Early use of insulin in the management of type 2 diabetes--the time is now.

Recently the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) have published guidelines that describe a consensus approach to the management of hyperglycemia in patients with type 2 diabetes. (1) While effective weight loss, increased physical activity, and dietary control remain the pillars of therapy, the inability of many patients to successfully institute lifestyle changes and reach glycemic goals has prompted new recommendations from the leading professional groups. One of the hallmarks of the new recommendations is the earlier use of insulin therapy.

In this issue of the Journal, Meneghini describes in detail the rationale for this new approach. (2) In addition, he describes the principles of insulin therapy in patients with type 2 diabetes, reviews the newer insulins, and delineates practical steps for clinicians to institute earlier insulin therapy. The information in Meneghini's article should be read by everyone who treats patients with diabetes in primary care, so that earlier control of hyperglycemia can be achieved, and the microvascular and macrovascular complications of hyperglycemia can be reduced.

The first step in diabetes care is still lifestyle management. One of the great public health disappointments of current times is that so few of our patients follow a healthy lifestyle, despite the well-documented benefits. (3,4) Adhering to a Mediterranean diet, moderate alcohol use, physical activity, and nonsmoking are associated with a 65% lower risk of all-cause mortality and a similar reduction in cardiovascular disease. (5) In patients with diabetes, the benefits of diet and exercise are indeed well established. (6) However, due to the frequent failure of lifestyle management to achieve and maintain glycemic goals, metformin is recommended at the initiation of diabetes treatment.

Common current practice is to add a second oral agent when lifestyle plus metformin fails, and then to add a third oral agent if needed. The updated approach presented by Meneghini describes a more aggressive therapy algorithm that uses insulin treatment much earlier, right after lifestyle plus metformin. Why? The advantages include reduced glucose toxicity, less glucose variability, an improved cardiovascular profile, and lower mortality. Using insulin within a few months of diagnosis and initiation of therapy can have a long-term beneficial impact. Postponement of insulin following several years of suboptimal glycemic control leads to organ toxicity and cardiovascular disease. The details of these untoward consequences are outlined by Meneghini.

Clinicians who want to start insulin earlier and improve glycemic control in their patients face several barriers. In my experience, two of the biggest are fear of injection and anticipated weight gain. Patients' fear of injection can be overcome partly by emphasizing the availability of smaller and finer needles and more user-friendly delivery devices, such as disposable insulin pens. In-office demonstrations of insulin administration using these new devices, by either the physician, nurse, or certified diabetes educator, can dispel preconceived notions of pain and discomfort from needle injection. Although modest weight gain is often observed with insulin treatment during the first year, new long-acting insulin analogs such as insulin detemir can minimize such effects. As Meneghini points out, use of metformin with insulin therapy may also limit weight gain. The benefits of improved glycemic control should offset the impact of weight gain in most individuals.

Another barrier to earlier insulin use in everyday practice is that not all clinicians are knowledgeable and experienced with the newer insulins, their improved pharmacodynamics, and when to use the various types available. Meneghini describes the use of long-acting basal insulins, rapid-acting insulins, and the newer mixed insulins in detail. This guide for primary care clinicians on the early use of insulin treatment in type 2 diabetes is a welcome and timely addition to the literature. I salute the Journal for the publication of this excellent article, and Meneghini for his excellent work. A new era of treatment has dawned in type 2 diabetes, and our valued patients will be the beneficiaries.

References

1. Nathan DM, Buse JB, Davidson MB, et al. Management of hyperglycemia in type 2 diabetes: A consensus algorithm for the initiation and adjustment of therapy: a consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2006;29:1963-1972.

2. Meneghini L. Why and how to use insulin therapy earlier in the management of type 2 diabetes. South Med J 2007;100:164-174.

3. Tranche S, Galgo A, Mundet X, et al. Cardiovascular risk factors in type 2 diabetic patients: multifactorial intervention in primary care. Kidney Int 2005;93 (Suppl):S55-62.

4. Kurth T, Moore SC, Gaziano JM, et al. Healthy lifestyle and the risk of stroke in women. Arch Intern Med 2006;166:1403-1409.

5. Knoops KT, de Groot LC, Kromhout D, et al. Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: the HALE project. JAMA 2004;292:1433-1439.

6. Hamdy O, Goodyear LJ, Horton ES. Diet and exercise in type 2 diabetes mellitus. Endocrinol Metab Clin North Am 2001;30:883-907.

Dana E. King, MD, MS

From the Department of Family Medicine, Medical University of South Carolina, Charleston, SC.

Reprint requests to Dana E. King, MD, MS, Department of Family Medicine, Medical University of South Carolina, 295 Calhoun Street, Charleston, SC 29425. Email: [e-mail]

Accepted November 3, 2006.