For the integrated multidisciplinary approach to patient care

Return to the Southern Medical Journal

Current User S2 Access Level: -1 ()
CAN NOT ACCESS LEVEL 2
Review Article

Treating the Whole Patient for Optimal Management of Type 2 Diabetes: Considerations for Insulin Therapy

Carlos Campos, MD, MPH
Volume: 100 Issue: 8 August, 2007

Abstract:

Primary care physicians are responsible for providing healthcare to most patients with type 2 diabetes. In this role, it is critical that physicians utilize a whole-patient treatment approach that includes lifestyle modifications and pharmacotherapy aimed to achieve glycemic control, in addition to the management of any comorbid conditions or risk factors for cardiovascular complications of diabetes. Due to the progressive nature of the disease, most patients with type 2 diabetes will eventually require insulin to achieve and maintain glycemic control, because of both increased insulin resistance and diminished secretory capacity of the pancreatic β cells. Thus, physicians need to be knowledgeable about and comfortable with the use of insulin, as well as with educating patients and discussing any potential barriers to insulin therapy. The use of a stepwise approach—beginning with basal insulin therapy and adding prandial insulin if necessary—is simple, effective, and appropriate for use in many patients.


Key Points


* Traditional treatments for diabetes involve diet and exercise, followed by 1 or more oral antidiabetic medications to achieve glycemic control.


* Most patients with type 2 diabetes eventually will require insulin, due to the progressive nature of the disease, which results in both increasing insulin resistance and diminishing secretory capacity of the insulin-producing β cells.


* Basal insulin therapy with a long-acting insulin (such as insulin glargine) can help patients with type 2 diabetes improve their overall glycemic control and achieve recommended glycosylated hemoglobin A1c goals (ie <7.0%), thereby reducing the risk of diabetic complications and improving quality of life.


* Education of patients about proper self-monitoring of blood glucose, in conjunction with discussions of how to recognize, avoid, and treat the symptoms of hypoglycemia, may be helpful in addressing the fear of hypoglycemia as a potential barrier to treatment.


* It is important to explore the potential barriers to treatment with each patient and enlist family members to help encourage the patient to accept and adhere to the treatment regimen.

Article:

This content is limited to qualifying members. Please click on an option below to view in full. Click here to compare all member plans.

Login

Silver/Gold members login for full access. Other members login to view purchase options.

Create a New Account

Create a new complimentary account/login to view purchase options.

Images:

This content is limited to qualifying members. Please click on an option below to view in full. Click here to compare all member plans.

Login

Silver/Gold members login for full access. Other members login to view purchase options.

Create a New Account

Create a new complimentary account/login to view purchase options.

References:

1. Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2005. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2005.
 
2. American Diabetes Association. Diabetes statistics for African Americans. Available at: http://www.diabetes.org/diabetes-statistics/african-american.jsp. Accessed April 8, 2007.
 
3. Skyler JS, Oddo C. Diabetes trends in the USA. Diabetes Metab Res Rev 2002;18(suppl 3):S21–S26.
 
4. Pinhas-Hamiel O, Zeitler P. The global spread of type 2 diabetes mellitus in children and adolescents. J Pediatr 2005;146:693–700.
 
5. DeWitt DE, Hirsch IB. Outpatient insulin therapy in type 1 and type 2 diabetes mellitus: scientific review. JAMA 2003;289:2254–2264.
 
6. Gæde P, Pedersen O. Multi-targeted and aggressive treatment of patients with type 2 diabetes at high risk: what are we waiting for? Horm Metab Res 2005;37(suppl 1):76–82.
 
7. Wingard DL, Barrett-Connor E. Heart disease and diabetes. In: Harris MI, Cowie CC, Stern MP, Boyko EJ, Reiber GE, Bennett PH, et al (eds). Diabetes in America. 2nd ed. Washington, DC, National Institutes of Health, 1995: pp. 429–448.
 
8. American Association of Clinical Endocrinologists. State of diabetes in America [press release] Available at: http://www.aace.com/newsroom/press/2005/index.php?r=20050510. Accessed April 8, 2007.
 
9. Saydah SH, Fradkin J, Cowie CC. Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes. JAMA 2004;291:335–342.
 
10. American Diabetes Association. Standards of medical care in diabetes: 2006. Diabetes Care 2006;29(suppl 1):S4–S42.
 
11. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998;352:837–853.
 
