Optimal insulin treatment for patients with type 2 diabetes: Basal or prandial insulin supplementation?

During the natural course of type 2 diabetes (T2D), insulin therapy is needed in order to maintain appropriate glycaemic control in a substantial part of patients. Although the definition theoretically is arbitrary, prandial and basal insulin could be used for insulin supplementation in clinical practice. To improve both prandial and basal insulin supplementation, short- and long-acting insulin analogues were recently developed. Clinical studies indicated that better prandial glucose control could be achieved by using short-acting insulin analogues, such as insulin lispro insulin, insulin aspart and glulisine than that observed by treatment with regular human insulin. Using new long-acting insulin analogues such as glargine or detemir, the risk of hypoglycaemia, especially nocturnal, could be decreased as compared with NPH insulin treatment. It is obvious that adequate prandial and basal insulin supplementation and nearly physiological insulin replacement could be carried out by using basal–bolus insulin therapy. Nevertheless, patients with T2D and stable lifestyle, or those who are unwilling to perform multiple daily insulin injections and blood glucose readings could sufficiently be treated by using premix human insulin preparations or more recently, by premix insulin analogues. Given the importance of clinical benefits of short-acting, long-acting and premix insulin analogues, the long-term effects of treatment with these relatively new insulin preparations are yet to be determined. Instead of the question whether basal or prandial insulin supplementation is more critical, the mode of treatment providing appropriate basal and prandial insulin supplementation is of importance. Using optimal insulin supplementation, all components of glucose triad (fasting glucose, postprandial glucose, HbA1c) should be targeted by proper management of patients with T2D.