Starting Insulin Therapy in Type 2 Diabetic Patients
Does it really matter how?
- From the Clinical Trials Unit, King-Drew Medical Center, Charles R. Drew University, Los Angeles, California
- Address correspondence to Mayer B. Davidson, MD, Clinical Trials Unit, Charles R. Drew University, 1731 East 120th St., Los Angeles, CA 90059. E-mail: madavids{at}cdrewu.edu
Type 2 diabetic patients failing oral antidiabetes medications need insulin. If used appropriately and with patient cooperation, almost all patients can be well controlled. There is no agreed upon optimal mode of initiating insulin in this situation. In recent years, adding NPH insulin at bedtime (1–3) or 70/30 premixed insulin at suppertime (4) to the oral medications have been studied. Adding NPH insulin at bedtime has yielded similar improvements in control as two or more injections of insulin for 3 (1), 6 (2), or 12 (3) months. Recently, several studies have compared the peakless insulin, glargine, with bedtime NPH insulin and showed similar levels of control but less nocturnal hypoglycemia (5–7).
Two reports in this issue of Diabetes Care pertain to this matter. In the first, Janka et al. (8) compared adding a morning injection of glargine insulin to type 2 diabetic patients failing oral medications with discontinuing the pills and starting premixed 70% NPH insulin/30% regular insulin twice a day. The patients receiving glargine insulin during the 24-week study were also taking 3 or 4 mg of glimepiride and 850 mg or more of metformin. A weekly forced-titration algorithm was used to achieve a target fasting glucose concentration of ≤100 mg/dl in both groups and ≤100 mg/dl before supper in the patients taking premixed insulin. Patients in the glargine group had a statistically greater fall in A1c levels (−1.6 vs. −1.3%) and less …
