Approaches to rapid acting insulin intensification in patients with type 2 diabetes mellitus not achieving glycemic targets

Abstract

Type 2 diabetes mellitus (T2DM) is a growing problem in the USA, affecting 30.3 million Americans, or 9.4% of the US population. Given that T2DM is a progressive disease, intensification of rapid acting insulin (RAI) to address hyperglycaemia is often required. The American Diabetes Association and the European Association for the Study of Diabetes recommend individualizing the treatment approach to glucose control, considering factors such as age, health behaviours, comorbidities and life expectancy. There are several validated treatment algorithms in the literature, which can be helpful for providing guidance on initiation of RAI while simultaneously considering patient preferences and clinical needs during treatment intensification. This paper provides expert recommendations on prandial insulin regimens and how to use treatment algorithms to promote better glucose control through best practice guidelines. To help patients reach HbA1c targets through treatment intensification, the FullSTEP, SimpleSTEP, ExtraSTEP and AUTONOMY algorithms are discussed in this paper.

KEY MESSAGES

• Clinical inertia should be prevented with timely intensification of therapy when HbA1c levels are greater than 7% (or rising above a patient’s individual target) according to national guidelines.

• Increased personalization in the intensification of T2D treatment is necessary to improve HbA1c targets while addressing risk of hypoglycaemia, concern about weight gain, and overall health goals.

• Healthcare providers are encouraged to address glycaemic control with a variety of strategies, including prandial insulin, while developing evidence-based treatment plans on the basis of algorithms discussed in the literature.

Keywords:

• Algorithms
• bolus insulin; meal time insulin
• personalized care
• rapid acting insulin
• treatment intensification
• type 2 diabetes mellitus

Acknowledgments

The authors thank Katie Crosslin, PhD, of Syneos Health for medical writing support.

Disclosure statement

Alexandra Migdal reports no conflicts of interest; Martin Abrahamson served on advisory boards for Novo Nordisk, WebMD Health Services and holds stock in Health IQ; Anne Peters served on advisory boards, consulted and spoke for Abbott Diabetes Care, Becton Dickinson, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Lexicon, Medscape, Merck, Novo Nordisk, Omada Health, OptumRx, Roche, Sanofi in addition to receiving research support from Dexcom; Nan Vint reports employment with Eli Lilly and Company.

Additional information

Funding

Eli Lilly and Company funded this manuscript.