Insulin Treatment for Type 2 Diabetes—Reply

In Reply.—Our study found that "conventional insulin therapy" as managed by generalist physicians was very effective in achieving moderate glycemic control for patients who were previously in poor control but was relatively ineffective in achieving tight control in this setting. In our article, we discussed several possible explanations for this, none of which "blamed the drug." Our results also suggest that it is probably wrong to blame the physicians. There was no evidence that some physicians achieved better results than others, so they would all have to be equally inadequate. This seems unlikely, especially since they achieved levels of average glycemic control that were substantially better than those in most previous reports. Rather, we think it is most likely that for insulin therapy to achieve tight glycemic control for most patients, you will likely need very motivated patients, who are overrepresented in experimental trials, or will need to supply more support to physicians and patients to further aid the management of insulin beyond what can be achieved in 2 to 3 additional brief visits per year. As Drs Riddle and Karl point out, one possible implication of our results is that simpler, yet highly efficacious regimens (such as nocturnal insulin, daytime oral medications)¹ may be underused.