Volume 1 number 1 Summer 2003
Special issue for the abstracts of the 7th Pan Arab Conference on Diabetes
PACD7 , 25 – 28 March 2003 Cairo

Abstract Number : 35
Insulin Treatment of Type 2 Diabetes: New Regimens, New Techniques

Christopher D. Saudek, M.D.

The natural history of type 2 diabetes is for patients to become increasingly insulin-deficient over the years, with insulin resistance remaining. The UKPDS gave evidence, in fact, that by the time type 2 diabetes is diagnosed, insulin secretory reserve is as much a 50% reduced. Therefore, clinicians can count on the fact that the longer a person has had type 2 diabetes, the less responsive they will be to diet, exercise and oral agents, and the more likely it is that they will need insulin. 

Starting insulin therapy in a person with type 2 diabetes may mean overcoming a difficult psychological barrier, but relative to type 1 diabetes it should be therapeutically less challenging. A bedtime dose of long-acting insulin is often the simplest first step, using the fasting blood glucose as an indication of efficacy. Glargine insulin provides a smoother, longer-lasting approach to once-a-day injection, and has been used successfully with type 2 diabetes, causing less nocturnal hypoglycemia than is the case with NPH insulin given at bedtime. While oral agents can be continued along with a single nighttime dose of insulin, the insulin regimen may need to be intensified over time, depending on daytime blood glucose results. Short-acting insulin secretagogues such as nateglinide or rapeglinide may be tried or pre-meal short-acting insulin. 

New regimens are being developed, and few have been tested in head-to-head randomized trials. But two main lessons stand out in the treatment of type 2 diabetes: glycemic control requires aggressively increasing therapy over the years; and glycemic control is not enough—treatment of other risk factors and other conditions may be equally or more important.

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