Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. Although frequently undiagnosed, OSA is highly prevalent and presents most often with excessive daytime sleepiness (EDS). While obesity is the major predisposing factor, patients with OSA and EDS are at increased risk of other conditions, including cardiovascular disease, type 2 diabetes, cognitive impairment, and depression. Significant consequences include morbidity and mortality from the associated conditions in addition to personal and societal consequences of cognitive impairment, such as driving and workplace accidents. Primary care physicians are ideally placed to screen for OSA and EDS in patients who present with commonly comorbid conditions such as obesity, cardiovascular disease, metabolic syndrome, and depression. Conversely, treatment of OSA and associated EDS might help alleviate significant comorbidities and their clinical and societal consequences.

Depression often presents with physical symptoms, primarily fatigue, pain, or sleep disturbance. Depressed mood may or may not be present. Supportive counseling and pharmacotherapy are more effective than either modality alone. The newer drugs are better tolerated than earlier agents, and they achieve much greater patient adherence. Depression is considered a chronic disease. The likelihood of recurrence increases with the number of episodes, often calling for prolonged maintenance of medication. Most patients with mild to moderate depression can be effectively managed by their primary care physician, with referral required only for those who are unresponsive to therapy or who are suicidal.

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Type 2 diabetes is characterised by insulin resistance and progressive beta-cell deterioration. As beta-cell function declines, most patients with type 2 diabetes will require insulin therapy. Clinical studies show that tight control of blood glucose levels prevents the development of the microvascular and macrovascular complications caused by diabetes. Insulin is the most potent drug currently available to achieve tight glycaemic control; however, often it is not used early or aggressively enough for patients to achieve the glycaemic targets needed to prevent chronic complications. New basal insulin analogues and premixed insulin analogues, which have more physiological time-action profiles compared with human insulin formulations, offer flexibility and convenience, thereby improving quality of life. It is crucial that doctors initiate insulin therapy as soon as other diabetes therapies are no longer effective. This article reviews the improvements provided by basal insulin analogues, premixed insulin analogues, and insulin delivery systems; provides sample algorithms for initiating and titrating the various insulin analogue preparations; and discusses how to individualise treatment regimens to maximise outcomes in patients with type 2 diabetes.

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