Insulin intensification for people with type 2 diabetes: a practical approach

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 clinician’s 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 individual’s 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.