Insulin analogs for the management of type 2 diabetes

Evolving practice recommendations on the use of insulin analogs versus other forms of insulin therapy in adults with type 2 diabetes are reviewed, with an emphasis on supporting evidence from practice guidelines and clinical trials published over the last six years.

Current consensus guidelines call for aggressive pharmacotherapy to attain specific glycosylated hemoglobin (HbA(1c)) targets as a means of reducing the risk of macrovascular events (e.g., myocardial infarction, stroke, cardiovascular [CV] death) and the tailoring of HbA(1c)-lowering regimens according to patient-specific factors such as the duration of diabetes, life expectancy, and comorbid conditions. Joint guidelines issued in 2009 by two leading organizations of endocrinology specialists recommend the use of insulin analogs (e.g., detemir, glargine) versus neutral protamine Hagedorn insulin, citing a more predictable time course and a lower potential for hypoglycemia; growing evidence indicates that the use of insulin analogs may offer other advantages such as enhanced dosing flexibility (with the possibility of self-titration by some patients) and less weight gain. Some evidence from trials published since 2007 indicates that early or intensive insulin analog therapy and very aggressive glycemic goals (e.g., HbA(1c) of <6%) may be associated with an increased mortality risk, especially in patients with longstanding diabetes and major CV comorbidities. Ongoing research is expected to help elucidate the comparative merits of intensive and standard HbA(1c)-lowering regimens and optimal strategies for individualized treatment of diabetic and prediabetic patients.

Published evidence suggests that insulin analogs may ofer advantages over other insulins as part of individualized pharmacotherapy regimens for appropriately selected patients with type 2 diabetes.