Experts say there is a balancing act of medication, insulin, and lifestyle changes that must be considered when drawing up a treatment plan.
Treating type 1 and type 2 diabetes with medication is more complicated than you might think.
And finding the right balance may be more difficult than anticipated.
A recent study concluded that some people with diabetes are being overmedicated, and their treatment plan is actually too intense.
Some past research has indicated that the majority of people with type 2 diabetes aren’t being treated aggressively enough and aren’t seeing improvements in their blood sugar levels.
However, the more recent study reports that a number of people taking insulin or other diabetes medications are experiencing hypoglycemia (low blood sugar levels) severe enough to send them to the emergency room.
The research discovered that when patients in the United States received more medication than required in order to achieve their HbA1c goals, it directly contributed to 4,774 hospitalizations and 4,804 emergency room visits over the course of two years.
The research estimates that about 20 percent of adults with diabetes in the United States are being overtreated — especially those with type 2 diabetes. This translates to approximately 2.3 million people being overtreated between 2011 and 2014, explained the study.
“This isn’t break-through science,” Dr. Rozalina McCoy, an endocrinologist and primary care physician at the Mayo Clinic in Minnesota and a lead researcher on the study, told Healthline.
“But it demonstrates the real human impact of overly intensive treatment in a patient with diabetes,” she explained.
“We know as clinicians that we shouldn’t be overtreating older patients or those with multiple health conditions, but other patients can be overtreated, too. The toll it takes on a patient’s life is real, especially if they are winding up in the emergency room.”
While a person could take an oral or an injectable diabetes medication or have insulin injections to treat diabetes, the way those medications work are vastly different.
In addition, the amount of insulin a person needs for different times of day or different aspects of blood sugar management varies.
The amount of medication or insulin a person needs is based on a number of variables, including body weight, age, activity level, diet, stress, and overall beta-cell function.
These factors largely determine whether a person with type 2 diabetes will eventually need insulin or not.
“Even though type 1 diabetes is incredibly challenging to live with and very complicated, we at least understand why low blood sugars are happening,” said McCoy, “and as clinicians, we generally know where to start when making adjustments in their treatment to reduce those severe and recurring hypoglycemic events.”
She added, “With type 2 diabetes, it’s much harder to pinpoint the exact problem — especially when a patient’s A1c is still high but they’re experiencing frequent hypoglycemia, and they’re taking multiple medications.”
McCoy said that many clinicians don’t realize how easily a person with type 2 diabetes can experience hypoglycemia. Overall, the rate of low blood sugars in those with type 2 diabetes is lower compared to those with type 1, but its occurrence in people with type 2 is more than previously thought.
“One issue that contributes to the problem is that the risk of hypoglycemia for a patient with type 2 diabetes doesn’t come right away when they are first diagnosed,“ explained McCoy.
“First, they try to manage their diabetes through diet, exercise, and metformin — which cannot cause low blood sugars.”
In a person with type 1 diabetes, McCoy said hypoglycemia is expected and is essentially part of the diagnosis package.
A person with type 1 diabetes immediately receives an education about the signs and symptoms of low blood sugars, what can cause them, how to treat them, and how to prevent them from occurring too often.
A person with type 2 diabetes will only get financial reimbursement from their health insurance plan to see a diabetes educator for a specific number of years after the initial diagnosis.
By the time they are starting more intensive diabetes medications or insulin, the opportunity for a thorough education on blood sugar management may be minimal because of cost.
“Only a small fraction of patients with type 2 are getting proper education because there are not enough diabetes educators, not enough time with practitioners, and not enough financial reimbursement years down the road when they start taking insulin,” said McCoy.
“The risk of low blood sugar in a patient with a low A1c is actually very low because they’re not usually on an intensive treatment plan,” she added.
The higher the person’s A1c is, explained McCoy, the higher their risk of hypoglycemia is because the person’s doctor may be intensifying their treatment by increasing their dosages or by adding additional medications in an effort to lower their blood sugar levels.
People with type 1 diabetes are taught how to count carbohydrates and adjust their insulin dosage to account for the amount of food they want to eat.
One unit too much or too little can easily lead to a high or low blood sugar, but people with type 1 are taught to expect these fluctuations and encouraged to check their blood sugars many times a day to help juggle this type of challenge.
People with type 2 diabetes aren’t encouraged to check their blood sugar routinely. They may be taking their insulin as prescribed, but they may not understand how imperative it is that the amount of food they’re eating matches the insulin dose, or how to adjust it if they don’t want to eat that much food.
Too often, people with type 2 are told to take “X” amount of insulin at every meal, which means they’ll need to eat “X” amount of carbohydrates to meet that insulin dose.
This creates a problem of “feeding your insulin,” which can lead to overeating, weight gain, and dangerous blood sugar fluctuations when you don’t eat enough to meet the insulin dose.
“There’s an assumption that type 2 diabetes is easier to manage than type 1 diabetes, but the moment a patient with type 2 is prescribed insulin, we should start treating them more like a patient with type 1 diabetes,” said McCoy.
“One of the biggest things I do with my type 2 patients taking insulin is to ‘undo’ that prescribed insulin dose and carb quantity at every meal,” explained McCoy.
“Instead, if they aren’t willing to learn how to count carbohydrates and adjust the insulin dose specifically, we talk about dosing for meals in more general terms of a ‘small’ or ‘medium’ or ‘large’ meal, with insulin dose options for each size. Eyeballing the meal is still better than forcing a patient to eat a certain amount of food to cover the insulin dose they’re told to take no matter what,” she explained.
“Glucose targets must be individualized based on a patient’s abilities, risks, and limitations,” Scheiner told Healthline.
“Tighter is not always better — such as with patients at risk of falls, like the elderly, or those with hypoglycemic unawareness during which they can’t physically feel the symptoms of a low blood sugar, those in high-risk professions, and in children.”
On the other hand, Scheiner argues that for some people, more intensive treatment is worthwhile, and the risks of low blood sugars are part of the pursuit of healthier blood sugar levels.
“For patients battling diabetes complications like retinopathy, patients entering pregnancy, or patients looking to maximize athletic performance, for example, tighter control is generally desirable.”
Scheiner added that one of the biggest mistakes he feels clinicians make is assuming that tighter blood sugar control and a lower A1c automatically reduces the long-term risk of developing a complication.
“This simply is not true,” said Scheiner. “There are multiple factors that contribute to complications — not just glucose levels — and there is a point at which tighter control just does not provide benefits. Like taking 10 aspirin for a headache instead of two.
“And of course, there is a point at which the risks outweigh the benefits. For a person taking insulin, wearing a continuous glucose monitor has helped ‘shift the curve’ by alerting patients when they are approaching a low blood sugar so they can prevent more serious hypoglycemia,” he noted.
Again, it comes down to individualizing a patient’s treatment plan, which can’t be done properly in a five-minute appointment.
“Managing diabetes with a one-size-fits-all approach will not work,” said McCoy.
“I have the luxury of 30-minute appointments at the Mayo Clinic and sometimes that is still not enough. What is the patient’s life like? What are their resources and support system? How can we help them safely fit diabetes into their routine?”
To truly reduce the number of hypoglycemic-related hospital visits, the bigger problem that needs addressing may be far more than changing how doctors prescribe insulin. Instead, perhaps they need more time with their patients.
“An appropriate treatment plan,” explained McCoy, “depends on a good relationship with the patient.”