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Starting Insulin Earlier Can Limit Weight Gain for Type 2 Diabetes

Early initiation of therapy hoped to reduce long-term morbidity, mortality by getting to goal earlier; potentially alter the natural history of the disease.

We have seen that basal insulin causes less weight gain than other insulin regimes.  In this prospective, multicenter analysis, we see data that suggests initiation of basal insulin therapy earlier on in disease duration may be beneficial for therapy on the grounds of concern over weight gain appears to be counter-productive. This is especially true given the potentially superior glycemic control also associated with early insulin initiation, further limiting weight gain. As such, prolonging the start of insulin.

Peter Bramlage, MD, of the Institute for Pharmacology and Preventive Medicine in Mahlow, Germany, and colleagues analyzed data from two groups of patients with type 2 diabetes diagnosed on or after Jan. 1, 2011, identified through the Diabetes Versorgungs-Evaluation (DIVE) registry, a German multicenter registry involving 200 physician offices specializing in type 2 diabetes. The first group included insulin-naive patients receiving basal insulin for the first time (n = 113; concomitant oral antidiabetic use was permitted); the second group included patients receiving their first oral antidiabetic therapy without simultaneous basal or short-acting insulin (n = 408).

Researchers found that, relative to baseline body weight, patients in the basal insulin group gained an average of 0.98 kg at 1 year vs. a loss of 1.52 kg for those not using insulin (P < .001); results persisted when expressed as a proportional change from baseline (P < .001).

In multivariable analysis, researchers observed that baseline weight (regression coefficient = 0.89; 95% CI, 0.81-0.97) and diabetes duration (regression coefficient = 2.52; 95% CI, 0.53-4.52) were the only factors that were predictors of weight gain between baseline and 1 year in the basal insulin group.

The researchers noted that the duration of diabetes before basal insulin therapy as an independent predictor of weight gain was “logical,” as early initiation would minimize HbA1c escalation and avoid the creation of a “BMI deficit.”

The researchers wrote that, “Despite disagreement over the direction of weight change, findings from prior and present studies suggest that shorter diabetes duration is associated with more favorable weight outcomes, and early initiation of basal insulin therapy may be advantageous

Many of these clinical case studies exemplify the diversity of patients who may benefit from early insulin initiation. Ultimately, it is hoped that early initiation of therapy will not only prevent weight gain and short-term complications, but also reduce long-term morbidity and mortality by getting to goal earlier and potentially alter the natural history of the disease. This latter concept is currently of intense interest. Although optimal disease management is patient-specific, achieving and maintaining tight glycemic control are the primary goals of therapy. Because many type 2 diabetes patients will eventually require insulin therapy, overcoming fears and therapeutic barriers to initiating therapy early as needed are essential for reducing the vascular comorbidities of this highly prevalent disease in patients of all ages. Fortunately, a number of new clinical tools are available, including both prandial and basal insulin analogs, new insulin-delivery devices, and an ever-improving knowledge of the pathophysiology and natural history of diabetes.

Practice Pearls:

  • All newly diagnosed type 2 patients should be educated as to the benefits of early initiation of insulin therapy.
  • Baseline weight and diabetes duration were the only factors that were predictors of weight gain between baseline and 1 year in the basal insulin group.
  • Duration of diabetes before basal insulin therapy as an independent predictor of weight gain was “logical,” as early initiation would minimize HbA1c escalation and avoid the creation of a “BMI deficit.”

PLOS Feb.2nd, 2017