More than 29 million adults in the United States are diagnosed with type 2 diabetes, and insulin therapy is estimated to be needed in up to 15% of cases. Insulin should be considered first-line treatment in patients with severe hyperglycemia (eg, A1C greater than 10%, blood glucose 300 mg/dL or higher), symptoms of hyperglycemia, or catabolism. To optimize insulin use in an outpatient setting, family physicians must consider strategies for initiation, titration, and adherence. The preferred starting regimen is basal insulin with stepwise intensification to prandial or premixed insulin. Insulin regimens can be titrated as frequently as every 2 to 3 days until blood glucose targets are reached. Long-acting insulin analogues offer improved duration of action and reduced risk of hypoglycemia compared with intermediate-acting insulin. Continuous glucose monitoring may improve diabetes control and can be considered in patients who need insulin. Weight gain, hypoglycemia, and insulin regimen complexity are key challenges in diabetes management. Family physicians should use individualized targets that consider life expectancy, age, medical comorbidities, and hypoglycemia risk. Insulin treatment remains a significant but complex aspect of managing type 2 diabetes.
In the United States, more than 29 million adults are diagnosed with type 2 diabetes.1 Prevention, early diagnosis, and proactive management are essential to reduce the risk of vascular, kidney, and neurologic complications.2,3 Type 2 diabetes is characterized by peripheral insulin resistance in skeletal muscle, adipose tissue, and the liver.2 Insulin resistance causes increased insulin demand with initial beta cell compensation followed by decompensation.4
WHAT'S NEW ON THIS TOPIC
| Out-of-pocket costs on many insulin products are now limited at approximately $35 per month due to federal legislation and changes to pricing by major insulin manufacturers. |
| A meta-analysis of 26 randomized controlled trials showed that continuous glucose monitors were associated with an average reduction in A1C of 0.19%. No evidence supports that the monitors improve patient-oriented outcomes (eg, lifestyle adjustments, hypoglycemic risk, cardiovascular events, mortality) in patients with type 2 diabetes. |
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
| Initiating insulin therapy with basal insulin should be considered to augment oral antihyperglycemic agents or as first-line therapy in patients with an A1C > 10%, blood glucose ≥ 300 mg/dL (16.65 mmol/L), or symptoms of hyperglycemia or catabolism.7,8 | C | Expert opinion and consensus guideline in the absence of clinical trials |
| A1C goals should be individualized based on multiple factors including age, life expectancy, medical comorbidities, patient goals, and risk of hypoglycemia. An A1C target < 6.5% may be appropriate in pregnant patients and in those who have fewer comorbidities, low hypoglycemia risk, or no known cardiovascular complications. Older adults with comorbid health conditions, poor functional status, limited life expectancy, and hypoglycemia risk should have an A1C goal of 8% or greater.9,11,12,14,15 | C | Consensus guidelines and cohort study |
| Long-acting insulin analogues are equally effective as human insulin in reducing A1C and offer a decreased risk of hypoglycemia.16,17 | C | Expert opinion and Cochrane review of randomized controlled trials on diabetes control and hypoglycemia |
| Consider initiation or continuation of glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors in patients with type 2 diabetes taking insulin. Insulin doses may need to be decreased when starting these medications to avoid hypoglycemia.8,40–44 | C | Consensus guideline, expert opinion, and studies on insulin requirements |
| Real-time continuous glucose monitors can be offered to patients with type 2 diabetes taking insulin therapy to improve glycemic control, but little evidence suggests that the monitors improve patient-oriented outcomes (eg, lifestyle adjustments, hypoglycemic risk, cardiovascular events, mortality).48,56 | C | Consensus opinion and multiple randomized controlled trials showing improved diabetes control |
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.
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