Insulin intensification for people with type 2 diabetes: a practical approach
Fulcher, G and Colagiuri, S and Phillips, P and Prins, J and Sinha, A and Twigg, S and Dalton, BS, Insulin intensification for people with type 2 diabetes: a practical approach, The Australasian medical journal, 3, (12) pp. 808-813. ISSN 1836-1935 (2010) [Refereed Article]
Background: Type 2 diabetes is a progressive disorder and
with time, it is appropriate for insulin therapy to be initiated in
the majority of people. Insulin is commonly initiated with
once-daily basal insulin. However, when glycaemic control
becomes unsatisfactory despite the introduction of basal
insulin, no clear guidelines exist for intensifying the insulin
regimen. In this article we aim to provide a clinicianís
approach to both the optimisation of the basal insulin dose,
and strategies to intensify insulin therapy.
Methods: An expert consensus panel, consisting of the
authors, was convened to review the current practice of
insulin intensification in people with type 2 diabetes and to
develop a pragmatic algorithm for clinicians. The panel
reviewed the published literature on the use of insulin in
clinical practice, the evidence for different intensification
strategies, and the potential impact of patient-related factors
on insulin choices.
Results: Insulin intensification should only be considered
after the basal insulin dose has been optimised. This is
achieved by taking into account basal and prandial (pre
and post) blood glucose levels, individualised target
HbA1c, and dietary factors. If optimal basal insulin
together with oral medications is not sufficient to reach
glycaemic targets, the next step is to introduce a basal
plus 1 regimen or switch to twice-daily premixed insulin.
Each has advantages and disadvantages and existing
guidelines do not emphasise or support any particular
regimen. Therefore, it is important to individualise the
choice according to the individualís needs. A practical
algorithm has been developed to help clinicians choose an
appropriate second-line regimen.
Conclusion: As beta-cell failure progresses in people with
type 2 diabetes, basal insulin regimens need to be
optimised and then intensified when necessary to
maintain agreed glycaemic targets.