Nothing raises as much fear in the minds of most people with type 2 diabetes as the thought of having to go on insulin. This is a tragedy, because, of all the medications available to diabetics, insulin is the only one capable of not just lowering, but of normalizing, their blood sugar.

There are a lot of things about diabetes that should be terrifying: blindness, amputation, kidney failure, impotence, and, worst of all, the very high likelihood of dying, much too young, of a heart attack. All of these are caused by prolonged exposure to high blood sugars, including those that result in the A1c of 6.5 - 7.9% that many doctors consider unworthy of any drug treatment at all. Insulin, on the other hand can prevent all these things from happening. So why waste your fear on it?

But before you can lay that fear aside, you need to look at what it is that people with Type 2 fear about insulin and why these fears are unnecessary.

Painless Needles

It's a shock to many type 2s, but it turns out that the ultra-thin short needles used for injecting insulin under the skin are far less painful than the lancets you use to test your blood. Most of the time they are so painless that you may have to visually check to see if you actually have penetrated the skin, because you can't feel the needle!

The key to making injections painless is to equip yourself with a very thin needle, 30 or 31 guage, and to use the shortest needle compatible with your body size.

Many family doctors seem to be unaware that there are newer thinner, shorter needles available for insulin. Mine, for example, had his nurse demonstrate injections with a 1 inch needle. The one I ended up getting, after doing some research, was 5/16" which is almost 1/4 of the size of her railroad spike.

The second important thing to know about injecting insulin is that when you first start out, and are panicking at the idea of giving yourself a shot, it helps to "throw" the syringe at your target the way you'd throw a dart, holding the syringe with three fingers and tossing it at your target starting from 6 or 7 inches away. The swift motion of the needle completely eliminates any sting or feeling of the needle going in.

You can learn all the details of how to do this properly, and much more in Dr. Richard K. Bernstein's book, "Dr. Bernstein's Diabetes Solution".

Learning How To Dose Correctly Avoids Hypos

The other major fear people with Type 2 diabetes have when confronting insulin is the fear of dangerous, if not fatal hypos.

Hypos are a possibility, but no more so than they are with drugs like Amaryl. But unlike the case with Amaryl, you have a lot more control over the dose of insulin you get than you have with a pill, and if you take some time and study how to use insulin you should be able to avoid serious hypos completely.

The Most Important Thing About Insulin

The most important thing to understand about insulin is that the dose that works for you is going to be different than the dose that works for someone else, because your physiology is different. This means that you'll have to spend some time starting from a very low dose, recording your blood sugars, slowly raising the dose, and gradually reaching the level where your blood sugars should be.

If your doctor isn't willing to work with you to pick a starting dose and then work towards getting it just right, so that your blood sugars approach normal, you probably need to find a better doctor or a Certified Diabetes Educator who can help you do this.

All too often, alas, doctors give Type 2s generic doses of insulin. These may be high enough that the patient is always hungry and has to keep eating to balance out the insulin, resulting in weight gain, or the dose may be too little and may not lower their blood sugar enough to improve health. Only if your doctor or educator takes the time to help you "walk up" to the correct dose that doesn't leave you hungry or with blood sugars spikes will you end up with the correct insulin doseages for you.

Even then, you'll still have to test and check on what is going on because your insulin needs are likely to change over time. Insulin needs change with changes in your health and even with changes in the seasons.

Understand the Two Different Kinds of Insulin

Most Type 2s, when they do go to insulin, are put on Lantus or Levemir, which are basal insulins. It is important to understand what a basal insulin is--and what it is not.

Sadly, one major reason that doctors believe they can't normalize blood sugars for Type 2s with insulin is that they are using the wrong kind of insulin for the patient's needs.

Basal Insulin

Basal insulin is insulin that, once injected, slowly dribbles into the body providing a background dose. Lantus lasts from 18-24 hours. Levemir lasts 12 hours or more depending on dose size. These insulins do not peak but deliver a small but steady dose.

NPH, an older basal insulin, is not steady in its action but does peak, significantly and unpredictably, which can make it very tough to use. The poor performance of NPH insulin and its tendency to cause hypos because of its peaks is one reason that doctors worry so much about hypos. The newer insulins are much more predictable in their effect and if you get your dose set right, you should not have to worry about hypos.

The point of basal insulin is NOT to counteract the blood sugar spikes caused by eating carbohydrates. In fact, when dosed properly, basal insulin should have little or no impact on your post-meal numbers.

The point of basal insulin is to control your blood sugar when you are fasting. It should lower your morning fasting blood sugar and your reading before a meal.

But if you've paid any attention to the rest of this site, by now you should realize that high blood sugars after meals are a major cause of organ damage. And knowing that, you should be able to see what the problem is with an insulin regimen that only involves basal insulin: It doesn't lower post-meal spikes enough to prevent a high A1c, which is why all too many Type 2s on insulin still have A1cs over 7%, often quite a bit over 7%.

A Very Rare Problem with Lantus You Should Know About

Over the past year I've heard reports from four different people who have injected Lantus and then, within an hour, had their blood sugar drop very low. Apparently they hit a blood vessel and the Lantus all hit the system at once, instead of dissolving slowly as it is intended to do when injected into fat.

