Starting insulin in type 2 diabetes: Overcoming barriers to insulin therapy.
BACKGROUND
Several barriers to insulin therapy are encountered by both the providers and the patients with type 2 diabetes mellitus. These barriers include the fear of the needles i.e. number of injections as well as number of times of self blood glucose monitoring, fear of hypoglycemia and weight gain as well as the convenience, compliance and the cost. However, most of these patients are likely to require insulin therapy with increasing duration of the disorder because of the progressive cell failure. Therefore the most important aspect of insulin therapy must revolve around the regimen most suitable and acceptable because of its ability in overcoming these barriers while being effective in attaining and maintaining desirable glycemic control.


METHODS
Recently published studies using different regimens with combinations of various oral agents and insulins in patients with type 2 DM and manifesting lapse of glycemic control when treated with various oral agents are discussed. Specific attention is paid to the capacity of each individual regimen in overcoming aforementioned barriers.


RESULTS
Comparative analysis amongst various insulin regimens shows that combination of metformin, and glimeperide with SC administration of basal insulin Lantus required the least daily dose of insulin with least consequential hypoglycemia as well as weight gain. Moreover, the number of injections as well as the number of times of self blood glucose monitoring, were lesser with this regimen with better compliance and more convenience in comparison to other combination insulin regimens.


CONCLUSIONS
The insulin regimen with fewest barriers consists of one SC injection of basal insulin lantus in combination with oral agents. However, to be effective, oral agents must include a secretogogue i.e. glimeperide in addition to a sensitizer i.e. metformin and not multiple sensitizers without a secretogogue. Moreover, this regimen apparently is also the most preferred by the patients, and is cost effective.
Kabadi
Udaya M
UM
Department of Veterans Affairs, VAMC, Iowa City, IA and Roy and Lucille Carver College of Medicine, University of Iowa, Iowa City, IA, USA.