The when and how of insulin initiation in type 2 diabetes

ABSTRACT

Background: Insulin has traditionally been viewed as a ‘last resort’ in the treatment of type 2 diabetes. However, accumulating evidence on the benefits of early insulin initiation brings this traditional viewpoint into question. Increasing recognition of the importance of insulin therapy in type 2 diabetes has also raised the issue of how best to initiate insulin in this patient group. Evidence-based guidelines are currently limited and, sometimes, conflicting.

Aims and scope: In the absence of clear evidence-based guidelines, this commentary focuses on clinical experience and recent findings, to ascertain the most commonly used and effective insulin initiation regimens for patients with type 2 diabetes. Recent findings were identified via a literature search using PubMed during the last 5 years in addition to key congress abstract searches from the last 2 years.

Findings: Two commonly used regimens that have emerged as effective, safe and easy to implement are bedtime basal and premixed insulin analogues. In addition, the latter treatment option provides greater post-prandial glucose regulation and the prospect of simple intensification, such that patients’ ongoing clinical needs can be more easily met, with minimal disruption to their lifestyle.

Conclusion: Current data and clinical experience highlight bedtime basal and premixed insulin analogues as favourable options for the initiation of insulin in patients with type 2 diabetes. Further insights on the optimal initiation regimen will be provided by studies such as the ongoing 4T trial, which is comparing the long-term impact of three different approaches to commencing insulin therapy in patients with type 2 diabetes.

Key words: :

• Early initiation
• Intensification
• Premixed insulin, once-daily
• Type 2 diabetes mellitus