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Insulin Therapy in Type 2 Diabetes

Dislike of the idea of injections and frequent blood glucose monitoring keeps many people with type 2 diabetes from going on insulin therapy, even if their blood glucose control is not satisfactory. Dutch physicians conducted a study to see how a group of patients fared when they were switched to insulin therapy.

Patients with HbA1c levels of eight percent or higher while on oral medication were divided into two groups. One group had a 12-week period of enhanced care to optimize their noninsulin therapy through diet and oral medications. The other group began insulin therapy. Over a nine-month period, patients were assessed for cardiovascular risk factors and events, complications, quality of life and glycemic control.

All patients - those who went on insulin and those who did not - experienced a significant improvement in glycemic control and fewer symptoms associated with hyperglycemia. This kind of improvement is frequently seen in research studies and is no doubt a result of paying more attention to the day-to-day aspects of diabetes care. Without making overt changes, most patients in the "run-in" period of studies that precede the intervention show a substantial improvement in their blood glucose control.

In this study body weight increased, while blood pressure and lipid profiles showed improvements. No increase in hypoglycemia symptoms was noted in those patients who started on insulin. There were no changes in any of the quality-of-life measurements, and there was a trend toward significant improvement in perceived health.

In conclusion, the patients with poorly controlled type 2 diabetes can be switched to insulin therapy without an increase in hypoglycemic episodes or deterioration in quality of life. The Clinical Advisory Board notes that such a finding should not be over-interpreted to mean that all people with type 2 diabetes will do better on insulin. The Board also noted that there are different ways to introduce insulin therapy to patients with type 2 diabetes:

(1) stop oral medications and switch immediately to several insulin shots a day; or
(2) add a bedtime dose of insulin while continuing with oral medications. The second approach has been shown to reduce HbA1c with less hypoglycemia and less weight gain than the more abrupt method.


Type 2 diabetes is characterized by progressive beta-cell failure. Indications for exogenous insulin therapy in patients with this condition include acute illness or surgery, pregnancy, glucose toxicity, contraindications to or failure to achieve goals with oral antidiabetic medications, and a need for flexible therapy. Augmentation therapy with basal insulin is useful if some beta-cell function remains. Replacement therapy with basal-bolus insulin is required for beta-cell exhaustion. Rescue therapy using replacement regimens for several weeks may reverse glucose toxicity. Replacement insulin therapy should mimic normal release patterns. Basal insulin, using long-acting insulins (i.e., neutral protamine Hagedorn [NPH], ultralente, glargine) is injected once or twice a day and continued on sick days. Bolus (or mealtime) insulin, using short-acting or rapid-acting insulins (i.e., regular, aspart, lispro) covers mealtime carbohydrates and corrects the current glucose level. The starting dose of 0.15 units per kg per day for augmentation or 0.5 units per kg per day for replacement can be increased several times as needed. About 50 to 60 percent of the total daily insulin requirement should be a basal type, and 40 to 50 percent should be a bolus type. The mealtime dose is the sum of the corrective dose plus the anticipated requirements for the meal and exercise. Adjustments should be made systematically, starting with the fasting, then the preprandial and, finally, the postprandial glucose levels. Basal therapy with glargine insulin provides similar to lower A1C levels with less hypoglycemia than NPH insulin.
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