The when and how of insulin initiation in type 2 diabetes

Insulin has traditionally been viewed as a 'last resort' in the treatment of type 2 diabetes. However, accumulating evidence on the benefits of early insulin initiation brings this traditional viewpoint into question. Increasing recognition of the importance of insulin therapy in type 2 diabetes has also raised the issue of how best to initiate insulin in this patient group. Evidence-based guidelines are currently limited and, sometimes, conflicting.

In the absence of clear evidence-based guidelines, this commentary focuses on clinical experience and recent findings, to ascertain the most commonly used and effective insulin initiation regimens for patients with type 2 diabetes. Recent findings were identified via a literature search using PubMed during the last 5 years in addition to key congress abstract searches from the last 2 years.

Two commonly used regimens that have emerged as effective, safe and easy to implement are bedtime basal and premixed insulin analogues. In addition, the latter treatment option provides greater post-prandial glucose regulation and the prospect of simple intensification, such that patients' ongoing clinical needs can be more easily met, with minimal disruption to their lifestyle.

Current data and clinical experience highlight bedtime basal and premixed insulin analogues as favourable options for the initiation of insulin in patients with type 2 diabetes. Further insights on the optimal initiation regimen will be provided by studies such as the ongoing 4T trial, which is comparing the long-term impact of three different approaches to commencing insulin therapy in patients with type 2 diabetes.