More and more of our patients are developing diabetes, many of them at a much earlier age, so treatment has to be more focused and intense: the sooner this starts the better. This Special Edition brings you the background and basis for starting insulin therapy earlier.

Two leading endocrinologists, Dr. Stanley Schwartz and Dr. Aaron I. Vinik, gave us their thoughts on early insulin use in exclusive interviews, and we've added in comments from clinicians like you who see patients in a variety of settings to help you make the correct decision for your case. We've also included a feature on the Early Use of Insulin to Improve Beta Cell Preservation, covering the science of how early use of insulin preserves beta cells.

And check out our new Tools for your Practice: the Insulin Stability Charts provide your patients with the facts on how long their insulin will last once they open it, and a chart that gives you the information on when and how to start your patients on insulin.

Be sure to read the entire edition to take full advantage of all the information we have for you!

Diabetes In Control staff contacted several physicians all across the US to find out what they had to say about early insulin initiation. What they said may surprise you....

Stanley Schwartz, MD, FACP, FACE, shares his views on early insulin initiation.

Insulin is the most effective agent available for lowering glycemia. If given in appropriate doses, insulin may decrease any elevated HbA1c to, or close to, the therapeutic goal.

However, insulin therapy is associated with weight gain of 2 to 4 kg (e.g. 4 kg in ~10 years in UKPDS), which is proportional to the patient's caloric intake and reduction of glycosuria, that is, "storing the calories that otherwise would be excreted with the urine when they are hyperglycemic"....

One of the leading diabetes researchers in the world, Dr. Aaron I. Vinik, Director of Research and Neuroendocrine Unit, EVMS Strelitz Diabetes Research Center, shares his views on early insulin initiation.

The natural history of type 2 Diabetes (T2DM) is a progressive worsening of glycemic control as a consequence of progressive beta cell failure so that ultimately all patients with T2DM are equivalent to patients with type 1 DM and are insulin deficient. In addition the clock starts ticking for macrovascular complications such as heart attacks, strokes and peripheral vascular diseases before the advent of fasting or postprandial hyperglycemia indicating that there are, in addition to hyperglycemia, a host of risk factors conducive to macrovascular disease. In contrast, the glycemia milieu is the single most important determinant of microvascular complications such as retinopathy, nephropathy and neuropathy....

The advantages of insulin pens may reduce resistance to initiating and adhering to insulin therapy. Many patients resist insulin initiation due to concerns about complexity or a general resistance to injections; many patients' concerns about insulin initiation may stem from perceptions about the pain and inconvenience of using vials and syringes for delivering insulin; however, insulin pen devices are regarded as simpler, less painful, and more discreet in comparison with vials and syringes; advances in insulin pen technology have increased their accuracy, reduced the injection force required, and display the dose, time, and date of previous insulin injections; and substantial evidence demonstrates that insulin pen devices are preferred by both patients and clinicians and have the potential to improve adherence, enhance quality of life, reduce the risk of hyperglycemia, and decrease costs. Am J Ther. 2011 Sep;18(5):392-402.

By David Joffe, BSPharm, CDE; Steve Freed, BSPharm CPT; Brandon Flohr and Vanessa Cepero, PharmD candidates, LECOM College of Pharmacy

Type 2 diabetes is a heterogeneous disorder, characterized by glucotoxicity, beta cell dysfunction and decreased insulin sensitivity. Presence of amyloid deposits in the islets and decreased beta cell mass are the pathological hallmark of the disease.¹ Several clinical and experimental studies have clearly shown that even minimally preserved beta cell function is metabolically beneficial. This leads to lower HbA1C levels, lower insulin dosage and lesser metabolic decompensation after insulin withdrawal.

Approach to Use of Insulin Chart (pdf)

Use this concise and informative chart to help guide your determination of when and how to initiate insulin in your patients. Follow this link to download the Approach to Use of Insulin Chart (pdf).

Insulin Stability Charts

Use these two charts to determine the stability of different brands of insulin over time. The first chart covers vials and includes visuals to make identification easier. The second chart covers pens. Just follow this link to download these convenient and helpful charts (in pdf format).

Correction: Please note that a reader discovered an oversight on our part which has now been corrected in the version on our site.

Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath

Mrs. MJ was referred to a diabetes centre by her GP.  Mrs. MJ, a 60-year-old woman with type 2 diabetes since 2000, presents with...

Instructions and a simple case study regarding physiological insulin dosing based on pre-meal readings and carb counting....

In a current study it was found that there are certain barriers for physicians that prevent them prescribing insulin much earlier in the treatment of diabetes....