Initiating Insulin for Type 2 Diabetes

The classic setting for the use of insulin is in a newly diagnosed type 1 diabetic patient. However, insulin is more frequently used in the treatment of type 2 diabetes to compensate for the secretory defect that often progresses to a profound loss of insulin secretory reserve. This is suggested when FSG or HbA1c continue to rise despite the patient's best behavioral efforts and multiple oral drugs. A patient with type 2 diabetes can also present late in its course with marked hyperglycemia and even ketosis. In these patients, insulin treatment protocols used in type 1 diabetes are appropriate until the type 2 pattern of glucose homeostasis is recognized. In most patients, convenience insulins such as human or synthetic 70/30 or 75/25 combinations can be used for several days until the effects of behavioral measures and oral agents "kick in." Dosage is usually from 0.2 to 0.5

units (U)/kg body weight/day (in elderly patients, consider 0.1 U/kg/day). The initial dosage selected is a probe of insulin sensitivity and responsiveness, which will be informative in advising further adjustments in therapy. The dosage can be given before meals to offset postprandial hyperglycemia and at bedtime to control inappropriate overnight hepatic glucose production.

The oral drugs frequently used with insulin are the insulin-stimulating agents and metformin. With multiple therapies, the duration and peak actions of long-acting insulin preparations must be considered to avoid an overlapping effect and precipitous decline in glucose. This phenomenon may occur if multiple doses of insulin are necessary. Once FSG falls below 200 mg/dL, insulin therapy should be decremented to determine if oral drugs are effective and beta-cell functioning is recovering; continued indefinite insulin therapy may be indicated. In this case, basal bolus insulin regimens as described later may be required as ineffective oral drugs are discontinued.

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