This past month I have seen four adults with type 2 diabetes who have
gained 40 lb or more in weight during a 12-month period and they all blamed it
on their insulin therapy. Whether insulin therapy for diabetes results in
weight gain continues to be a debated topic with many prescribers saying "no"
and many patients saying "yes."
My recent experience with the four patients prompts me to say yes, but
not because of the insulin per se but because of the way it had been
prescribed. Each had been placed on a multiple insulin dosing schedule with
different levels of complexity.
Case one was prescribed glargine in a dose of 102 units (yes, that was
the prescribed dose) every evening, 10 units of lispro with each meal, and
additional lispro on a sliding scale if the glucose was >200 mg/dL. That
adds up to four injections per day and at least three finger sticks per day. He
gave up after a while and decided to skip the finger sticks and just take 15
units of lispro with each meal. Not a bad idea until he started to feel "a
little off" more often than he liked. His blood glucose on those occasions was
always below 70 mg/dL and he felt better after he took a snack. Essentially he
was chasing his hypoglycemia with more and more food and chasing his
hyperglycemia with more rapid acting insulin. It should be no surprise that he
blamed the insulin for his weight gain and was quite frustrated.
Case two was on a similar regimen but her basal regimen was twice-daily
detemir 65 units each time. Her rapid acting insulin was aspart. The other two
patients were on similar schedules of injections and glucose checking.
Don’t worry, oral therapies were included in the mix for each of
them! And don’t think for one minute that they were not also on medication
for hypertension and dyslipidemia.
Colleagues who know me and read these blogs (there are one or two) know
that my background has focused on bone and mineral disorders and I don’t
have the expertise of my colleagues who have devoted their clinical and
academic careers to diabetes. But common sense should tell us that the above
approaches are doomed to fail in many, probably most, patients.
Living with diabetes is not easy but we have an obligation to keep
pharmacologic management to a minimum and spend as much time as we can find to
teach and continually reinforce the benefits of lifestyle modification. Each of
these four patients had been to classes to teach them about good eating habits,
carbohydrate counting, etc., but there is a limit to what we can expect of our
There is ongoing debate about the merits or otherwise of tight glycemic
control in the inpatient setting but all are in agreement that wide
fluctuations on blood glucose are best avoided. Surely the same must hold for
outpatients. The cycle of chasing hyperglycemia with insulin and the resultant
hypoglycemia with food can be avoided in most patients. We should not dilly
dally in our attempts to control hyperglycemia but there is no mandate to
overshoot morning noon and night!
I know that there are many colleagues and patients out there who have
found a way around this issue. You would be helping a lot of us if you shared
your successful approaches with us.