When should insulin therapy be initiated in patients with diabetes?

From the Guidelines

Insulin therapy should be initiated in patients with type 2 diabetes when oral medications and lifestyle modifications fail to maintain adequate glycemic control, typically when HbA1c remains above 7-7.5% despite maximum oral therapy, or earlier if patients present with severe hyperglycemia (blood glucose >300 mg/dL), HbA1c >10%, or symptoms of hyperglycemia with weight loss, as recommended by the American Diabetes Association standards of medical care in diabetes 1.

Key Considerations for Insulin Initiation

• The decision to start insulin therapy should be based on the individual patient's needs and circumstances, taking into account factors such as the degree of hyperglycemia, the presence of symptoms, and the patient's overall health status.
• Initial insulin regimens often begin with basal insulin (like glargine, detemir, or NPH) at 0.1-0.2 units/kg/day, typically given at bedtime, with dose adjustments based on fasting glucose levels 1.
• More intensive regimens may include mealtime rapid-acting insulin (lispro, aspart, or glulisine) added to basal insulin, and the choice of insulin regimen should be individualized based on the patient's lifestyle, preferences, and needs.

Important Factors to Consider

• The progressive nature of type 2 diabetes should be regularly and objectively explained to patients, and providers should avoid using insulin as a threat or describing it as a sign of personal failure or punishment 1.
• Comprehensive education regarding self-monitoring of blood glucose, diet, and the avoidance of and appropriate treatment of hypoglycemia are critically important in any patient using insulin.
• The cost-effectiveness of different antihyperglycemic agents, including insulin, should be considered in a patient-centered approach to care, given the substantial increases in the price of insulin over the past decade 1.

From the Research

Initiating Insulin Therapy

Insulin therapy is a crucial aspect of managing diabetes, particularly for patients with type 2 diabetes (T2D) who have high HbA1c levels. The decision to start insulin therapy depends on various factors, including the patient's symptoms, HbA1c levels, and response to other treatments.

Guidelines for Initiating Insulin Therapy

• The American Association of Clinical Endocrinologists and the American Diabetes Association recommend considering insulin therapy for patients with T2D who have HbA1c levels exceeding 9.0% and 10%, respectively 2.
• The American Diabetes Association/European Association for the Study of Diabetes consensus statement suggests initial insulin therapy as an option when HbA1c ≥9% and definite consideration with HbA1c ≥10-12% 3.
• The Israeli guidelines recommend considering immediate, sometimes short-term, insulin treatment for patients with HbA1c >9% or with symptoms 3.

Benefits of Early Insulin Therapy

• Short-term intensive insulin (STII) therapy can quickly normalize glycemic control, improve β-cell function, and restore first-phase insulin secretion in newly diagnosed T2D patients 3.
• STII therapy has been shown to have beneficial effects on both β-cell function and insulin resistance, with a significant proportion of patients achieving drug-free remission 3.
• Early insulin therapy can also improve patient-reported quality of life and treatment satisfaction 3.

Considerations for Initiating Insulin Therapy

• The decision to start insulin therapy should be based on individual patient factors, including symptoms, HbA1c levels, and response to other treatments 2, 4.
• Healthcare providers should not delay the initiation and intensification of insulin unnecessarily, as this can lead to poor glycemic control and increased risk of complications 5.
• Patients should be educated on the importance of self-monitoring, diet, and exercise, and provided with structured education to support patient self-management 5.