Intensive Insulin Therapy in Type 2 Diabetes

Steven V. Edelman, MD

INTRODUCTION

Type 2 diabetes is characterized by a decline in both insulin sensitivity and insulin secretion due to the progressive loss of pancreatic β-cell function. Most patients with type 2 diabetes will require insulin therapy at some point in the course of the disease. Insulin is commonly introduced into an existing treatment regimen of oral antidiabetic drugs (OADs) as a single evening or bedtime dose of basal insulin when the OAD regimen alone is failing to achieve treatment goals. This strategy will achieve the glycosylated hemoglobin (A1C) target of ≤ 7% recommended by the American Diabetes Association in ~60% of patients over a 6-month treatment period.^1,2 However, because loss of β-cell function is progressive in type 2 diabetes, insulin regimens must also become more intensive with time. If patients continue to miss their A1C goal despite treatment with OADs plus basal insulin, a conversion to intensive insulin therapy may be required. Intensive insulin therapy refers to regimens that require multiple daily injections of insulin, as well as basal-bolus regimens that attempt to mimic the physiologic pattern of insulin secretion. This paper discusses the various approaches to intensive insulin therapy used in patients with type 2 diabetes.