There is a general lack of awareness about the benefits of insulin in the treatment of Type 2 diabetes among diabetic patients and doctors treating the disease in the country, according to medical experts. As a result, doctors initially prescribe pills for their patients with insulin prescribed only when the disease advances to a complicated level.

Fear of hypoglycaemia or the patient's blood sugar level to go below the normal level is cited as a major factor why doctors do not prescribe insulin at an early stage of diabetes detection. Meticulous instructions and lack of time with the doctors is another reason that restricts a doctor in prescribing insulin for his patient. The fear of injections and the thought that insulin is a last resort after diet, exercise and oral medications keep patients away from requesting insulin treatment from their doctors, said Dr Hannele Yki-Jarvinen, head of the diabetes division at the Helsinki University Central Hospital, Finland and professor of medicine at University of Helsinki.

She was speaking at an event titled 'Lantus Treat to Target' seminar organized at New Delhi by Aventis Pharma (India).

"A proper diet, exercise, medications involving a combination of oral medication and insulin or purely insulin with regular sugar monitoring would help a diabetic lead the right way of life," said Dr Jarvinen. Treatment with oral medication should be encouraged as long as the sugar level is under control. "If the patient is able to keep his sugar level under control with pills alone, its fine. Otherwise there is no point in increasing the dosage of the pill or changing pills. He should immediately change to insulin as no other therapy has an efficacy level equivalent to insulin," she added. If the patient still continues with the pill, his condition might deteriorate early resulting in complications striking early, which is a costly affair for him.

"By western standards, it takes 345 euros to treat diabetes alone compared to 8,400 euros to treat complications arising from the disease. The complications can be considerably controlled if the insulin therapy is started early. There is no logic in taking insulin at the onset of complications," she said.

Kidney damage, heart diseases, stroke, blindness, ulcer, infections, and diabetic foot are some of the more severe complications that would emerge in a diabetic if the sugar level were not kept under check i.e. below 120 mg/dl.

Along with the fear of insulin administration, there is also a lack of consensus from physicians in prescribing the right treatment at a particular stage of diabetes. "The Indian Council of Medical Research (ICMR) has issued guidelines to various medical associations of the country for feedback. The guidelines will soon be issued to all the practicing diabetologists and endocrinologists in the country," said Dr. Nikhil Tandon, additional professor, Department of Endocrinology, All India Institute of Medical Sciences (AIIMS).

India has the largest diabetes population in the world with 32.7 million diabetics. This number if unchecked would reach 57 million, said Dr Tandon.

Among glucose monitoring tests, HbA1C is considered to be the ideal one. HbA1C or A1C is formed when glucose in the boodstream binds to haemoglobin, a protein carried by the red blood cells that carries oxygen to the body. A1C levels are directly proportional to the concentration of glucose in the blood over the life of the red blood cell - approximately 2-3 months. Therefore when the blood is analysed for A1C levels, this level provides an estimate of glucose concentration and thus glycemic control, over 2-3 month period. The result is expressed as per cent of haemoglobin in the RBCs that has glucose attached. In people without diabetes the normal range for A1C is 4-6 per cent. Recent consensus guidelines from the American Diabetes Association recommend people with diabetes achieve an A1C of less than 7 per cent or A1C<7 per cent.

The UK Prospective Diabetes Study or UKPDS is the largest and longest study involving people with Type 2 diabetes. In the study, the rate of microvascular complications was 25 per cent lower in people who achieved an A1C target below 7 per cent through intensive therapy (a combination of diet, exercise, frequent self monitoring daily insulin injections), compared with those in the study who achieved an A1C of 7.9 per cent.