A case for introducing insulin early in the treatment of type 2 diabetes mellitus

Background:Type 2 diabetes mellitus (DM) is characterized by insulin resistance and insulin deficiency. The majority of patients with type 2 DM will eventually require insulin therapy. The traditional paradigm for starting insulin has been to use it after therapy with oral antidiabetic agents has failed. However, changing this paradigm and introducing insulin therapy early in the course of treatment may have advantages beyond improving glycemic control.Objective:The goal of this article was to describe the rationale and potential benefits of using insulin therapy early in the course of type 2 DM.Methods:Materials used for this article were identified through a search of MEDLINE from 1966 to 2006. English-language articles were chosen using the search terms diabetes mellitus type 2, insulin resistance, and islets of Lanagerhans.Results:The pathogenesis of type 2 DM is characterized by 2 major processes: insulin resistance (which results in increased glucose Production by the liver and decreased glucose disposal by peripheral tissues) and a progressive irnpairment of β-cell function (which leads to a corresponding decline in insulin secretion with time). Studies in patients with newly diagnosed type 2 DM have shown that short-term intensive therapy with insulin that achieves near-normal glycemic control may lead to prolonged periods of good glycemic control, without the need for pharmacologic therapy. Early, aggressive use of insulin therapy may improve β-cell function, wrhich in turn could delay, halt, or even possibly reverse the natural progression of type 2 DM.Conclusions:With a more aggressive approach to starting and intensifying insulin therapy, patients may be more likely to achieve and maintain glycemic goals, thereby reducing the development of DM complications. Over time, this intervention may Icad to healthier and longer lives for patients with type 2 DM.