Strategies for implementing effective mealtime insulin therapy in type 2 diabetes

Abstract

Background: Type 2 diabetes mellitus (T2D) is a growing global epidemic. Due to the progressive nature of the disease, many people with T2D require insulin at some point, most commonly a long-acting (basal) insulin to assist with 24-h control of glucose levels.

Objective: This opinion paper provides an overview of considerations for primary care providers (PCPs) in intensifying the treatment regimen when basal insulin therapy is inadequate.

Results: Control of mealtime hyperglycemia, in addition to fasting hyperglycemia, has been shown to be crucial in reaching A1c goals of <7.0%. However, initiating and optimizing mealtime insulin therapy can be challenging for both people with T2D and PCPs, due to a perceived lack of efficacy and burden of insulin treatment, causing “psychological insulin resistance” in people with T2D and clinical inertia among PCPs. Successful implementation of mealtime insulin therapy requires not only choosing appropriate treatment strategies, but also addressing patient-related behavioral and emotional barriers. Simplified treatment algorithms, combined with the use of advanced technology (devices such as insulin pens, pumps, and patches), and collaborative decision-making can help decrease barriers to effective mealtime insulin therapy.

Conclusions: It is possible to implement an effective basal-bolus insulin regimen in people with T2D in a way that improves glucose control while minimizing negative effects on quality-of-life, treatment satisfaction, and psychological well-being.

Keywords:

• Algorithm
• Type 2 diabetes mellitus
• Insulin
• Postprandial period
• Glycemic control
• Patient preferences
• Quality-of-life

Transparency

Declaration of funding

Editorial and writing support in the preparation of this manuscript was funded by Calibra Medical, Inc. The authors received no financial support for the development of this manuscript.

Declaration of financial/other interests

MP has received consulting or speaking fees from Calibra, Eli Lilly, Novo Nordisk, and Valeritas, as well as research support from Novo Nordisk. TSB has received research support from Abbott, Ambra, Ascensia, BD, Boehringer Ingelheim, Calibra, Companion Medical, Dexcom, Elcelyx, Glysens, Janssen, Lexicon, Lilly, Medtronic, Novo Nordisk, Sanofi, Senseonics, Versartis, and Xeris, as well as consulting honoraria from AstraZeneca, Ascensia, BD, Calibra, Lilly, Medtronic, Novo Nordisk, and Sanofi, and speaking honoraria from Abbott, Insulet, Medtronic, Lilly, Novo Nordisk, and Sanofi. BC has received research support from Roche and Calibra. GR has received speaking honoraria from Abbott, AbbVie, Bayer Diagnostics, Beckton Dickinson, Biogen, BMS, Dexcom, GSK, Ipsen, Lifescan, Lilly, Merck-Serono, Novartis, Novo Nordisk, Pfizer, Roche Pharma, Roche Diagnostics, Sanofi-Aventis, and Servier, and is on advisory boards for Abbott, Bayer Diagnostics, Lifescan, Lilly, Novo-Nordisk, and Sanofi-Aventis. A CMRO reviewer on this manuscript declares that they serve as an advisor to NovoNoridsk and Lilly diabetes. A CMRO reviewer on this manuscript declares that they consult for all insulin manufacturers and also others working in diabetes. All CMRO peer reviewers on this manuscript have no other relevant financial or other relationships to disclose.

Acknowledgments

Editorial and writing support in the preparation of this manuscript was provided by Excerpta Medica, funded by Calibra Medical, Inc.