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Achieving glycaemic targets with basal insulin in T2DM by individualizing treatment

Key Points

  • HbA1c goals should be individualized, particularly for patients who have a long history of type 2 diabetes mellitus, multiple comorbidities and a short life expectancy

  • Insulin should be added where needed to achieve glycaemic control, and insulin can be chosen as a second-line therapy after treatment failure of metformin

  • The primary goal of insulin replacement is to mimic a normal physiological insulin response, which consists of basal insulin between meals and a boost of insulin at mealtimes

  • Any type of insulin will lower HbA1c levels, but all types are associated with weight gain; risk of nocturnal and overall hypoglycaemia is lower for long-acting analogues than for neutral protamine Hagedorn insulin

  • As opposed to physician-driven instructions on increasing insulin dose, patients can be taught how to self-titrate insulin doses

  • Barriers to initiating insulin therapy include a wide range of obstacles relating to patients, providers and health-care systems

Abstract

Insulin therapy is an effective method for reducing blood glucose levels in patients with type 2 diabetes mellitus (T2DM), and most patients with T2DM eventually require insulin replacement to attain and preserve satisfactory glycaemic control. All patients with T2DM should be considered as potential candidates for intensive insulin treatment; however, there are certain considerations regarding replacement therapy for different types of people and special populations, such as patients with multiple comorbidities, adolescents, pregnant women and the elderly. Lowering HbA1c levels in isolation without assessing the patient as a whole is becoming redundant. HbA1c targets should be individualized to the specific patient, and insulin treatment ought to be customized accordingly. There are several questions that need to be taken into account when considering adding insulin therapy to other oral antidiabetic agents, for example, for whom and when insulin therapy is indicated and which basal insulin should be utilized. Potential barriers exist related to patients, providers and health-care systems that can delay the start of insulin therapy, and every effort should be made to identify and address these obstacles.

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Correspondence to Vivian A. Fonseca.

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Fonseca, V., Haggar, M. Achieving glycaemic targets with basal insulin in T2DM by individualizing treatment. Nat Rev Endocrinol 10, 276–281 (2014). https://doi.org/10.1038/nrendo.2014.17

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