This is a rare occurrence, Many people use Lantus for many years without having it happen. But if you are using Lantus, it is one you should be aware of.

If you should feel strange within an hour of injecting Lantus, test your blood sugar. If it is lower than 70 mg/dl you should immediately take as much glucose as you would need to raise your blood sugar 60 mg/dl and then test every fifteen minutes and take more glucose until you are back at a safe blood sugar level. (Pure Glucose, found in Smarties or Sweetarts and Glucose pills will act within 15 minutes). If you are a Type 2, your liver has the ability to dump glucose into your bloodstream if you go dangerously low, so unlike many Type 1s you aren't likely to end up in the ER with a hypo. But you should always keep some Smarties around if you use insulin, just in case you need it.

Bolus Insulin

Bolus insulin is faster acting insulin that is injected to cover a specific meal. Humalog, Novolog, Humulin R and Novolin R are all bolus insulins. Typically they stay in the body anywhere from 3 hours to 5 hours after injection and reach a peak in their action within 1-2.5 hours after injection.

Bolus insulin is the "magic bullet" when it comes to controlling blood sugars, because used properly it can eliminate dangerous spikes. Even more important, many people with Type 2 will find that if they control spikes their fasting blood sugar will decrease, too, so that they need a lot less, or even, sometimes, no, basal insulin.

But in order to use bolus insulin correctly, you have to be intelligent. You have to learn, with the help of your doctor or Certified Diabetes Educator, how many grams of carbs are covered by one unit of your bolus insulin, and you have to learn how to accurately assess how many grams of carbs you are eating in a meal. In all cases, you have to err on the side of conservatism, because if you use too much bolus insulin you can have nasty hypos.

Dr. Bernstein makes the point in his book that the only way to use bolus insulin safely is to use it with a lowered carb intake. This is because the more carbs you eat, the more likely you are to be off in estimating how many carbs are on your plate and the more likely you are to inject too much or not enough insulin.

Another problem with injected insulin is that it is very tough to match its speed of reaching the bloodstream with the speed with which the carbohydrates you eat hit the blood stream.

For example, if you take enough insulin to cover the 80 grams of carbohydrate in a plate of spaghetti and sauce, you may end up shooting as much as 16 units of insulin. If all that insulin arrives in the blood stream before the food does, which is almost guaranteed to happen, as spaghetti takes a while to digest, you may end up with a severe hypo. Alternatively, if you take enough insulin to match a quickly digesting bagel, the carbs from the bagel may hit your blood sugar before the insulin does and cause a high blood sugar spike. Then later on, you might have a low low when the insulin finally shows up because since you are a Type 2, you have some residual beta cell activity that may kick in and mop up some of the bagal carbohydrate.

And that doesn't even get into the question of what happens if the plate of spaghetti you eat only has 50 grams instead of the 80 grams you dosed for.

This should make it clear why bolus insulin is tricky. But the other side of this is that if you are reasonable about your carbohydrate intake, and learn how to time your insulin so that the dose does meet the food--something you can only learn through weeks and months of careful measurement and experimentation--you can get extremely good control: A1cs in the lower 5% range rather than the 7-8% range guaranteed to result in complications.

If you want to learn more about insulin for type 2, there is no better reference than the book, Dr. Bernstein's Diabetes Solution by Dr. Richard K. Bernstein. Don't even consider using insulin until you have read through Dr. Bernstein's insulin chapters a few time and mastered the points he is making.

I have found I am able to eat more grams of carbohydrate than he recommends, safely, while using bolus insulin, but that is largely a function of my own metabolism. You'll have to learn what your body can handle through careful testing and adjustment.

Regular (R) Insulin and Analogs (Humalog and Novolog)

One more issue that you need to understand when looking at insulin is that the new insulins which have come onto the market are what are known as "insulin analogs". This means they are genetically engineered molecules that are not identical to the stuff your body makes on its own. The analogs have an additional chain stuck onto the fundamental insulin molecule, usually to affect the timing with which it hits the body. Humalog, Novolog, Lantus and Levemir are all analog insulins.

Regular insulin, in contrast, is chemically the same molecule as what your body makes. Humulin and Novolin R and NPH are regular insulins. They are much cheaper than analogs. Novolin R is available for about $20 a vial at Wal-Mart while Humalog or Novolog may be $60 or more.

The analog bolus insulins are much faster in action than R insulin, but they may, in some cases, cause allergic reactions or they may be more unpredictable in when they peak. Even so, most people who can afford them prefer them because of their speed. You can inject Humalog 15 minutes before a meal.Novolog works even faster for many people, and can often be injected when you eat while R may require that you inject 45 minutes to an hour earlier to meet up properly with the food.

I, personally, have found I'm happier with R insulin because it is more predictable in its action for me than analogs and less likely to cause hypos. I will use Novolog if I'm going to eat at a restaurant and can't predict when my food will arrive, but if I am at home or know exactly when I'm going to be eating, I prefer R insulin as it is a bit gentler in action and much less likely to cause a low.

R insulin does not get the marketing push the analog insulins get so your doctor may have been convinced it is "obsolete", but this is not true. You can get very good control with R insulin, it just takes some time to learn its ins and outs. If you are having trouble with Humalog, and are having highs followed by lows, as I was, trying either Novolog or R might help you get better control.