Wil Dubois

Happy Saturday! Welcome back to Ask D'Mine, our weekly advice column hosted by veteran type 1, diabetes author and clinical educator Wil Dubois.

This week, Wil dives into a question about the best "non-insulin" options for those in the type 2 world. Read on, for Wil's unbridled opinion (as usual)...


{Got your own questions? Email us at AskDMine@diabetesmine.com}


Achat, type 3 from India, writes:Kindly advise me whether there is any alternative to insulin. My daddy was diagnosed with type 2 diabetes four to five years back and since then he is being treated with regular insulin. I therefore would like to know if there is substitute medicine to take orally as an alternative to insulin. Thank you.  

Wil@Ask D’Mine answers: You bet. All kinds of substitutes. There are tons of pills for type 2 diabetes. There are pills that coax the pancreas to produce more insulin. There are pills that keep the liver from releasing too much of its stored sugar. There are pills that fight the insulin resistance that is the foundation of type 2 diabetes. There are pills that make you pee the sugar out of your blood. There are pills that fight the digestive hormones that are running amok in the intestines. There are pills that keep you from digesting carbohydrates. There are pills that reduce digestive juices to lower blood sugar. There are pills that mess around with the central nervous system to lower glucose production in the body. There are so many pills that I’ve probably left some of them out. Most of these pills are made by several different manufacturers, and there are even many combo pills that have more than one of these medicines in them.

Plenty of substitutes. Plenty of alternatives.

But all of that said, why do you want an alternative to insulin for your daddy? Surely his doctor must have considered all of those many piles of pills before (s)he prescribed the insulin. There must have been some good reason to choose insulin over pills. So my question to you is: Is your daddy unhappy with taking insulin, or are you the unhappy one? The reason I ask is that I’ve found that it’s usually the people who don’t actually use insulin who have the biggest problems with it, while people who take insulin are generally pretty satisfied with it.

So let’s talk about that.

Among non-insulin-using insulin-haters, I’ve found that people usually have two problems with insulin: The first is that insulin is misunderstood. And the second is that insulin requires an injection. You know. With a needle. (Although they are working on both insulin pills and oral insulin films as I write this.) Let’s debunk some needle myths first, then I’ll take on insulin’s bad rep.

On the surface, I’ll grant you that taking shots sounds scary. Nobody likes shots. But insulin shots are different from other kinds of shots. As someone who’s taken literally thousands of insulin shots, you need to trustInsulin injection me on this: It’s no big deal. And it’s not just that I got used to them. The fact is that insulin injections have very little in common with other types of shots.

Most of the nasty shots people get are vaccines -- things like immunizations, flu shots, tetanus shots, and the like. These vaccines use pretty large, long needles. In fact, adult vaccines commonly use a 19-gauge three-inch-long needle. You could harpoon a Salmon with one of these things. Plus the shots themselves are often what we call intramuscular injections, which means the needle, which we’ve already established is big, also goes deeeeeeep into your body. Through the skin, through the fat, down deep into the muscle, almost to the bone.

Muscles are pretty rich in nerve endings, so poking things into them causes a pain response. Ouch! Next, the fluid volume of most vaccines is on the large side. A lot of liquid is being forced into the tissues, and tissues don’t like that. Ow, ow, ow! Plus, some shot-givers are more skilled than others. Hint: Never get a shot from a doctor. Always opt for a nurse instead, and if you have a choice don’t pick the young, pretty one. Pick the old crabby-looking one! When it comes to painless shots, there’s no substitute for experience. 

Anyway, all of these factors add up to one thing: Shots are often a painful experience. It can hurt getting poked, and the vaccine site can ache for hours (or days) afterwards. Most of us avoid pain at nearly all costs. After all, with all due respect to the Fifty Shades of Grey Fan Club, if you really love pain, there’s probably something wrong with your head.

So I understand why you might worry about your daddy taking shots all the time. But have you asked him about it? Because here’s the deal: The only thing an insulin shot has in common with a vaccine shot is the syringe. Well, the vague appearance of the syringe, anyway. Not all syringes are created equal, and insulin syringes are the Brazilian Super Models of the syringe world. They are ultra-skinny and hold a ridiculously small amount of fluid compared to some other types of syringes. Remember that three-inch needle? Most modern insulin syringes use needles that are only a quarter-of-an-inch long, and at 31 gauge, the diameter of the needle is similar to a human eyelash. You’d be hard pressed to harpoon a Minnow with these babies.

The shot doesn’t go deep into the body at all. It never reaches muscle, instead going into the fat layer just below the skin. Fat doesn’t have much in the way of nerve endings. And the fluid volume of most insulin shots is small compared to most vaccines, so the pool of insulin isn’t pushing much tissue out of the way.

All of that adds up to the fact that insulin shots really aren’t as bad as most people think. In fact, they are virtually painless. Nearly 100% of the several hundred people I’ve started on insulin have said the exact same thing (once they summon the courage to take the first shot): “I didn’t feel it at all! The frickin' fingersticks hurt worse!”

But don’t take my word for it.

Try it for yourself. On yourself. Take one of your daddy’s unused syringes and give yourself a poke. You’ll be surprised. Of course, use an empty one, then dispose of it afterwards.

OK. So that’s one issue. Some shots do hurt. Damn straight. But insulin shots generally don’t.

Now, on to insulin’s bad rep. Frankly, insulin needs to fire its PR firm. I doubt there’s ever been a more unjustly maligned substance in human history. It’s amazing to me how much a life-saving, effective, simple, reliable medicine that plays well with other medicines and has virtually no nasty side effects, can be so hated and reviled.

Hell, Hitler had a better reputation.

You would not believe the things that are said about insulin. It will make you go blind. It will make your kidneys fail. It causes amputations. That insulin will kill you!

If insulin were a celebrity, it would be rich beyond belief from libel suit settlements.

None of those things are true. Consider that everyone alive on the planet is “on” insulin. It is a naturally-occurring substance in all of our bodies. In your daddy’s case, he either doesn’t make quite enough of his own, or his body doesn’t use it very efficiently, so he has to take some extra to keep his sugar in control.

Yes, for type 2s, there are many substitutes for insulin. Many pills that can be taken. But they are all workarounds. They are complex backdoor maneuvers designed to compensate for the deficit of insulin in a type 2’s body, without having to take the obvious step of just supplementing what is missing. If you are short on insulin, just add insulin. If you car doesn’t have enough gas to get where you want to go, what makes more sense -- filling up the tank with gas, or greasing the tires to make it roll better when it runs out?

And, to be honest, diabetes pills scare me a bit, and as time goes by I get a bit more scared of them every day. Insulin is simple, understood, and has never needed to be recalled, banned, or black-boxed—all things that have happened with diabetes pills. Plus, some of the diabetes pills carry very long lists of contra-indicated medications. In short, they don’t play well in the sand box with other meds, while insulin plays well with other drugs.

So in my book, while there are pills that can be substituted for insulin, there’s really just no substitute for insulin.

This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.