Insulin – myths and facts
Statement 1
Insulin is the last resort for patients with Type 2 diabetes
After initial metformin and sulfonylurea therapy, NICE and SIGN suggest a number of options
in the progressive treatment of hyperglycaemia in Type 2 diabetes1,2,3. Glitazones, dipeptidyl
peptidase-4 (DPP-4) inhibitors, glucagon like peptide (GLP)-1 analogues and sodium-glucose
co-transporter-2 (SGLT2) inhibitors may all be appropriate if insulin is considered unacceptable1,2.
Since Type 2 diabetes is a disease heterogeneous in pathogenesis and clinical manifestation,
choice of therapy should be individualised to the patient and take into account numerous factors
including patient choice, co-morbidities, baseline and personalised target level HbA1c
4.
As beta cell function declines over time, the need for replacement insulin will increase in order
to normalise hyperglycaemia5. Beta cell decline can occur due to a number of factors and the
rate of beta cell decline and the degree of insulin resistance will be different for each individual5.
Therefore the right time to commence insulin will differ in each individual5. Insulin should not be
seen as the last resort in optimising glycaemic control or as failure by the patient to control their
diabetes5. Insulin should be seen as an option in care to optimise glycaemic control to prevent
longer term complications5.
National studies have shown that there is an average delay of between six to seven years before
starting insulin in those with uncontrolled Type 2 diabetes6. Optimal control in Type 2 diabetes
reduces, in the long term, the risk of microvascular complications7. Evidence shows that if we
optimise glycaemic control earlier in the pathway, we can also protect beta cells for longer8.
Insulin is an important part of the treatment package and currently, there are so many different
types of insulins and regimens, that actually it’s not the last resort, it’s the beginning of a wide
range of further options5.
In clinical practice, insulin may be the most appropriate choice in the following circumstances:
1 Patients who have symptomatic hyperglycaemia e.g weight loss, polydipsia, polyuria,
blurred vision, recurrent infections or tiredness, or marked hyperglycaemia1,4,7.
2 Patients unable to control blood glucose levels despite dual therapy, who are markedly
hyperglycaemic and the patient agrees to start insulin1.
3 Patients who are unable to adequately control blood glucose levels despite triple therapy
with oral glucose lowering drugs2,9.
4 When other hypoglycaemic agents will not reduce baseline HbA1c to personalised
HbA1c levels5.
5 Patients who cannot tolerate/have allergies with non-insulin hypoglycaemic medication10.
6 Patients who are limited with other hypoglycaemic medication due to renal or hepatic
function decline11.
7 Patients who have progressive microvascular complications10,11.
8 When concomitant therapies that cause hyperglycaemia such as steroids are prescribed12
(depends on type of steroid please discuss with diabetes team).
9 Women who are pregnant or planning pregnancy10,11.
10 Where the patient preference is to start insulin10.
Statement 1
Insulin is the last resort for patients with Type 2 diabetes
After initial metformin and sulfonylurea therapy, NICE and SIGN suggest a number of options
in the progressive treatment of hyperglycaemia in Type 2 diabetes1,2,3. Glitazones, dipeptidyl
peptidase-4 (DPP-4) inhibitors, glucagon like peptide (GLP)-1 analogues and sodium-glucose
co-transporter-2 (SGLT2) inhibitors may all be appropriate if insulin is considered unacceptable1,2.
Since Type 2 diabetes is a disease heterogeneous in pathogenesis and clinical manifestation,
choice of therapy should be individualised to the patient and take into account numerous factors
including patient choice, co-morbidities, baseline and personalised target level HbA1c
4.
As beta cell function declines over time, the need for replacement insulin will increase in order
to normalise hyperglycaemia5. Beta cell decline can occur due to a number of factors and the
rate of beta cell decline and the degree of insulin resistance will be different for each individual5.
Therefore the right time to commence insulin will differ in each individual5. Insulin should not be
seen as the last resort in optimising glycaemic control or as failure by the patient to control their
diabetes5. Insulin should be seen as an option in care to optimise glycaemic control to prevent
longer term complications5.
National studies have shown that there is an average delay of between six to seven years before
starting insulin in those with uncontrolled Type 2 diabetes6. Optimal control in Type 2 diabetes
reduces, in the long term, the risk of microvascular complications7. Evidence shows that if we
optimise glycaemic control earlier in the pathway, we can also protect beta cells for longer8.
Insulin is an important part of the treatment package and currently, there are so many different
types of insulins and regimens, that actually it’s not the last resort, it’s the beginning of a wide
range of further options5.
In clinical practice, insulin may be the most appropriate choice in the following circumstances:
1 Patients who have symptomatic hyperglycaemia e.g weight loss, polydipsia, polyuria,
blurred vision, recurrent infections or tiredness, or marked hyperglycaemia1,4,7.
2 Patients unable to control blood glucose levels despite dual therapy, who are markedly
hyperglycaemic and the patient agrees to start insulin1.
3 Patients who are unable to adequately control blood glucose levels despite triple therapy
with oral glucose lowering drugs2,9.
4 When other hypoglycaemic agents will not reduce baseline HbA1c to personalised
HbA1c levels5.
5 Patients who cannot tolerate/have allergies with non-insulin hypoglycaemic medication10.
6 Patients who are limited with other hypoglycaemic medication due to renal or hepatic
function decline11.
7 Patients who have progressive microvascular complications10,11.
8 When concomitant therapies that cause hyperglycaemia such as steroids are prescribed12
(depends on type of steroid please discuss with diabetes team).
9 Women who are pregnant or planning pregnancy10,11.
10 Where the patient preference is to start insulin10.
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