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Early Insulin Initiation in Type 2 Diabetes Is Essential 

May 9, 2020
 
Editor: David L. Joffe, BSPharm, CDE, FACA

Author: Taylor-Eugene Simmons, Florida A&M University, College of Pharmacy & Pharmaceutical Sciences, PharmD Candidate

The majority of patients with type 2 diabetes fail to maintain glycemic goals over time after initial success with standard interventions; would early insulin initiation help? 

At the Cardiometabolic Health Congress in Chicago, October 10-13th, 2019, Irl B. Hirsch, MD, professor of medicine at the University of Washington in Seattle, presented the theory of introducing insulin earlier to improve therapeutic outcomes in patients with type 2 diabetes. According to Hirsh, health providers who treat these patients need to include insulin amongst other antidiabetic medication options earlier in the treatment process. Hirsch stated that although insulin’s role was different than it was before the introduction of SGLT2 inhibitors and GLP-1 receptor agonists, it remains a vital part of treatment for type 2 diabetes.  

 

The majority of patients with type 2 diabetes fail to maintain glycemic goals over time after a successful initial response to therapy from weight reduction, diet, and oral medication (usually metformin). Adding a second- or third-line oral agent or an injectable, such as GLP-1 receptor agonists, SGLT2 inhibitors, or insulin are all therapeutic options to consider when needing to manage blood glucose. Intensive therapy of insulin was initially used in patients with type 1 diabetes. Insulin is also used in patients with type 2 diabetes if they have high A1c levels and for those who have become insulin deficient.   

Furthermore, A1c goals in patients with type 2 diabetes should be tailored to everyone, considering the reduction in microvascular complications with the risk of hypoglycemia and weight gain when initiating insulin. According to American Diabetes Association (ADA) guidelines, the target A1c goal for most patients with diabetes should be ≤7.0 percent, and insulin is recommended at an A1c of 9% and considered necessary greater than 10%.  

Insulin preparations are provided in three ways. Basal insulin with intermediate to longacting durations is used to suppress hepatic glucose production and maintain normal blood glucose levels during the fasting state. Examples include neutral protamine Hagedorn (NPH), neutral protamine lispro (NPL), glargine, detemir, and degludec. A prandial or pre-meal bolus insulin of short-acting (regular) or rapid-acting is used to cover foods that are ingested during mealtime. Examples of bolus insulins are lispro, aspart, and glulisine. Lastly, insulin can also be prepared as a pre-mixed combination of intermediate-acting and short-acting or rapid-acting insulin. 

During the presentation at Cardiometabolic Health Congress, Hirsch noted that insulin is being used in many people with type 2 diabetes. Still, insulin analogs are not easily accessible due to economic barriers. This brings about the propaganda of how-to best use insulin for those who can’t afford analog insulin. There is need to reexamine the order in which medications are selected for therapy to accomplish this goal. If cost is a significant issue, generic medications are recommended. Hirsch described that insulin is far from outdated and may be needed before second-line agents such as GLP-1 receptor agonists and SGLT2 inhibitors.  

According to Hirsch, when addressing hyperglycemia and high A1c levels, insulin should still be considered top choice since medications may take longer to show efficacy or may not be available due to financial issues. He proposed that incorporating insulin into the diabetes management plan earlier can reduce the risk of myocardial infarction and improve microvascular endpoints. He said that normally metformin is an appropriate first-line therapy, but if improvements are not made, insulin should be considered earlier and not last resort.  

Hirsch theorized that if a patients HbA1c is above 9% or 9.5% and they are having blood glucose readings often in the 300s, at least consider basal insulin, especially if they do not already have heart disease, heart failure or kidney disease. He questioned, why not consider basal insulin at least to get the glucose toxicity down to reduce glucose levels for a short period? 

Conversely, Hirsch explained the concern of hypoglycemic events with newer basal insulins like degludec (Tresiba, Novo Nordisk) and U300 glargine (Toujeo, Sanofi Aventis). There is also a more significant potential of hypoglycemia risks when in combination therapy with GLP-1 receptor agonist, that both perform complementary actions. Hirsch said that data had been accessed that more significant decreases in baseline HbA1c have been seen in patients taking basal insulin and a GLP-1 receptor agonist, which can lead to these hypoglycemic events. 

Initiating insulin earlier in diabetes therapy is not a guarantee for reaching HbA1c goals, mainly due to the hypoglycemic risk, weight gain, and higher baseline HbA1cs, but any lowering possibilities are helpful. Hirsh believes that if health care professionals should ensure that all patients have improved access to insulin and other diabetes medications, patients can gain great benefit. 

Practice Pearls: 

  • According to Irl B. Hirsch, at the Cardiometabolic Health Congress, insulin should be initiated earlier in therapy for type 2 diabetes.  
  • Hirsch stated that insulin is being used in many patients with type 2 diabetes, but insulin preparations are not easily accessible due to economic barriers. 
  • Health care professionals should ensure that all patients have access to insulin and other diabetes medications. 

 

References for “Early Insulin Initiation in Type 2 Diabetes Is Essential”:

Hirsch IB. Navigating Insulin Management in Patients with T2DM. Presented at: Cardiometabolic Health Congress; Oct. 10-13, 2019; Chicago. 

October 12, 2019. “Earlier Introduction of Insulin May Improve Type 2 Diabetes Care for Some Patients.” Healio, Endocrine Today, https://www.healio.com/endocrinology/diabetes/news/online/{9d634a78-e657-4424-acc3-e79f703db5e5}/earlier-introduction-of-insulin-may-improve-type-2-diabetes-care-for-some-patients. 

 

Taylor-Eugene Simmons, Florida A&M University, College of Pharmacy & Pharmaceutical Sciences, PharmD Candidate 

 

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