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The Proper Time for Insulin Treatment

Question: At what point should insulin treatment beconsidered for a patient with type 2diabetes?

Answer: Insulin is an effective treatment for type 2 diabetes thatis often withheld for too long. Insulin should be used when oral agents failor when oral agents alone are not predicted to achieve the target glucoselevels. (The primary focus of any treatment strategy is reaching the targetglycated hemoglobin [A1C] level of less than or equal to 7% with a fastingblood glucose of less than 126 mg/dl.)

When the initial A1C value exceeds 9%, a single agent is unlikely toaccomplish thegoal.¹ Thecombination of an insulin secretagogue and metformin or a thiazolidinedione(TZD) can produce a greater effect than monotherapy. Combinations of threeoral agents are becoming increasingly popular for use before a patient'stransition to insulin therapy. However, failure of oral therapy appears tocorrelate with loss of beta-cell function, and insulin use eventually isrequired in most persons with type 2 diabetes.

It has been suggested that insulin be started for a patient who has an A1Cgreater than 7.5% and a fasting blood glucose greater than 240mg/dl.²

Nevertheless, the decision to transition to insulin often is delayed due toperceptions that patients may be unable or unwilling to inject insulin orbecause of concerns about hypoglycemia. The transition can be made within 3 to4 months with titration of the secretagogue and sensitizer.

We know that insulin is the most effective treatment for lowering very highblood glucose levels. Fasting hyperglycemia can be effectively treated withbedtime long-acting or intermediate-acting insulin. However, at lower A1Clevels, data suggest that the impact on overall glycemic control is greatesttargeting postprandial bloodglucose.³

The therapies for type 2 diabetes have different effects on the targets andcan be used effectively to treat patients. However, since type 2 diabetes isprogressive, most of our patients ultimately will need insulin.

Footnotes

Eugene E. Wright, Jr., MD, is medical director of Primary Care Practices atthe Cape Fear Valley Health System in Fayetteville, N.C.

Do you have a clinical question? Send it todocnews{at}diabetes.org.

References

1. Ahmann AJ, Riddle MC: What to do when two oral agents fail tocontrol type 2 diabetes—a matter of opinion or a matter of fact?Am J Med 116:276–278, 2004.[Medline]

2. Feinglos MN, Bethel MA: Oral agent therapy in the treatment of type2 diabetes. Diabetes Care 22(Suppl. 3): C61–C64, 1999.

3. Monnier L, Lapinski H, Colette C: Contributions of fasting andpostprandial plasma glucose increments to the overall diurnal hyperglycemia oftype 2 diabetic patients: variations with increasing levels ofHbA_1c. Diabetes Care 26: 881–885, 2003.[Abstract/Free Full Text]

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