HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

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 Google Scholar Google Scholar Articles by Raskin, P. Search for Related Content PubMed PubMed Citation Articles by Raskin, P. Social Bookmarking                What's this?

Initiation of Insulin Therapy in Patients With Type 2 Diabetes Failing Oral Therapy

Response to Mikhail and Cope and to Janka

Department of Internal Medicine, Southwestern Medical Center at Dallas, University of Texas, Dallas, Texas

Address correspondence to Dr. Philip Raskin, University of Texas, Southwestern Medical Center at Dallas, Department of Internal Medicine, 5323 Harry Hines Blvd., Dallas, TX 75235-8858. E-mail: philip.raskin{at}utsouthwestern.edu

In a recent editorial (1), Davidson commented on two studies (2,3) in which insulin initiation using a basal insulin analog was compared with either a human insulin premix or an analog insulin premix. These articles have prompted further correspondence concerning the design and results of these studies (4,5).

Mikhail and Cope (4) and Janka (5) commented that the greater HbA_1c reduction observed in patients taking biphasic insulin aspart 70/30 (BIAsp 70/30), as compared with insulin glargine, may be attributed to a greater dose of BIAsp 70/30. They suggested that glargine was not titrated to the fullest extent in the INITIATE study. However, the fasting blood glucose values achieved with titration of the evening dose of glargine were the same in the INITIATE, Treat-to-Target (6), zand Janka et al. (2) studies (from 117 to 115 mg/dl). These blood glucose values, as well as those for the BIAsp 70/30 in INITIATE, were slightly above the targeted fasting glucose values and suggest a reluctance by clinicians to titrate insulin to the fullest extent. It is not surprising that there was a greater BIAsp 70/30 dose, as there was a second insulin injection to titrate. The administration of twice-daily BIAsp 70/30 during INITIATE provided coverage of postprandial glycemia during breakfast and the evening meal, often the biggest meals of the day. With the growing acceptance of the importance of postprandial glycemia on overall glycemic control, a premix analog insulin has the advantage over a single basal injection of targeting and reducing postprandial glucose excursions.

With a greater insulin dose, more hypoglycemia and weight gain might be expected. However, no subjects in the BIAsp 70/30 group had a major hypoglycemic episode, nor did any withdraw from the study because of hypoglycemia. Therefore, hypoglycemia was not an impediment to the pursuit of glycemic control for the BIAsp 70/30 group, which had a greater percentage of patients reach the target HbA_1c of <7%, compared with the glargine group (66 vs. 40%, respectively).

As aptly stated in the Davidson editorial, the most important factor in initiating insulin therapy is to "intensify the approach until targets are achieved and then to maintain them." With the success rate observed in the INITIATE study, the premixed formulation of BIAsp 70/30 clearly is a viable option for initiating insulin therapy and for achieving glycemic targets in a majority of insulin-naïve patients with type 2 diabetes.

References

1. Davidson MB: Starting insulin therapy in type 2 diabetic patients: does it really matter how? (Editorial). Diabetes Care 28:494–495, 2005[Free Full Text]
   
2. Janka HU, Plewe G, Riddle MC, Kliebe-Frisch C, Schweitzer MA, Yki-Järvinen H: Comparison of basal insulin added to oral agents versus twice-daily premixed insulin as initial insulin therapy for type 2 diabetes. Diabetes Care 28:254–259, 2005[Abstract/Free Full Text]
   
3. Raskin P, Allen E, Hollander P, Lewin A, Gabbay RA, Hu P, Bode B, Garber A, the INITIATE Study Group: Initiating insulin therapy in type 2 diabetes: a comparison of biphasic and basal insulin analogs. Diabetes Care 28:260–265, 2005[Abstract/Free Full Text]
   
4. Mikhail NE, Cope D: Initiation of insulin in patients with type 2 diabetes failing oral therapy (Letter). Diabetes Care 28:1537–1538, 2005[Free Full Text]
   
5. Janka HU: Initiation of insulin in patients with type 2 diabetes failing oral therapy (Letter). Diabetes Care 28:1538, 2005[Free Full Text]
   
6. Riddle MC, Rosenstock J, Gerich J, the Insulin Glargine 4002 Study Investigators: The Treat-to-Target Trial: randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients. Diabetes Care 26:3080–3086, 2003[Abstract/Free Full Text]
   

CiteULike

Del.icio.us

Digg

Reddit

Technorati

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 Google Scholar Google Scholar Articles by Raskin, P. Search for Related Content PubMed PubMed Citation Articles by Raskin, P. Social Bookmarking                What's this?