When Insulin Is Still Needed
Reviewed by CDE Mehandi Sharma · Updated
Most writing about monogenic diabetes emphasises getting off insulin, which can leave people feeling that continuing it means something went wrong. Often it simply means insulin is the right treatment.
When a treatment change does not succeed. In the UK study, 62% of those attempting sulfonylurea or diet alone reached target — meaning a substantial minority did not. Longer diabetes duration, a higher starting HbA1c and a higher BMI all made success less likely, and none of those are failures of effort.
When the subtype has progressed. HNF1A and HNF4A-MODY involve gradual beta-cell decline. Someone diagnosed decades ago may have too little beta-cell function left for a sulfonylurea to stimulate, in which case insulin is doing genuinely necessary work.
In pregnancy. Insulin is the usual treatment in pregnancy across the subtypes, including in GCK-MODY where it may be indicated depending on the baby's genotype. Sulfonylureas are generally not continued.
In other subtypes. Not every monogenic form responds to tablets, and some — including certain neonatal diabetes causes — need insulin.
So the useful framing is that the genetic result tells you which treatment fits your biology. Sometimes that answer is a tablet, sometimes none, and sometimes insulin. All three are correct answers to different genes.