Early Insulin Treatment in Type 2 Diabetes
What are the pros?
- Luigi F. Meneghini, MD, MBA
- From the Division of Endocrinology, Diabetes and Metabolism and the Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, Florida.
- Corresponding author: Luigi F. Meneghini, lmeneghi{at}med.miami.edu.
The prevalence of diabetes in the world is growing at an unprecedented rate and rapidly becoming a health concern and burden in both developed and developing countries (1). In addition, we are now witnessing an upsurge in the incidence of type 2 diabetes in children and adolescents, with the potential of translating into a future catastrophic disease burden as vascular complications of the disease begin affecting a younger population. Although there may be contention regarding the impact of lowering glycemia on macrovascular disease risk, there is strong consensus of the definite benefits of lowering blood glucose to reduce the risk of retinopathy and nephropathy in either type 1 or type 2 diabetes (2,3). Despite supporting data and multiple guidelines advanced by professional organizations, overall glycemic control falls far below expectations (4). Overall, <36% of individuals with diabetes are at recommended glycemic targets, with the most difficult-to-control cases represented by insulin-deficient individuals on insulin therapy to manage their diabetes (4). Furthermore, as β-cell dysfunction progresses over time, many patients with type 2 diabetes, treated with oral agents, fail to achieve or maintain adequate glycemic control. Unfortunately, in many of these cases, antiglycemic therapy is not adjusted or advanced, thereby exposing patients to prolonged hyperglycemia and the increased risk of diabetes-related complications. The term “clinical inertia,” which has come to define the lack of initiation, or intensification of therapy when clinically indicated (5), is most pronounced in the setting of insulin initiation. Subjects with type 2 diabetes, managed in a large integrated health care system, were initiated on additional blood glucose–lowering treatment only when the mean baseline A1C reached a value of 9.0% (6). Patients started on insulin had an even higher mean A1C of 9.6% and tended to have more severe baseline complications and comorbidities than those started on …
