You may delay, but time will not. Beta cells lost are never found again: a case for timely initiation of basal insulin in type 2 diabetes

ABSTRACT

Since its first use just over a century ago, insulin treatment has evolved dramatically, such that the molecules are physiologic in nature, and treatment can now closely resemble the natural hormone response over 24 hours. Newer, longer-acting basal insulin analogs have provided insulin therapies with improved characteristics and, therefore, ease of use, and can readily be incorporated as part of routine treatment for type 2 diabetes (T2D), but evidence suggests that insulin remains underused in people with T2D. We review the barriers to initiation of basal insulin and the education needed to address these barriers, and we provide practical pointers, supported by evidence, for primary care physicians and advanced practice providers to facilitate timely initiation of basal insulin in the people with T2D who will benefit from such treatment.

Plain Language Summary

Type 2 diabetes is a complex disease. It causes increased amounts of sugar in the blood, which can cause damage to the body. Medications are given to people with type 2 diabetes to keep their blood sugar at normal levels. Unfortunately, type 2 diabetes worsens over time, so regular adjustments to medications are needed to keep blood sugar levels controlled.

Basal insulin, which is a type of insulin that works over the entire day, is a key treatment for type 2 diabetes. It works best if it is started as soon as other medications (tablets or non-insulin injections) are not working to control blood sugar levels. Unfortunately, delays in starting basal insulin are common. Some healthcare professionals and people with type 2 diabetes believe insulin is difficult to use. False information on insulin is common; for example, some people with diabetes believe that their symptoms are caused by insulin treatment rather than high blood sugar.

This review summarizes key information to encourage effective conversations between healthcare professionals and people with type 2 diabetes about starting basal insulin. Proactive, positive, early discussion of the benefits of basal insulin can help to: 1) address concerns, 2) set appropriate, individual treatment targets, and 3) provide practical information and training to help with injecting insulin. This will give people living with type 2 diabetes the knowledge and confidence to take an active part in managing their diabetes and overcome any barriers to using basal insulin.

Graphical abstract

KEYWORDS:

• Basal insulin
• hypoglycemia
• patient education
• patient-provider communication
• titration
• treatment
• type 2 diabetes

Abbreviations

A1C	=	glycated hemoglobin A1C
ADA	=	American Diabetes Association
CVD	=	cardiovascular disease
DSMES	=	diabetes self-management education and support
EASD	=	European Association for the Study of Diabetes
FPG	=	fasting plasma glucose
GLP-1 RA	=	glucagon-like peptide 1 receptor agonists
HCP	=	healthcare professional
ITAS	=	insulin treatment appraisal scale
MDT	=	multidisciplinary team
SGLT2	=	sodium–glucose cotransporter 2
TAR	=	time above range
TBR	=	time below range
TIR	=	time in range
T1D	=	type 1 diabetes
T2D	=	type 2 diabetes
UK CPRD	=	United Kingdom Clinical Practice Research Datalink

Declaration of financial/other relationships

J Freeman has participated in speakers’ bureau for Bayer Corporation, MannKind, Novo Nordisk, and Sanofi. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgments

The authors thank Charlotte Singh (Sanofi) for her critical review of this manuscript. Medical writing support was provided by Helen Jones of Envision Pharma Group.

Author contributions

Susan Renda and Jeffrey Freeman made substantial contributions to conception and design of this manuscript, have revised it critically for important intellectual content, have given final approval of the version to be published, and have agreed to be accountable for all aspects of the work.

Data sharing statement

Data sharing is not applicable to this article as no new data were created or analyzed.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

Medical writing support for this manuscript was funded by Sanofi. Envision Pharma Group provided support in routing publication drafts for review and approval. This support was funded by Sanofi.