Post by cm5 on Aug 7, 2016 20:07:55 GMT -5
Insulin Therapy for Type 2 Diabetes WHEN SHOULD INSULIN THERAPY BE INITIATED?
Sanne G. Swinnen, MD, Joost B. Hoekstra, PHD, and J. Hans DeVries, PHD
From the Department of Internal Medicine, Academic Medical Center, Amsterdam, the Netherlands.
Corresponding author: Sanne G. Swinnen, Email: ln.avu.cma@nenniws.g.s.
Diabetes Care. 2009 Nov; 32(Suppl 2): S253–S259.
doi: 10.2337/dc09-S318
Sanne G. Swinnen, MD, Joost B. Hoekstra, PHD, and J. Hans DeVries, PHD
From the Department of Internal Medicine, Academic Medical Center, Amsterdam, the Netherlands.
Corresponding author: Sanne G. Swinnen, Email: ln.avu.cma@nenniws.g.s.
Diabetes Care. 2009 Nov; 32(Suppl 2): S253–S259.
doi: 10.2337/dc09-S318
A number of landmark randomized clinical trials established that insulin therapy reduces microvascular complications (1,2). In addition, recent follow-up data from the U.K. Prospective Diabetes Study (UKPDS) suggest that early insulin treatment also lowers macrovascular risk in type 2 diabetes (3). Whereas there is consensus on the need for insulin, controversy exists on how to initiate and intensify insulin therapy. The options for the practical implementation of insulin therapy are many. In this presentation, we will give an overview of the evidence on the various insulin regimens commonly used to treat type 2 diabetes.
Traditionally, there has been a stepwise introduction of glucose-lowering interventions, with the final “step” of insulin therapy being administered 10–15 years after diagnosis (8).
Both patients and physicians are often reluctant to start insulin because of fears of painful injections, hypoglycemia, and weight gain (21,22).
Additional reasons for “psychological insulin resistance” among patients are negative beliefs about insulin treatment permanence, restrictiveness, low self-efficacy, personal failure, and illness severity (22).
Drawback of the stepwise approach is that the introduction of successive interventions after treatment failure is often delayed, exposing patients to many years of uncontrolled hyperglycemia (9). Another reason for a more rapid response to treatment failure is that lowering glycemia has been shown to improve insulin resistance as well as endogenous insulin secretion (23)
Both patients and physicians are often reluctant to start insulin because of fears of painful injections, hypoglycemia, and weight gain (21,22).
Additional reasons for “psychological insulin resistance” among patients are negative beliefs about insulin treatment permanence, restrictiveness, low self-efficacy, personal failure, and illness severity (22).
Drawback of the stepwise approach is that the introduction of successive interventions after treatment failure is often delayed, exposing patients to many years of uncontrolled hyperglycemia (9). Another reason for a more rapid response to treatment failure is that lowering glycemia has been shown to improve insulin resistance as well as endogenous insulin secretion (23)
This was recently confirmed by Weng et al. (24) who found that a brief course of insulin therapy in subjects with newly diagnosed type 2 diabetes not only restored, but also maintained, β-cell function, resulting in prolonged glycemic remission. Interestingly, remission rates were significantly higher in the intensive insulin groups than in the intensive oral therapy group.
However, Weng's findings need to be confirmed, and also for reasons of practicality and patients' acceptance, we advocate stepwise diabetes treatment, provided that “an A1C of ≥7.0% serves as a call to action to initiate or change therapy” (5)
Moreover, the response to this call should be swift; given the great (cost-)effectiveness, we advocate the initiation of insulin when glycemic goals are not attained after 2–3 months of maximally dosed dual oral therapy.
For patients intolerant to one or more oral glucose-lowering agents and who do not achieve glycemic control with oral monotherapy, as well as those with a personal preference, earlier initiation of insulin is indicated. It is noteworthy that rapid addition of insulin therapy is supported by numerous studies showing improved treatment satisfaction and quality-of-life for type 2 diabetic patients who had started using insulin (25,26).
However, Weng's findings need to be confirmed, and also for reasons of practicality and patients' acceptance, we advocate stepwise diabetes treatment, provided that “an A1C of ≥7.0% serves as a call to action to initiate or change therapy” (5)
Moreover, the response to this call should be swift; given the great (cost-)effectiveness, we advocate the initiation of insulin when glycemic goals are not attained after 2–3 months of maximally dosed dual oral therapy.
For patients intolerant to one or more oral glucose-lowering agents and who do not achieve glycemic control with oral monotherapy, as well as those with a personal preference, earlier initiation of insulin is indicated. It is noteworthy that rapid addition of insulin therapy is supported by numerous studies showing improved treatment satisfaction and quality-of-life for type 2 diabetic patients who had started using insulin (25,26).