12. Harris MI, Klein R, Cowie CC, et al. Is the risk of diabetic retinopathy greater in non-Hispanic blacks and Mexican Americans than in non-Hispanic whites with type 2 diabetes? A US population study. Diabetes Care 1998;21:1230–1235.
 
13. Hamman RF, Marshall JA, Baxter J, et al. Methods and prevalence of non-insulin-dependent diabetes mellitus in a biethnic Colorado population: the San Luis Valley Diabetes Study. Am J Epidemiol 1989;129:295–311.
 
14. Hamman RF, Franklin GA, Mayer EJ, et al. Microvascular complications of NIDDM in Hispanics and non-Hispanic whites: San Luis Valley Diabetes Study. Diabetes Care 1991;14:655–664.
 
15. Cruickshank JK, Alleyne SA. Black West Indian and matched white diabetics in Britain compared with diabetics in Jamaica: body mass, blood pressure, and vascular disease. Diabetes Care1987;10:170–179.
 
16. American Diabetes Association. Standards of medical care in diabetes. Diabetes Care 2005;28(suppl 1):S4–S36.
 
17. Rohlfing CL, Wiedmeyer H-M, Little RR, et al. Defining the relationship between plasma glucose and HbA1c: analysis of glucose profiles and HbA1c in the Diabetes Control and Complications Trial. Diabetes Care 2002;25:275–278.
 
18. Dailey G. A timely transition to insulin: identifying type 2 diabetes patients failing oral therapy. Formulary 2005;40:114–130.
 
19. Inzucchi SE. Oral antihyperglycemic therapy for type 2 diabetes: scientific review. JAMA 2002;287:360–372.
 
20. DeFronzo RA. Pharmacologic therapy for type 2 diabetes mellitus. Ann Intern Med 1999;131:281–303.
 
21. Willett LL, Albright ES. Achieving glycemic control in type 2 diabetes: a practical guide for clinicians on oral hypoglycemics. South Med J 2004;97:1088–1092.
 
22. Turner RC, Cull CA, Frighi V, et al. Glycemic control with diet, sulfonylurea, metformin, or insulin in patients with type 2 diabetes mellitus: progressive requirement for multiple therapies (UKPDS 49). JAMA 1999;281:2005–2012.
 
23. UK Prospective Diabetes Study Group. UK Prospective Diabetes Study 16: overview of 6 years' therapy of type II diabetes: a progressive disease. Diabetes 1995;44:1249–1258.
 
24. Wright A, Burden ACF, Paisey RB, et al. Sulfonylurea inadequacy: efficacy of addition of insulin over 6 years in patients with type 2 diabetes in the UK Prospective Diabetes Study (UKPDS 57). Diabetes Care 2002;25:330–336.
 
25. Yale J-F, Valiquett TR, Ghazzi MN, et al. The effect of a thiazolidinedione drug, troglitazone, on glycemia in patients with type 2 diabetes mellitus poorly controlled with sulfonylurea and metformin: a multicenter, randomized, double-blind, placebo-controlled trial. Ann Intern Med 2001;134:737–745.
 
26. Hirsch IB. Insulin analogues. N Engl J Med 2005;352:174–183.
 
27. Heine RJ, Van Gaal LF, Johns D, et al. Exenatide versus insulin glargine in patients with suboptimally controlled type 2 diabetes: a randomized trial. Ann Intern Med 2005;143:559–569.
 
28. Carroll MF, Izard A, Riboni K, et al. Fasting hyperglycemia predicts the magnitude of postprandial hyperglycemia: implications for diabetes therapy. Diabetes Care 2002;25:1247–1248.
 
29. Lepore M, Pampanelli S, Fanelli C, et al. Pharmacokinetics and pharmacodynamics of subcutaneous injection of long-acting human insulin analog glargine, NPH insulin, and ultralente human insulin and continuous subcutaneous infusion of insulin lispro. Diabetes 2000;49:2142–2148.
 
30. Fritsche A, Schweitzer MA, Häring HU. Glimepiride combined with morning insulin glargine, bedtime neutral protamine Hagedorn insulin, or bedtime insulin glargine in patients with type 2 diabetes: a randomized, controlled trial. Ann Intern Med 2003;138:952–959.
 
