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Title: Indications and Management Strategies for Insulin Therapy in the Treatment of Type 2 Diabetes

URL: http://www.postgradmed.com/issues/2003/06_03/3cooppan.htm

Postgrad Med 2003 Jun;113:6:59-64. "The changing model of insulin use in type 2 diabetes"
09/08/2003 04:05:52 PM
By Keely S. Solomon, PhD

Type 2 diabetes is a progressive disease, and constant monitoring is needed to maintain glucose control. Lifestyle modification and oral antihyperglycaemic drugs can be effective treatment options during early stages, but insulin therapy is often required as the disease advances. Designing a successful insulin treatment program can be complex, causing physicians and patients to be hesitant to start therapy. To address this concern, Ramachandiran Cooppan, MBChB, FRCP(C), of the Joslin Diabetes Center, Boston, Massachusetts, United States, has reviewed the indications for insulin use and outlined insulin management strategies for patients with type 2 diabetes. The American Diabetes Association goals for glucose control are a haemoglobin A1c level of less than 7%, a fasting glucose level between 90 and 130 mg/dL, and a post-prandial glucose concentration of less that 180 mg/dL. According to Dr. Cooppan, insulin therapy should be introduced when these goals can no longer be maintained through diet, exercise, and oral medications. Indications for starting insulin in type 2 diabetes include the following: newly diagnosed symptomatic type 2 diabetes with severe hyperglycaemia, poor glucose control despite maximal doses of a combination of oral medications, intercurrent illness or operation, pregnancy, renal disease, hepatic disease, and inability to tolerate oral antidiabetic medication. The patient may have concerns about adverse effects of insulin therapy, and Dr. Cooppan stresses the importance of addressing these fears. A frequent concern is that exogenous insulin may exacerbate cardiovascular risk factors, and the patient should be reassured that there is no good evidence supporting this idea. Duration of use should be considered when planning an insulin treatment program. Acute use may be required to reduce the adverse effects of glucotoxicity in newly diagnosed patients. In this situation, insulin can be used twice daily, starting at a dose of 0.5U/kg/24h. Long-term use may be indicated when maximal oral antidiabetic therapy has failed to achieve adequate control. In this case, insulin therapy can be initiated more gradually than in the acute situation. "The proper total daily doses of insulin depends on the patient's concurrent oral therapies, residual insulin secretory capacity, degree of insulin resistance, and ability and willingness to follow the therapeutic plan," writes Dr. Cooppan. Several other issues should also be considered. The initial insulin type should be chosen on the basis of blood glucose patterns, especially post-prandial concentrations. Goals should be customised for the patient based on their ability to participate in the treatment program. Regular follow-up is required to monitor progress and adjust doses, and support from a healthcare team should be considered for patients requiring a more intensive replacement program. "Healthcare providers caring for patients with this disease need to become more comfortable and skilled at starting and maintaining insulin therapy when it is clinically indicated," advises Dr. Cooppan.

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