Achieving goal glycosylated hemoglobin levels in type 2 diabetes mellitus: Practical strategies for success with insulin therapy

Background:As the prevalence of diabetes mellitus (DM) continues to increase at an alarming rate, achieving glycosylated hemoglobin (AIC) target levels is crucial to prevent microvascular and macrovascular complications and to reduce the impact this disease has on individuals and society as a whole.Objective:This article discusses various approaches to intensive therapy, focusing on insulin regimens designed to mimic physiologic basal-bolus insulin secretion in type 2 DM, with the goal of helping patients with type 2 DM achieve normal glycemic control.Methods:Relevant articles were identified through a search of the English-language literature indexed on MEDLINE (1966-present) using the terms type 2 diabetes mellitus, glycemic control, glycosylated hemoglobin, postprandial hyperglycemia, insulin analogues, and continuous subcutaneous insulin pump therapy.Results:Patients with type 2 DM are often initially managed with diet modification, exercise, and oral antidiabetic agents; however, as β-cell function continues to decline, many of these individuals will require exogenous insulin supplementation. Because of the time-action profiles and large variability of the conventional insulins, including regular human and neutral protamine Hagedorn, their use makes it difficult to provide intensive treatment without significant risk of hypoglycemia, especially nocturnal hypoglycemia. The advent of recombinant DNA technology has allowed modification of the insulin molecule to produce insulin analogues with improved pharmacokinetic parameters. These new insulins that can more accurately simulate endogenous insulin secretion—along with advances in insulin pump technology, improved delivery devices, and frequent glucose monitoring—make intensive treatment regimens feasible for more patients than ever before. The mealtime insulin requirement can best be met through administration of a rapid-acting insulin analogue (such as insulin lispro, aspart, or glulisine) either by SC injection or as a bolus from an insulin pump. Basal insulin supplementation can best be achieved using injections of insulin glargine or detemir or through the use of a rapid-acting insulin analogue in an infusion pump.Conclusions:For patients with type 2 DM, every effort must be made to continue achieving target A1C goals, with frequent blood glucose monitoring in conjunction with oral therapy plus basal and bolus multiple daily injection regimens, BID mixed insulins, or the use of an insulin pump.