Response to type 2 diabetes: epidemiologic trends, evolving pathogenic concepts, and recent changes in therapeutic approach.

To the Editor: I recently read with interest the Rizvi article in the November issue of the Southern Medical Journal. (1) The author neatly outlined some important issues regarding epidemiology and pathophysiology of type 2 diabetes. A discussion about the treatment of this disease was also presented. Although the merits of combining insulin to oral therapy and basal-bolus therapy were discussed, I feel that the author omitted an important insulin regimen that is widely used in the treatment of patients with type 2 diabetes. Premixed insulins, particularly analog mixes, are among the most common startup therapies (2) used worldwide by both specialists and primary care physicians. Premixes, such as biphasic insulin aspart 30, comprise a soluble, rapid-acting portion of insulin, which acts to cover meal-time glucose excursions, and a longer-acting insulin, usually in the form of protaminated analog in these formulations, which means it is released slowly and can therefore cover basal insulin needs. Thus, postprandial glucose and fasting blood glucose, both of which contribute to overall glycemic control, are addressed and controlled in one injection.

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When premixed analogs are administered twice daily, many patients can achieve HbA1c targets set by leading diabetes authorities, such as the American Diabetes Association (HbA1c < 7%) (3) and International Diabetes Federation (HbA1c s 6.5%). (4) In a recently published trial, Raskin and colleagues (5) demonstrated that these HbA1c targets could be met with twice-daily biphasic insulin aspart 30 and that more patients met target than when they received once-daily glargine (Fig. 1). They also found that a significantly greater reduction in HbA1c was achieved compared with patients receiving once-daily glargine (-2.79 [+ or -] 0.11 versus -2.36 [+ or -] 0.11%, respectively; P < 0.01).

In summary, premixed analogs provide a convenient and flexible treatment option when initiating insulin in type 2 diabetes patients. Furthermore, such insulin preparations should always be considered alongside the other treatments available at this important step in the management of type 2 diabetes.

Jose Ramon Calle, MD

Servicio de Endocrinologia y Nutricion

Hospital Clinico San Carlos

Madrid, Spain

References

1. Rizvi AA, Type 2 diabetes: epidemiologic trends, evolving pathogenetic concepts, and recentchanges in therapeutic approach. South Med J 2004 97 1079-1087.

2. Mudaliar S. Edelman SV. Insulin therapy in type 2 diabetes. Endocrinol Metab Clin North Am 2001;30:935-982.

3. American Diabetes Association. Standards of Medical Care in Diabetes. Diabetes Care 2005;28:S4-36.

4. European Diabetes Policy Group. A desktop guide to type 2 diabetes mellitus. Diabet Med 1999;16:716-730.

5. Raskin P, Allen E, Hollander P, et al. Initiating insulin therapy in type 2 diabetes: a comparison of biphasic and basal insulin analogs. Diabetes Care 2005;28:260-265.