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From the Current Issue

Should You Be Taking Insulin for Type 2 Diabetes?
New research suggests that starting insulin therapy earlier may be beneficial.

The first treatment for people newly diagnosed with type 2 diabetes is usually lifestyle changes, such as improvements in diet and exercise. If these measures do not sufficiently control blood glucose levels, one or more oral medications (often metformin and/or a sulfonylurea drug) are prescribed. Over time, type 2 diabetes usually worsens, oral medications become less effective, and more than a third of people must add insulin injections to their treatment regimen.

New research, however, is challenging this treatment approach, suggesting that adding insulin earlier can greatly improve blood glucose control. In addition, newer insulin formulations such as insulin glargine are convenient to take and less likely than older types to cause hypoglycemia—a big concern for many people who are beginning insulin therapy.

Why Some People With Type 2 Diabetes Need Insulin

Unlike people with type 1 diabetes, who are unable to produce their own insulin and require insulin injections to survive, people with type 2 diabetes do produce insulin. The problem in type 2 diabetes is that the cells are less responsive to the actions of insulin. The pancreas compensates by producing more insulin, but over time it cannot produce enough to overcome the cells’ reduced response. In addition, as type 2 diabetes progresses, the ability of the pancreas to produce insulin may become impaired, and the body does not have enough insulin to move glucose into cells.

Evidence for Change

A 2004 review article in The American Journal of Medicine points out that many people with type 2 diabetes are not prescribed insulin until 10 to 15 years after their diagnosis and often not until complications from the disease have already occurred. The author calls this practice outdated and ineffectual and points to an emerging trend that involves the earlier use of insulin to help people with type 2 diabetes control their blood glucose levels and reduce their risk of complications.

The article points out that for many people, lifestyle changes and oral medication are not enough. For example, a substudy of the UKPDS (see page 26 for more information) found that six years after diagnosis, more than 50% of people with type 2 diabetes treated with a sulfonylurea alone needed insulin injections to achieve their target blood glucose levels. In addition, 50% of those who took insulin plus a sulfonylurea had a desirable median HbA1c level of 6.7% after six years.

Newer Types of Insulin

Earlier addition of insulin is made even more attractive by newer types of insulin that reduce the risk of side effects. The review author points to two recent clinical trials supporting this idea. (The first, published in the Annals of Internal Medicine in 2003, compared three treatment regimens: the oral medication glimepiride (Amaryl) with NPH insulin at bedtime; glimepiride with insulin glargine at bedtime; and glimepiride with morning insulin glargine. After 24 weeks, fewer patients taking insulin glargine (17% for bedtime and 23% for morning) experienced hypoglycemia during the night than those taking NPH insulin (38%). HbA1c levels also decreased more significantly with insulin glargine: -1.24% for morning insulin glargine, -0.96% for bedtime insulin glargine, and -0.84% for NPH insulin.

The other study, published in Diabetes Care in 2003, compared insulin glargine and NPH insulin when added to a treatment plan that already included oral therapy. After 24 weeks, 58% of participants randomized to bedtime insulin glargine achieved an HbA1c level of less than or equal to 7%, similar to the 57% of those taking bedtime NPH insulin. However, more participants (33%) taking insulin glargine achieved that goal without a single incident of hypoglycemia than did participants taking NPH insulin (27%).

The Bottom Line

The author of the 2004 review article, as well as another author in the same issue of The American Journal of Medicine, suggests that in treating people with type 2 diabetes, the ideal may be aggressive treatment to keep patients at an HbA1c level of less than 7% for life. In practical terms, for a newly diagnosed person with type 2 diabetes, the treatment plan might still follow the same pattern: lifestyle changes, followed by oral medications, followed by the addition of insulin. However, each step might be given only a few months to work; if the target HbA1c level is not reached, treatment would progress to the next step.

Many people are reluctant to begin insulin therapy, feeling that the change means they have failed or their diabetes will worsen. These and other obstacles—such as the fear of hypoglycemia, weight gain, or pain caused by the needles—are surmountable, suggests the author of the first review article mentioned above.

He adds, “Most importantly,…the concept of insulin as expected therapy in the management of type 2 diabetes should be introduced on diagnosis, whether or not the patient’s blood glucose levels at the time can be adequately controlled by other means. Better adherence and more successful outcomes will result when the erroneous idea that insulin therapy is a sign of failure or worsening disease is permanently dispelled.”


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The Diabetes White Paper from The Johns Hopkins White Papers series is an annual, in-depth report written by Hopkins physicians.



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