Benefits of early initiation of insulin therapy to long-term goals in type 2 diabetes mellitus

Background:The natural history of type 2 diabetes mellitus (DM) includes a progressive worsening of glycemic control and accelerated cardiovascular risk. Aggressive glycemic control early in the course of the disease has the potential to significantly reduce the risk of DM-related microvascular and macrovascular complications.Objective:The purpose of this article was to present the rationale and evidence supporting early initiation of insulin therapy, even on a short-term basis, for the treatment of type 2 DM. The article also summarizes the current understanding of the impact of insulin therapy on this disease.Methods:English-language articles were identified primarily through searches of PubMed (1991–2005). Search terms included insulin, insulin therapy, early use, beta-cell, and type 2 diabetes.Results:Current algorithms for the treatment of patients with type 2 DM take a stepwise approach, beginning with the introduction of an oral antidiabetic agent and intensification of the oral regimen over time as the patient fails to achieve glycemic control. However, a lengthy stepwise approach with oral antidiabetic therapy alone is often inadequate and prolongs the patient's exposure to glucotoxic effects, which in turn contribute to microvascular and macrovascular complications. Conversely, early introduction of insulin therapy, even on a short-term basis, may alter the course of the disease and minimize its clinical sequelae. This approach is a reversal of the traditional treatment algorithm and places the emphasis on treatment success, as opposed to intensification based only on treatment failure. However, barriers to the initiation of insulin therapy on the part of the physician and the patient are pervasive.Conclusions:A fundamental change in the approach to DM management and attitudes toward the use of insulin for people with type 2 DM is necessary. Insulin should not be viewed as a treatment option of last resort. The initiation of insulin early in the course of disease may help patients achieve long-term glycemic control and improved quality of life.