Insulin initiation in Type 2 diabetes

Insulin therapy is often required in type 2 diabetes mainly because type 2 diabetes is a disease of progressive beta cell failure. Whereas a patient may have been well treated with oral monotherapy, often over time they need to progress onto different and additional oral therapies and eventually even these will fail.1,2 It is at this point that the body is not making enough insulin from its beta cells and we need to replace the missing insulin with exogenous insulin. When this should take place is earlier than we had previously realised.3 Both the DCCT and the UKPDS long term follow up studies showed us that early good glucose control is of vital importance. These studies showed that very good glucose control early on in the early duration of type 2 and type 1 diabetes led to massive benefits in terms of complications later on.4 Whereas the ACCORD Study showed that where the complications already exist, then the sudden intensification, or lowering of HbA1c did not do very much to the final outcomes.5 When we are thinking about starting insulin, we need to think about both the fasting sugar and the postprandial sugars because we have come to realise that postprandial sugars are as important if not more important than fasting sugars, and in addition to this, postprandial glucose may be raised even in the context of normal fasting sugars.6 Therefore when we start insulin, we have to target the abnormalities that are present in a patient and sometimes, in fact often, the postprandial glucose is as important as fasting glucose. Therefore we need to choose therapies that target both PPG and FPG and premix insulin is one such therapy that targets both at the same time. Because of this the American Diabetes Association and the European Association for the Study of Diabetes have in their guidelines premix insulin as well as basal insulins as the starting options when initiating insulin.7 And this concept of postprandial glucose being important has reached such significance that the International Diabetes Federation have their own guidelines that target specifically postprandial glucose. Therefore when we think about starting insulin we have to think about not just fasting glucose but also postprandial glucose and premix insulin gives us the opportunity to target both at the same time. InSUlIn InItIatIOn In type 2 DIabeteS