Insulin Matters: A Practical Approach to Basal Insulin Management in Type 2 Diabetes

Abstract

It is currently estimated that 11 million Canadians are living with diabetes or prediabetes. Although hyperglycemia is associated with serious complications, it is well established that improved glycemic control reduces the risk of microvascular complications and can also reduce cardiovascular (CV) complications over the long term. The UKPDS and ADVANCE landmark trials have resulted in diabetes guidelines recommending an A1C target of ≤ 7.0% for most patients or a target of ≤ 6.5% to further reduce the risk of nephropathy and retinopathy in those with type 2 diabetes (T2D), if it can be achieved safely. However, half of the people with T2D in Canada are not achieving these glycemic targets, despite advances in diabetes pharmacological management. There are many contributing factors to account for this poor outcome; however, one of the major factors is the delay in treatment advancement, particularly a resistance to insulin initiation and intensification. To simplify the process of initiating and titrating insulin in T2D patients, a group of Canadian experts reviewed the evidence and best clinical practices with the goal of providing guidance and practical recommendations to the diabetes healthcare community at large. This expert panel included general practitioners (GPs), nurses, nurse practitioners, endocrinologists, dieticians, pharmacists, and a psychologist. This article summarizes the panel recommendations.

Rationale for Timely Insulin Therapy in Type 2 Diabetes Within the Framework of Individualised Treatment: 2020 Update

“…Berard et al [ 60 ] estimated that a minimum of 15% or 20% of pancreatic β-cell function is needed for an adequate glucose-lowering effect of most of the OADs. However, it does not seem to be reasonable to wait until β-cell failure exists to such a high degree, especially when some oral drugs lose more and more effectiveness with declining β-cell function.…”

Initiation and Titration of Basal Insulin in Primary Care: Barriers and Practical Solutions

“…In addition, a recently published review discusses practical considerations for insulin initiation and titration in patients with T2D. 91 These can be adapted based on the patient's capabilities, hypoglycemia risk, comorbidities, and other factors. Because of the PK/PD properties of insulin glargine 300 U/mL and insulin degludec 100 or 200 U/mL, they are not titrated as frequently as insulin glargine 100 U/mL.…”

Key Strategies for Overcoming Psychological Insulin Resistance in Adults with Type 2 Diabetes: The UK Subgroup in the EMOTION Study

“…Other strategies that extensively helped participants were HCPs explaining that insulin was a natural substance that the body needed, encouraging patients to contact them immediately in case of any problems/questions, presenting to patients their blood glucose numbers and helping them understand that their diabetes was not under control and needing action. A recent study in Canada in patients with T2DM not achieving recommended glycaemic targets provided similar practical recommendations to HCPs, highlighting that explaining the benefits of insulin therapy, allaying patients' concerns and collaborating with patients to explain the need for insulin were the key strategies to help patients overcome PIR [19]. Other studies that underlined the importance of HCP-patient collaboration to develop a shared action plan reported not only positive patient insulin initiation experiences but also improved concordance with insulin therapy [17,20].…”