Starting insulin in type 2 diabetes
Once daily insulin
| Targets for glucose control |
When first starting insulin in type 2 diabetes, once daily Levemir (detemir)
or Lantus (glargine) long acting insulins may be recommended. If the diabetes
is controlled with
this regime, then the once daily injection may be enough. Dose of the insulin
has to be increased until fasting sugars are controlled, and other sugars
are controlled as opposite.
The dose increase plan is discussed www.lantus.com/hcp/dosing.aspx.
Once daily insulin not keeping target: twice daily mixtures
If the once daily injection does not work, then multiple dose insulin (MDI, basal bolus regime,flexible insulin regime) is needed. Multiple dose insulin injection treatment will help patients keep their target HbA1c and glucose levels, and thereby prevent diabetic retinopathy. NEJM 09.
Many patients are offered twice daily insulin mixtures. If control is good with a twice daily regime then such departments advise patients to continue to use twice daily insulin, then this is reasonable. But often, whilst they may be effective for a while, they do not keep the diabetes controlled for long.
Therefore, for everyone not controlled on twice daily insulin mixtures, unless they are very elderly or are in very poor health, this author and many others do not recommend twice daily mixtures. This is Good Hope evidence, this is the published evidence (for type 2 diabetes) , also here, but others dispute the benefit of multiple dose injection therapy. There are other Russian studies also.
At present many people in the UK are using twice daily insulin treatment, and this study indicated they have 3 times the chance of developing retinopathy, renal failure, and neuropathy compared to patients using MDI.
Of course, if you are using multiple dose insulin, you will need to test your sugar and adjust your insulin dose to achieve good control. The best insulin injection regime at present is based on twice daily Levemir and a rapid acting insulin, and is covered here: lantus dose & rapid acting.
I and many others believe twice daily insulin is best reserved for patients with disabilities or very ill from diabetes, when tight diabetic control may be harmful. This is for both type1 and type 2 patients.
However, there is certainly a percentage of patients with type 2 diabetes who can be very well controlled with a twice daily insulin mixture, especially when insulin is begun for the first time.
Multiple dose insulin
See. Such complex insulin regimes do lead to better glucose control, fewer hypos, and better weight control than twice daily insulin (NEJM 2009).
ACCORD study
Severe hypos do increse risk of death BMJ 10 and BMJ 10 and these are commoner if control is poor.