Tuesday, June 25, 2013

Diabetes- Insulin Resistance and U 500 Insulin

Question from anonymous:

I am on 275 units of insulin a day and still my BS do not fall below 260. I am worried about taking so much insulin and not seeing any results. I would like to try this U500 insulin but I am also leary about taking something new. There is not much info on this insulin that I can read that is put into laymens terms. Is there a web sight that I can go to that will put it into words that I can understand? on severe insulin resistance and U 500 insulin

My thoughts:
   My personal experience with U 500 insulin was limited to 3 patients. They did achieve some slight improvement in their A1c but did not reach the target goal of 7 . all gained weight gained weight and the U 500 insulin is very expensive. My experience is not to much different than the results obtained in a study published a few years ago.

Clinical experience with U-500 insulin
risk and benefits
Angela Boldo, MD and Richard J. Comi , MD
Endocrine Practice 2012; 18(1):56-61

    66% decreased A1c by .5 or more
     8% achieved An A1c goal of of 7
     Weight gain- 61 to 74 pounds  ( 28 to 34 kg )

 They referenced another study for a definition of severe insulin resistance . 
     1.9 U/2.2 pounds ( 1.97 units/ kg )
 They also mentioned that U 500 insulin onset and duration of action is similar to NPH insulin.
      onset of effect about 45 minutes  
      peak effect 7 to 8.5 hours
      injection frequency 2 to 3 per day with it acting as a basal insulin and also using a rapid acting before meals.

I generally tried to help my patients avoid U 500 insulin for all of the above reasons. Most people with severe insulin resistance are over weight and many have polycystic ovary disease.
Suggested conversation with your doctor
    #1  Weight loss - increase your food management skills by working with a dietitian.
            Ask your dietitian about the Dash diet ( see reference to previous post below)
    # 2  increase exercise with your doctors approval
    # 3 medications to discuss with your physician. ( multiple medications are needed )
         -   Glucophage ( metformin ) is the first choice of medication for treating type 2 diabetes
         -     Byetta or the newer once a week injection of Bydureon
         -     Lantus insulin at bedtime to control your fasting glucose
         -     A rapid acting insulin such as Humalog or Novolog  regulated by insulin / carb.
               ratios may have to be added.

None of the above suggestion are easy and requires a lot of work with diabetes educators and dietitians. Your physician may want to refer you to an endocrinologist to help you work out the details of dealing with insulin resistance. My last consideration is a gastric bypass because of the risk  involved with any surgery.The newer procedures have corrected many of the problems we used to see with this procedure and I have to admit that some of the results have been very good.

Have fun , Be smart and just do what every is necessary to manage your diabetes and preserve your good health.
David Calder,MD

References to previous post on the above topic. Just click on the topic to review the discussion.


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Your comments and questions are appreciated. David Calder,MD