The suggestion of insulin is often met with genuine distress. Patients believe it means their diabetes has become severe, that it will lead to complications, or that once started it can never be stopped.
None of those is accurate, and the delay caused by these beliefs is itself a major cause of the complications people fear.
Why Insulin Becomes Necessary
In type 2 diabetes, the pancreas gradually loses its ability to produce enough insulin. This is part of the natural course of the condition, and it happens regardless of how well a patient has followed advice.
Needing insulin is not a punishment for poor control, and it is not a sign of moral failure. It reflects how long you have had diabetes and how much beta cell function remains.
Insulin is also used temporarily in situations that have nothing to do with disease progression: during serious infection, around surgery, in pregnancy, and when other drugs cannot be used because of kidney or liver problems. Temporary insulin can be stopped once the situation resolves.
The Cost of Delaying It
Clinical inertia, the tendency to postpone intensifying treatment, is one of the biggest problems in diabetes care. Patients spend years with HbA1c above nine percent while insulin is discussed and deferred.
Those years of high glucose cause retinal, kidney and nerve damage that is not reversible once established. Starting insulin two years earlier prevents damage that cannot be recovered later.
If your HbA1c has remained well above target on maximal oral treatment for more than six months, the conversation should be about starting insulin rather than trying harder with the same regimen.
The Types and What They Do
Understanding the categories makes the regimen make sense.
- Basal or long acting: provides a steady background level over twenty four hours. Usually the first insulin started, given once daily
- Rapid acting: taken with meals to cover the glucose rise from food
- Premixed: combines both in fixed proportions, usually twice daily. Convenient, but less flexible with meal timing
Most people with type 2 diabetes start with a single daily basal insulin alongside their existing tablets. That is a modest change, not the multiple daily injections people imagine.
Injecting Correctly
Technique errors are common and produce erratic control that gets blamed on the insulin.
- Inject into the fat layer, not muscle. The abdomen, outer thighs, upper arms and buttocks are suitable
- Rotate sites systematically. Repeatedly injecting the same spot causes lipohypertrophy, a lumpy fatty area from which absorption is unpredictable
- Use a new needle each time. Reused needles are blunt, painful and bend at the tip
- Hold the pen in place for ten seconds after pressing, otherwise part of the dose leaks out
- Prime the pen with two units before each injection to clear air
- Do not inject through clothing
- Store unopened insulin in the fridge, not the freezer. In use pens can stay at room temperature for around a month
Lipohypertrophy is worth checking for. Feel your injection sites for firm lumps, and if present, move to fresh areas, which often requires a dose reduction since absorption improves.
Recognising and Treating Low Sugar
Hypoglycaemia is the genuine risk of insulin, and knowing how to handle it removes most of the fear.
Early symptoms: sweating, shaking, palpitations, hunger, anxiety, tingling around the lips.
Later symptoms: confusion, difficulty concentrating, slurred speech, unusual behaviour, drowsiness, and eventually seizures or unconsciousness.
Treatment follows the fifteen rule: take fifteen grams of fast acting glucose, such as three or four teaspoons of sugar in water, half a cup of fruit juice, or glucose tablets. Wait fifteen minutes, recheck, and repeat if still below 70 mg/dL. Then eat a snack containing carbohydrate and protein.
Do not use chocolate or ice cream, since fat slows absorption. Never give anything by mouth to an unconscious person. Family members should know how to use glucagon and when to call for emergency help.
When Hypoglycaemia Warnings Disappear
Some people with long standing diabetes lose the early warning symptoms, a condition called hypoglycaemia unawareness. They go from feeling normal to being confused without the sweating and shaking stage.
This is dangerous, particularly while driving. It develops after repeated low episodes, which blunt the body's counter regulatory response.
It can be partially reversed by deliberately avoiding all hypoglycaemia for several weeks, usually by relaxing targets temporarily. Continuous glucose monitoring with alerts is particularly valuable in this group.
Report any episode you did not feel coming to your diabetes team, since it changes management.
Sick Day Rules
Illness raises blood sugar even when you are eating less, which confuses patients into stopping insulin exactly when they need it most.
- Never stop insulin during illness, even if you cannot eat
- Check blood glucose more frequently, every four hours
- Drink plenty of fluids to prevent dehydration
- Take small amounts of carbohydrate as fluids if you cannot eat solids
- Check for ketones if glucose is persistently high
- Contact your doctor if you cannot keep fluids down, if glucose stays above 250 mg/dL, if ketones are present, or if you are drowsy or breathless
Stopping insulin during a vomiting illness is a common route to diabetic ketoacidosis, which is a medical emergency. Our emergency service manages this, but it is far better prevented.
Practical Living With Insulin
A few practicalities make it considerably easier.
- Carry fast acting glucose with you at all times
- Wear or carry identification stating you are on insulin
- Check glucose before driving and every two hours on long journeys
- When travelling by air, carry insulin in hand luggage, never in checked baggage where it can freeze
- Carry a doctor's letter and extra supplies when travelling
- Plan for time zone changes with your diabetes team before travelling
- Adjust doses for planned exercise, which lowers glucose for hours afterwards
- Discuss fasting during Ramadan or other religious fasts in advance, since regimens need modification
Religious fasting deserves a proper conversation rather than an assumption in either direction. Many people with diabetes can fast safely with an adjusted regimen and monitoring plan.
Insulin is a treatment, not a verdict. Starting it when it is needed rather than years later prevents damage that cannot be undone. Learn the injection technique properly, know how to treat a low sugar, and never stop it when you are unwell.
Our diabetology department at T. Nagar provides insulin initiation with education and follow up.
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