Question

My mother was diagnosed as diabetic at the age of 45. She is now 75. Should she be on insulin yet?

Answer

The management of a diabetic person is not aimed solely at glycaemic control. Their whole clinical persona must be considered because, for example, insulin injections may be entirely impractical in someone who is confused and does not live with anybody who could supervise them. The overall aim therefore must be to use a holistic management plan to maintain good health as long as possible, and to try and avoid the complications associated with diabetes mellitus. There are many factors that affect control, including diet. It is probably better to give meals spread throughout the day. It is not just the carbohydrate content of food that is important, but also that of fats. The diet should provide a calorie intake that will support the necessary activity of the person and bring the patient's weight to the correct value. Obesity is associated with poor glycaemic control.

When diabetes is mild, drug therapy may not be necessary. As it progresses, patients may need drug therapy. Many diabetic people can be managed on tablets, without using insulin, because they still have some residual pancreatic function. How long they can be managed without using insulin depends on how much pancreatic function they have, and how quickly this declines. Perhaps about one third of people on sulphonylureas will have to be transferred to insulin within 4 years.

Changing a person to insulin may not be a simple manoeuvre, and whether to do so depends on the person themselves, the support they have and on their diabetic control and general health. Although it is generally agreed that the tightest possible control of diabetes is beneficial in preventing complications, this may not be practical in all patients, and each must be treated individually on their own merits. One might say that if somebody of 75 was well controlled on oral tablets and did not have any complications associated with diabetes, then they might well be left on their tablets, unless some untoward event took place, such as an operation. During that period, they may well require insulin. If, however, the person was not well controlled on their tablets, or had complications associated with diabetes, then it is probably time to consider a change to insulin.

We cannot emphasise enough that the decision is an individual one for each patient and must be taken in association with their physician.