Running… out of option or wrong direction

Every now and then, I come across a patient with Type II diabetes where he / she is already on maximum doses of oral medications or has some conditions such as renal impairment or contraindications that preclude the patient from further dose increase or adding a new medication to help manage the diabetes.

So the dreaded question starts to linger in my head: is it time to start insulin? The current guideline encourages starting insulin sooner than later so that the diabetes get under control more efficiently, thereby minimize or slowing the progression of diabetes related complications such as retinopathy (that affects the eyes), nephropathy (that affects the kidneys), and microvascular diseases (such as poor circulation to the feet with increased risk of infection that can lead to amputation).

There is a bad rep with starting insulin – makes people feel like they have failed to bring diabetes under control, plus starting insulin comes with a complicated set of training, monitoring and diet restriction – all of that translate into a need for significant lifestyle changes or just plain inconvenient and PAINFUL.  A lot of resources has gone into promoting insulin, educating its benefits and motivating patients so that they are empowered to do what’s necessary to manage diabetes.

Of course, the pharma industry recognizes that people rather take another pill than to start insulin, so there are constantly new drugs in the pipeline that offer hope to bring diabetes under control.  Diabetes is a costly disease but a lucrative business for the pharma industry.

I feel like there is no endgame for diabetes – just keep adding different medications or increasing insulin doses until we are satisfied with their blood sugar. For some people, this just never happens.

Type II diabetes is diagnosed later in life and is often correlated with obesity. But there is overwhelmingly convincing evidence that Type II diabetes is a very much PREVENTABLE disease. Yes, there are genetic predispositions that put specific populations at greater risk but, we can eliminate Type II diabetes for many individuals.  It takes a lot of changes in our North American lifestyle – to change our diet that is filled with unhealthy fat/sugar/carbohydrate and to change our expectations so that we can incorporate exercise in our daily routines.

I feel like when we treat diabetes, we are running in the wrong direction. If we invest in changing our lifestyle, we won’t have Type II diabetes in our society, we don’t need all these fancy oral medications for Type II diabetes and we won’t need insulin. We won’t see all the complications we see now with Type II diabetes (e.g. dialysis, leg amputation, blindness).  So why can’t we invest more in wellness education and disease prevention? I know we have started doing this – but the effort seems futile and inadequate.   Quite frankly if we are successful in preventing Type II diabetes, it will put many pharma companies and health care services out of business.  Too many parties are at stake here and until we clearly identify our strategy to prevent Type II diabetes, it will not happen naturally and successfully. We need a big game changer for it to happen. And I hope we know how one day.


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My name is Cynthia Leung and I am a practicing pharmacist in Kingston Ontario, Canada. This blog is for me to share my ideas, opinions and perspectives on how medications are used in our health care system. Note that these posts are my own opinions and do not represent the opinions of my current or former employers and / or organizations that I may belong to. Any possible case scenarios described in my posts would be modified to maintain patient confidentiality. This blog is not a platform for professional advise for patients or health care providers and the content is not meant to support any clinical decisions or replace professional opinions. Also the images are either taken or created by the author, or adapted with permissions. I hope you will enjoy reading my posts!

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