A Stepwise Approach to Insulin Therapy in Patients with Type 2 Diabetes Mellitus and Basal Insulin Treatment Failure (original) (raw)
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Diabetes & Metabolism, 2006
There are many reasons to believe that in the near future, the treatment of patients with Type 2 diabetes will be characterised by an increased use of insulin therapy. To ensure that insulin regimens are acceptable to patients, and implemented by physicians, they should be as simple and efficient as possible. Simplicity is synonymous with the regimen of once-daily basal insulin glargine given at any time of the day (at the same time each day). With such a strategy, the dose is adjusted by titrating to target fasting blood glucose values of 5.0-7.2 mmol/L (90-130 mg/dL). When these targets can no longer be achieved with reasonable doses of long-acting insulin, a rapid-acting insulin analogue should be added at meal times. A step-by-step strategy can be used; it is recommended that initially, a single daily prandial bolus of a rapid-acting insulin analogue is administered before the meal that leads to the highest post-meal blood glucose excursions. Further boluses can be added at other meal times as necessary, i.e, when postmeal blood glucose values remain above 10.0 mmol/L (180 mg/dL) and 7.8 mmol/L (140 mg/dL) at mid-morning and 2h-post-lunch or post-dinner times, respectively. This stepwise strategy may eventually lead to a standard basal-bolus regimen with 3 pre-meal injections of rapid-acting insulin analogues, a potentially small trade-off for achieving fairly-well controlled diabetes.
Diabetes, Obesity and Metabolism
The class of rapid-acting insulin analogues were introduced more than 20 years ago to control postprandial plasma glucose (PPG) excursions better than unmodified regular human insulin. Insulins, lispro, aspart and glulisine all achieved an earlier onset of action, greater peak effect and shorter duration of action resulting in lower PPG levels and a reduced risk of late postprandial hypoglycaemia. However, the subcutaneous absorption rate of these analogues still fails to match the physiological profile of insulin in the systemic circulation following a meal. Recent reformulations of aspart and lispro have generated a second generation of more rapid-acting insulin analogue candidates, including fast-acting aspart (faster aspart), ultra-rapid lispro and BioChaperone Lispro. These modifications have the potential to mimic physiological prandial insulin secretion better with an even earlier onset of action with improved PPG control, shorter duration of effect and reduced risk of hypoglycaemia. Recent phase 3 trials in type 1 and type 2 diabetes
Diabetic Medicine, 2013
Basal insulin provides an effective method for initiating insulin therapy in people with Type 2 diabetes, resulting in significant improvements in glycaemic control, lower rates of hypoglycaemia and less weight gain than either prandial or premixed insulin regimens. However, the progressive nature of Type 2 diabetes and the inability of basal insulin to correct excessive postprandial glucose excursions mean that insulin therapy will eventually need to be intensified, typically by adding prandial insulin as part of a basal-bolus or premixed insulin regimen. The aim of this review is to summarize recent clinical evidence for a staged 'basal-plus' strategy for insulin intensification where one, two or three prandial insulin injections are added to basal insulin according to individual need. In the early stages of insulin therapy, most individuals seem to achieve favourable glycaemic control with basal insulin alone, or in combination with a single prandial insulin injection. The addition of a single prandial insulin injection at the largest meal is well tolerated and associated with significant improvements in glycated haemoglobin (HbA 1c), low rates of hypoglycaemia and limited weight gain. More people achieve recommended HbA 1c targets with a basal-plus strategy, compared with twice-daily premixed insulin therapy, with lower rates of hypoglycaemia. The data indicate that a step-by-step approach with the basal-plus strategy is a promising alternative method of insulin intensification that allows for individualization of treatment and may delay progression to a full basal-bolus insulin replacement therapy for many individuals.
Insulin Matters: A Practical Approach to Basal Insulin Management in Type 2 Diabetes
Diabetes therapy : research, treatment and education of diabetes and related disorders, 2018
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 i...
Addressing barriers to effective basal insulin therapy
The Journal of the Association of Physicians of India, 2014
Diabetes has reached epidemic proportions worldwide. It is a major health hazard particularly in developing countries like India due to the genetic susceptibility and changes in lifestyle. Glycaemic control is very poor in India as reflected by recent studies showing average HbA1c of > 9%. Insulin therapy is the mainstay of diabetes management. Currently available insulins have certain limitations. Modern insulin therapy needs to overcome these limitations to effectively achieve the optimal glycemic control. Hypoglycaemia is one of the important barrier which limits the use of insulin therapy and incidence of hypoglycaemia increases with increased variability in glucose lowering effects of Insulin when one tries to achieve stricter glycaemic targets. Fixed time administration is another important barrier, particularly for basal insulin administration that may affect the quality of life. Also the available basal insulins do not provide complete 24 hours control of fasting hypergly...
Basal insulin or premix analogue therapy in type 2 diabetes patients
European Journal of Internal Medicine, 2007
Background: We sought to compare the safety and efficacy of biphasic insulin aspart 30 (BIAsp 30) given twice daily with once-daily insulin glargine in patients with type 2 diabetes beginning insulin therapy and who did not use thiazolidinediones, which are contraindicated with insulin in the European Union, in a subpopulation (N = 157) of the INITIATE study. Methods: At baseline, HbA 1c was ≥ 8.0% on ≥ 1000 mg/day metformin alone or in combination with other oral antidiabetic drugs (OADs; e.g. sulphonylurea or alpha-glucosidase inhibitors). Metformin was adjusted up to 2550 mg/day and other OADs were discontinued. Starting insulin doses were subsequently adjusted weekly for 26 weeks by algorithm-directed titration. Results: The proportion of patients achieving a HbA 1c below 7.0% at 28 weeks was greater with BIAsp 30 than with insulin glargine (65% vs 41%, P = 0.003). The mean reduction in HbA 1c was greater for BIAsp 30 than for insulin glargine: −2.89 ± 1.6% vs −2.46 ± 1.6%, respectively (P = 0.035). Postprandial glucose increments were lower for the BIAsp 30 group after breakfast (P = 0.003) and dinner (P = 0.033); post-lunch values were not significantly different. No major hypoglycemic episodes were recorded. Nocturnal hypoglycemia was reported by 25% of subjects in the BIAsp 30 group and by 10% in the insulin glargine group (P = 0.021). Weight gain was 5.6± 4.6 and 3.0 ± 4.3 kg (P = 0.0004) for BIAsp 30 and insulin glargine, respectively. Conclusions: BIAsp 30, given twice daily in combination with metformin, was more effective than insulin glargine, given once daily in combination with metformin, at controlling blood glucose in insulin-naïve patients with type 2 diabetes, but was associated with increased weight gain and minor hypoglycemic events.