease is that the pancreas eventually tends to shut down," he says. "But early treatment potentially can delay that." He's particularly enthused about the new glitazones, which help keep the pancreas from getting exhausted. "Most physicians start treating diabetes with sulfonylureas alone," Merkle says, "but I believe any treatment should also include glitazones or metformin. They can cause a small weight gain and fluid retention, but the benefits far outweigh the risks."

The bottom line for those with type 2 diabetes: be sure to discuss your medications with your doctor regularly.

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