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Short-Term Intensive Insulin Therapy in Newly Diagnosed Type 2 Diabetes

Response to Ryan, Imes, and Wallace

¹ Department of Diabetes and Endocrinology, Matsushita Memorial Hospital, Moriguchi, Osaka, Japan
² Department of Diabetes and Metabolism, Kyoto City Hospital, Kyoto, Japan
³ Department of Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan

Address correspondence to Keiji Yoshioka, MD, Matsushita Memorial Hospital, Department of Diabetes and Endocrinology, 5-55, Sotojima-cho, Moriguchi, Osaka, 570-8540 Japan. E-mail: yoshik{at}mue.biglobe.ne.jp

The recent report by Ryan et al. (1) demonstrated that in newly diagnosed type 2 diabetes, a short course of intensive insulin therapy successfully laid a foundation for long-term good glycemic control and suggested that the only predictors that could be maintained on diet alone in the long term were those concerned with the ease with which glycemic control could be achieved. We agree with their strategy of short-term intensive insulin therapy to restore ß-cell insulin secretion and/or insulin action that is impaired by glucose toxicity in cases of severe newly diagnosed type 2 diabetes.

Glucose toxicity has two different aspects: impaired insulin secretion (2) and decreased insulin action (3). In their report, however, the authors did not precisely discuss which mechanism (insulin secretion or action) was predominantly recovered or not rescued in better responders (diet-alone group) and lesser responders (oral hypoglycemic agent [OHA]/insulin group) with intensive insulin therapy in a short period. According to their results, both the area under the curve (AUC_i) (their Fig. 1B) and the insulin-to-glucose ratios at the 30-min point in a post–insulin therapy oral glucose tolerance test (OGTT) were not different between the diet-success and diet-failure groups, suggesting that restoration of insulin secretion was similar in both groups. Although the authors selected newly diagnosed type 2 diabetic subjects with similar hyperglycemia, it is important to assess whether the disease duration after onset of diabetes was the same in both groups, because duration of diabetes may be a key predictor of the reserve of insulin secretion.

With regard to insulin resistance, the authors did not provide the clinical parameters of insulin resistance such as homeostasis model assessment of insulin resistance (HOMA-IR). They showed that with the post–insulin therapy OGTT, the fasting insulin-to-glucose ratio was higher in the diet-failure group, despite a higher fasting glucose level (fasting insulin level was not shown), than in the diet-success group, meaning greater insulin resistance in the diet-failure group. The BMI values of each group before insulin therapy were similar, but it is possible that a type II error was present because of very small sample numbers. Moreover, the BMI in the diet-only group was significantly reduced at 6 months, while that in the OHA/insulin group did not change throughout the study. Taken together with their results, we consider that insulin sensitivity or resistance rather than insulin secretion may deeply influence the need for OHAs or insulin after short-term intensive insulin therapy in their study. Additional larger prospective studies are needed to use intensive insulin therapy in clinical practice in newly diagnosed type 2 diabetes.

References

1. Ryan EA, Imes S, Wallace C: Short-term intensive insulin therapy in newly diagnosed type 2 diabetes. Diabetes Care 27:1028–1032, 2004[Abstract/Free Full Text]
   
2. Hidaka H, Nagulesparan M, Klimes I, Clark R, Sasaki H, Aronoff SL, Vasquez B, Rubenstein SH, Unger RH: Improvement of insulin secretion but not insulin resistance after short term control of plasma glucose in obese type II diabetics. J Clin Endocrinol Metab 54:217–222, 1982[Abstract]
   
3. Garvey WT, Olefsky JM, Griffin J, Hamman RF, Kolterman OG: The effect of insulin treatment on insulin secretion and insulin action in type II diabetes mellitus. Diabetes 34:222–234, 1985[Abstract]
   

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				E. A. Ryan, S. Imes, and C. Wallace Short-Term Intensive Insulin Therapy in Newly Diagnosed Type 2 Diabetes: Response to Yoshioka, Yoshida, and Yoshikawa Diabetes Care, September 1, 2004; 27(9): 2282 - 2283. [Full Text] [PDF]

This Article Extract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Yoshioka, K. Articles by Yoshikawa, T. Search for Related Content PubMed PubMed Citation Articles by Yoshioka, K. Articles by Yoshikawa, T. Social Bookmarking                What's this?