Editorial

Steven V. Edelman, MD, and Derek LeRoith, MD, PhD

Initial therapy for patients with type 2 diabetes mellitus (DM) usually involves alterations in lifestyle—namely, diet and exercise—followed quickly by the addition of oral hypoglycemic agents. After the use of combinations of oral agents, insulin therapy or exenatide is then considered. Because type 2 DM is inherently a progressive disorder, most patients with this disease become candidates for insulin therapy, either in combination with oral agents, exenatide, or pramlintide, or by itself in regimens similar to those used by patients with type 1 DM.

Numerous regimens are available for starting insulin therapy. The addition of a long-acting, once-daily insulin as basal therapy, often with the continuance of daytime hypoglycemic agent(s), has become commonplace since the introduction of this regimen ~5 years ago. Advancing the insulin regimen can be achieved using short-acting analogues with each meal or by using a mixed insulin with an intermediate-acting insulin and a short-acting analogue 2 or 3 times daily.

One significant barrier to insulin use in patients with type 2 DM is the fear of injections; however, improvements in injectable devices (eg, syringes, needles, pens) and the develpment of a noninjectable option (ie, inhaled insulin) have helped overcome this fear in many patients. In particular, insulin pens offer several advantages for patients in terms of issues such as social acceptability and convenience. Self-monitoring of blood glucose (SMBG) is critical to assess the results of therapy and to avoid another major fear of patients—hypoglycemia. As these techniques improve and become less painful and more convenient, SMBG should increase in frequency. In addition, continuous glucose monitoring is an important clinical tool that, in conjunction with SMBG, can greatly help insulin-using patients.

Postprandial hyperglycemia is associated with worse cardiovascular outcomes, and attention to this problem has become a major area of discussion. It can be identified by means of SMBG and should be addressed by using agents that reduce postprandial blood glucose elevations; some oral agents, as well as exenatide and pramlintide, achieve this, as do prandial inhaled insulins.

This issue of Insulin covers many of these aspects of treatment. Hopefully, the articles presented here will help the readers and their patients deal with many of these difficult issues on instituting and maintaining a practical insulin regimen that is successful over the long-term.

Physicians' Corner: Advancing Change-Perspectives on Postprandial Glycemia
Charles F. Shaefer, Jr., MD, FACP, FCCP

Is achievement and maintenance of an A1C goal the end of our therapeutic road? It would certainly be convenient if that were all we had to do. There are clear signs on the horizon that reducing diabetic complication risk involves more than just A1C control. The way we manage DM may, once again, be in for a change.

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The Rationale for Prandial Glycemic Control in Diabetes Mellitus
Jennifer M. Perkins, MD, Stephen N. Davis, MD, FRCP

The objective of this article was to examine how prandial hyperglycemia-especially postprandial hyperglycemia (PPHG)-affects overall glycemic control and the complications of DM and to discuss the pharmacologic agents available to reduce PPHG.

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The Role of Rapid-Acting Insulin Analogues and Inhaled Insulin in Type 2 Diabetes Mellitus
Sandra Leal, PharmD, CDE, Richard N. Herrier, PharmD, Marisa Soto, PharmD, CDE

The availability of rapid-acting insulin analogues and inhaled insulin gives clinicians additional treatment options in the management of patients with diabetes mellitus (DM). Combining rapid-acting insulin analogues with basal insulin can more closely mimic physiologic insulin release to maximize glycemic control.

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The Use of Premixed Insulin Analogues in the Treatment of Patients with Type 2 Diabetes Mellitus: Advantages and Limitations
Ali A. Rizvi, MD, Robert J. Ligthelm, MD

Insulin therapy targeting both fasting and postprandial hyperglycemia is important in achieving optimal blood glucose (BG) control in patients with type 2 DM. A practical and feasible option is the use of >=1 injection of premixed insulin analogues. Clinicians should be aware of premixed insulin analogues' advantages and limitations so that these agents can be used appropriately in the treatment of patients with type 2 DM.

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Cultural Competence in Diabetes Mellitus Care: An Urgent Need
A. Enrique Caballero, MD

The standards of DM care apply to every individual with this disease and should continue to be the core of every clinician's practice. However, improving health care providers' cultural competence may help improve the quality of care provided to minority groups and may ultimately reduce health care disparities. Increased cultural competence may also improve patient-provider trust and communication, as well as help patients adhere to prevention and treatment plans.

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Insulin Therapy: The Question This Issue
Anuj Bhargava, MD, MBA, CDE, FACP, FACE

What choices do my patients have for insulin administration other than syringes and vials? What kinds of insulin pens are currently available? Why should my patients use insulin pens? If insulin pens have such advantages, why are they not used more commonly? Are there any special instructions for using pens compared with using syringes? What is the role of insulin pens in hospitals?

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Response to Previous Case Study
Derek LeRoith, MD, PhD

Priya D. Mohanty, MBBS.Diabetes-Endocrinology Center of Western New York, Kaleida Health, State University of New York at Buffalo, Buffalo, New York, Jan 01, 2007

The patient is a 30-year-old Hispanic man who was admitted to the surgical intensive care unit (ICU) with abdominal pain, vomiting, and a blood glucose level of 426 mg/dL.

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When Glucose Levels Are Too Low: A Major Barrier to Taking Control

Steven V. Edelman, MD

When taking control of your diabetes, the goal is to keep your blood glucose levels as close to normal as possible. By doing this, many diabetes-related complications, including eye, nerve, and kidney problems, can be avoided. Unfortunately, when blood glucose levels are kept close to normal, there is the chance that they can become too low. This condition is called hypoglycemia, and it is a major barrier to taking control of your diabetes.

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