October - 26 - 2009
For patients with type 2 diabetes, the objective of using an insulin supplement is glycemic control and reducing microvascular disease as well as avoiding hypoglycemia and weight gain. In an editorial accompanying the Treat to Target in Type 2 Diabets (4-T) trial, which involved 708 patients assigned to one of three types of insulin treatments, Dr. Michael Roden points out that less than 45 percent of the patients in the study reached the glycated hemoglobin target of 6.5 percent or less. The basal regimen was least successful in the first year but effective after three, possibly because of a progressively increased insulin dose. Roden also notes that the proportions of patients who withdrew from the 4-T study were twice as high among the patients who received the prandial-plus-basal regimen as among those who received the biphasic regimen. This may not have affected the outcomes, but the regimen's complications and inconvenience may have contributed to the proportion of withdrawal. The study also only used insulin analogues, although most consensus statements regard regular human insulin as the first choice. "Finally, although intensive glucose control decreases the risk of microvascular complications, the duration of hypoglycemia may explain only a fraction of microvascular changes," notes Roden.