Insulin therapy for type 2 diabetes

Insulin therapy provides effective glycemic control in patients with diabetes who have deficient beta-cell function and insulin secretion. Subjects with type 2 diabetes not adequately controlled on oral agents or incretin therapies can initiate basal insulin replacement to correct fasting hyperglycemia. While all basal insulin preparations have similar efficacy in lowering fasting plasma glucose and improving A1C, the newer basal insulin analogs are associated with a lower risk of hypoglycemia than NPH insulin. Patients whose A1C levels remain above goal despite adequate basal insulin replacement need to evaluate and correct post-prandial hyperglycemia. With progressive beta-cell deficiency, rapid-acting insulin preparations can be introduced before one or more meals and titrated to achieve post-prandial glycemic control. For many patients requiring full basal/bolus insulin replacement, a strategy of fixed prandial insulin doses can yield acceptable glycemic control when compared to a more sophisticated approach utilizing carbohydrate counting and matching to insulin. Concentrated insulin preparations such as U-500 have also been of value in patients with resistant type 2 diabetes. Regardless of the type of insulin replacement used, the blood glucose lowering effects of insulin need to be carefully balanced with the increasing risk of hypoglycemia, and the weight gain associated with insulin intensification.