[Starting insulin or not? And if so, which basal insulin?]

Area of Science:

• Endocrinology
• Metabolic Diseases
• Pharmacology

Background:

• Type 2 diabetes mellitus (T2DM) management can be challenging, especially in patients with obesity (BMI 30 kg/m2) and elevated HbA1c (71 mmol/mol).
• Standard oral therapies like metformin and glimepiride, along with initial weight loss, may not suffice for glycemic control.
• Patient reluctance towards insulin therapy necessitates exploring alternative or adjunct treatment strategies.

Observation:

• A 55-year-old male patient with T2DM, despite 8% weight loss and treatment with metformin and glimepiride, presented with uncontrolled hyperglycemia.
• Initial reluctance towards insulin therapy was overcome, leading to the consideration of treatment options.

Findings:

• Basal insulin therapy was initiated, with consideration for cost-effectiveness due to similar efficacy among available basal insulin types.
• A combination of basal insulin and a glucagon-like peptide-1 (GLP-1) receptor agonist achieved good glycemic control.
• This regimen successfully managed hyperglycemia without inducing further weight gain in the patient.

Implications:

• Combination therapy with basal insulin and GLP-1 receptor agonists represents an effective strategy for T2DM management in patients with obesity and high HbA1c levels.
• This approach offers an alternative for patients hesitant to initiate insulin, potentially improving adherence and long-term outcomes.
• Cost-effectiveness should be considered when selecting among similar basal insulin formulations.