31. Yki-Järvinen H, Dressler A, Ziemen M. HOE 901/3002 Study Group: less nocturnal hypoglycemia and better post-dinner glucose control with bedtime insulin glargine compared with bedtime NPH insulin during insulin combination therapy in type 2 diabetes. Diabetes Care 2000;23:1130–1136.
 
32. Rašlová K, Bogoev M, Raz I, et al. Insulin detemir and insulin aspart: a promising basal-bolus regimen for type 2 diabetes. Diabetes Res Clin Pract 2004;66:193–201.
 
33. Riddle MC, Rosenstock J, Gerich J, et al, on behalf of the Insulin Glargine 4002 Study Investigators. The Treat-to-Target Trial: randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients. Diabetes Care 2003;26:3080–3086.
 
34. Ryysy L, Yki-Järvinen H, Hänninen J. Simplifying treat to target - the LANMET study. In: Program and abstracts of the 40th European Association for the Study of Diabetes Annual Meeting. September 5–9, 2004; Munich, Germany. Abstract 749.
 
35. Massi Benedetti M, Humburg E, Dressler A, et al. A one-year, randomised, multicentre trial comparing insulin glargine with NPH insulin in combination with oral agents in patients with type 2 diabetes. Horm Metab Res 2003;35:189–196.
 
36. Rosenstock J, Schwartz SL, Clark CM Jr, et al. Basal insulin therapy in type 2 diabetes: 28-week comparison of insulin glargine (HOE 901) and NPH insulin. Diabetes Care 2001;24:631–636.
 
37. Miller CD, Phillips LS, Ziemer DC, et al. Hypoglycemia in patients with type 2 diabetes mellitus. Arch Intern Med 2001;161:1653–1659.
 
38. Monnier L, Lapinski H, Colette C. Contributions of fasting and postprandial plasma glucose increments to the overall diurnal hyperglycemia of type 2 diabetic patients: variations with increasing levels of HbA1c. Diabetes Care 2003;26:881–885.
 
39. Dailey G, Rosenstock J, Moses R, et al. Glycemic control with insulin glulisine versus regular human insulin in a basal-bolus regimen in patients with type 2 diabetes. In: Program and Abstracts of the American Diabetes Association 64th Annual Scientific Sessions. June 4–8, 2004; Orlando, FL.
 
40. Hunt LM, Valenzuela MA, Pugh JA. NIDDM patients' fears and hopes about insulin therapy: the basis of patient reluctance. Diabetes Care 1997;20:292–298.
 
41. Meneghini LF, Wick AK, Delamater AM, et al. Group-based self-management intervention for intensification of insulin therapy. In: Program and Abstracts of the American Diabetes Association 63rd Annual Scientific Sessions. June 13–17, 2003; New Orleans, LA. Abstract 131–OR.
 
42. American Diabetes Association. Por tu familia: la diabetes y los latinos. Available at: http://www.portufamilia.org. Accessed April 8, 2007.
 
43. Heuer L, Hess CW, Klug MG. Meeting the health care needs of a rural Hispanic migrant population with diabetes. J Rural Health 2004;20:265–270.
 
44. TIPHER: The Institute for Public Health and Education Research. Available at: http://www.tipher.com/index.htm. Accessed April 8, 2007.
 
45. American College of Endocrinology Consensus Statement on Guidelines for Glycemic Control. Endocr Pract 2002;8(suppl 1):5–11.
 
46. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA2003;289:2560–2572.
 
47. National Cholesterol Education Program. Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III): Final Report. Washington, DC: US Department of Health and Human Services, National Institutes of Health. September 2002. NIH Publication No. 02-5215.
 
48. Levemir [package insert]. Princeton, Novo Nordisk Inc, 2005.
 
49. Apidra [package insert]. Kansas City, Aventis Pharmaceuticals Inc, 2004.
 
50. Exubera [package insert]. New York, Pfizer Inc, 2006.

CME:

Portions of this issue may be available for CME credit. Please email education@sma.org for a complete listing of current Southern Medical Journal activities, as well as other SMA educational offerings.

This content is limited to qualifying members. Please click on an option below to view in full. Click here to compare all member plans.

Login

Silver/Gold members login for full access. Other members login to view purchase options.

Create a New Account

Create a new complimentary account/login to view purchase options.

This content is limited to qualifying members. Please click on an option below to view in full. Click here to compare all member plans.

Login

Silver/Gold members login for full access. Other members login to view purchase options.

Create a New Account

Create a new complimentary account/login to view purchase options.

Permissions