Abstract

Type 2 diabetes mellitus is an inexorably progressive disease. Over time, as insulin resistance increases and beta cell function declines, treatment with injected insulin becomes necessary for most patients to maintain euglycemia. In the landmark United Kingdom Prospective Diabetes Study (UKPDS), 53% of the patients who were started on a sulfonylurea drug required insulin treatment within six years, which correlates with known secondary sulfonylurea failure rates of 5% to 10% per year. Early insulin treatment was found to improve glycemic control and prevent complications when maximal sulfonylurea treatment was inadequate.¹ Combination treatment with sulfonylurea plus other oral agents can delay progression to insulin dependence,²but the fact remains that most patients with type 2 diabetes will eventually require insulin and will suffer more complications if insulin is not started promptly when oral agents fail. This aspect of the natural history of type 2 diabetes has profound clinical and economic implications. About 120 million people worldwide were estimated to have type 2 diabetes in 2000; by 2010, the number may swell to 220 million.³ Among Hispanics, the prevalence of type 2 diabetes is twice that of non-Hispanic whites, and rates of end-stage renal disease and other serious complications are also significantly higher. Inadequate treatment for these patients as they progress to insulin dependence could seriously overburden our public health resources. It is therefore critical that physicians understand the many barriers—cultural, psychological, economic, and technical—that their patients face when advised to start insulin treatment.