[Insulin treatment of Type II diabetes]

Secondary failure to oral hypoglycemic agents occurs in some 5% of type II diabetic patients per year, such that treatment with insulin becomes warranted. In most of the cases only hyperglycemia is apparent, while signs of severe metabolic derangement such as thirst, polyuria and weight loss are lacking. However, the hyperglycemic state adversely affects endogenous insulin secretion and favors the development of microvascular complications and neuropathy. In addition, dyslipidemia is often present, and the patient's well-being may be impaired. To differentiate between real secondary drug failure and transient metabolic impairment due to insufficient compliance with the diet prescriptions, plasma C-peptide should be measured. Insulin therapy should be initiated with a dose of 6-8 IU of an intermediate-action preparation and subsequently adjusted based on blood glucose measurements. Frequently it will be necessary to employ twice daily a mixture of (rapid- and intermediate-action) insulin in order to achieve adequate control of postprandial hyperglycemia. In some cases insulin therapy can be discontinued since the endogenous insulin secretion may improve during insulin treatment. We do not recommend to use as initial therapy of patients with secondary failure to oral hypoglycemic agents a combination of sulfonylureas and insulin since the 'insulin-saving' effect is small and not cost-effective.