Issues relating to the early or earlier use of insulin in type 2 diabetes

Abstract

Insulin therapy is increasingly being considered earlier in the management of people with type 2 diabetes. Its ability to achieve appropriate levels of glycaemic control and to maintain that control in the long term is not shared by other treatment options. The benefits of preventing deterioration to poorer levels of blood glucose control in order to avoid late complications of diabetes are now well established. Insulin also has a wellestablished safety profile. In spite of these and other advantages, a number of factors such as risk of hypoglycaemia, weight gain and, more controversially, the possibility of insulin-associated atherogenicity have been perceived as potential risks limiting its earlier use. Other factors, such as availability, needle phobia, dietary restriction, employment issues and economic considerations may also be seen as possible barriers.This review aims to address these issues in turn and, against this background, highlight the potential of earlier initiation of insulin therapy in the management of type 2 diabetes. It also attempts to identify which patients might benefit most from such a strategy. It is concluded that, in general, any possible risks or barriers (real or perceived) to the use of insulin should not discourage its early or earlier integration into the management of type 2 diabetes.

Once-daily insulin detemir in a cohort of insulin-naïve patients with type 2 diabetes: a sub-analysis from the PREDICTIVE study

“…Although insulin initiation is typically associated with weight gain 28,29 , a majority of patients in this analysis experienced either weight loss or no significant weight change despite significant improvements in glycemic control. While the observed mean weight loss in this study was modest, it may still be a relevant factor, especially in patients who cite unwanted weight gain as a concern when intensifying therapy with basal insulin 30 .…”

“…Mean changes in fasting blood glucose and fasting blood glucose variability were -3.62 mmol/L (SD AE 2.93; p50.0001) and À0.48 mmol/L (SD AE 1.03; p50.0001), respectively. Body weight decreased by a mean 0.5 kg (SD AE 3.3; p50.0001), with weight loss or no weight change occurring in a substantial percentage of patients in each BMI category ( 525,(25)(26)(27)(28)(29)(30)(30)(31)(32)(33)(34)(35), and 435 kg/m 2 ). Patients with higher baseline BMI lost the most weight, with the greatest weight loss (-1.20 kg) reported in those with BMI 435 kg/m 2 .…”

Efficacy of Inhaled Insulin in Patients With Type 2 Diabetes not Controlled With Diet and Exercise

“…Furthermore, the early use of insulin therapy may slow the loss of endogenous insulin secretion (3). Insulin therapy is, therefore, increasingly being considered earlier in the treatment cascade (4).…”

Overcoming obstacles: new management options

“…With the availability of several different classes of oral agents and the potential of multiple different mono-and combination-therapy treatment regimens, insulin has become widely considered as a treatment of last resort in patients with type 2 diabetes. However, the benefits of initiating insulin therapy earlier in the management of type 2 diabetes are receiving increasing attention (9). Unlike oral agents, insulin can achieve effective glycaemic control and maintain this in the long-term.…”