Recognition of fasting or overall hyperglycaemia when starting insulin treatment in patients with type 2 diabetes in general practice

Abstract

Objective. The efficacy of various regimens of initial insulin treatment in poorly controlled type 2 diabetes was compared with regard to diurnal glucose variation. Design. Randomized controlled trial. Setting. Insulin therapy initiated on hospital wards, follow-up as outpatients for 12 months. Subjects. Fifty-two type 2 diabetic patients (HbA1c >7.5%, mean 9.8%) on maximal oral therapy. Interventions. Insulin only (IO), bedtime insulin with sulphonylurea (glipizide) (IS), or bedtime insulin with metformin (IM). Main outcome measures. HbA1c and body weight. Results. HbA1c decreased on average by 1.8, 1.0 and 1.5 percentage points in the IO, IS, and IM groups, respectively (p always <0.025). Body weight increased, most in the IO patients (+6.2 kg), least in the IM patients (+3.4 kg). Analysing all treatment groups combined, a similar HbA1c reduction was observed in patients with overall hyperglycaemia (low fasting plasma glucose/HbA1c ratio) and in patients with fasting hyperglycaemia (high fasting plasma glucose/HbA1c ratio). Within the overall hyperglycaemia group, the IS and IM patients had smaller decreases in HbA1c (−1.5 and −1.3 percentage points, respectively) than the IO patients (−2.7 percentage points). On the other hand, within the fasting hyperglycaemia group HbA1c reductions were −1.2, −0.8 and −1.5 percentage points, in the IO, IS, and IM groups, respectively. Conclusion. Not all poorly controlled type 2 diabetic patients should automatically be treated with an oral agent and bedtime insulin. Two daily insulin injections is a valid choice, particularly if the patient has overall hyperglycaemia.

• Family practice
• fasting hyperglycaemia
• HbA1c
• postprandial hyperglycaemia
• type 2 diabetes