Insulin analogs or premixed insulin analogs in combination with oral agents for treatment of type 2 diabetes.

CONTEXT: Type 2 diabetes is a progressive disease that is reaching epidemic proportions. Whereas most patients are initially managed with oral antidiabetic agents (OADs), the majority eventually require insulin to maintain glycemic control. The availability of insulin analogs (rapid-acting, long-acting, and premixed), with more predictable time-action profiles than human insulin preparations and simple-to-use insulin delivery devices, can help ease the transition to insulin therapy, which is often delayed until glycemic control has been inadequate for several years.

OBJECTIVE: To review the rationale for and strategies to initiate therapy with insulin analogs earlier in the course of type 2 diabetes. Practical barriers that must be overcome to successfully initiate insulin therapy in patients with type 2 diabetes are also briefly described.

DESIGN: Narrative review of clinical evidence and current diabetes treatment guidelines.

SETTING AND PATIENTS: Outpatients with type 2 diabetes inadequately managed with OADs alone.

INTERVENTIONS: Three of the most common approaches to initiating insulin therapy with analogs are considered, with clinical evidence and detailed dosing algorithms provided. These approaches include: (1) addition of a basal insulin analog to oral therapy to reduce and stabilize fasting plasma glucose, (2) supplementation of oral therapy with a rapid-acting mealtime insulin analog to control postprandial glucose excursions, and (3) addition of or switching to a premixed insulin analog, which can be used to control both fasting and postprandial glucose in 1 injection.

CONCLUSIONS: Selection of appropriate insulin analog regimens and individualization of therapy can help patients achieve recommended glycemic goals while minimizing hypoglycemia. Education about the eventual need for insulin and improvements in insulin preparations and delivery systems at the time of diagnosis can also help overcome patient barriers.