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Insulin Therapy for Type 2 Diabetes Mellitus

Amisha Wallia, MD, MS1; Mark E. Molitch, MD1
[+] Author Affiliations
1Division of Endocrinology, Metabolism, and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
JAMA. 2014;311(22):2315-2325. doi:10.1001/jama.2014.5951.
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Published online

Importance  The incidence and prevalence of type 2 diabetes mellitus are increasing.

Objective  To review currently available insulin therapy, as well as evidence on the use, application, initiation, and intensification of insulin in the outpatient setting.

Evidence Review  Data sources included PubMed for trials and investigations in type 2 diabetes examining insulin use from January 1998 to April 2014.

Findings  The hemoglobin A1c target for most patients with type 2 diabetes is 7% but needs to be modified when there is increased risk of hypoglycemia, reduced life expectancy, extensive comorbidities, or reduced resources. Insulin therapy may be considered early or late in the disease course; adverse effects include weight gain and hypoglycemia. Basal insulin can be added to oral hypoglycemic agents (generally stopping sulfonylureas) initially, and later, prandial insulin can be added in a stepwise fashion. Insulin treatment must be individualized, and there are a number of challenges to insulin initiation and intensification.

Conclusions and Relevance  Insulin can help achieve ideal hemoglobin A1c goals for patients with type 2 diabetes. Barriers such as adherence, patient preferences, clinician preferences, and resource allocation must be addressed.

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Figure 1.
Initial Publication Search, 2008-2014

aTrials were examined for safety outcomes if they were large randomized clinical trials in diabetes mellitus and had adult patient populations, blind assessment, and prespecified outcomes and reported results from January 1998 to April 2014.bThe appendixes of all 7 randomized trials were reviewed.

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Figure 2.
Subsequent Publication Searches, 1998-2014

FDA indicates US Food and Drug Administration.

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Figure 3.
Suggested Algorithm for Initiating Insulin in Patients With Type 2 Diabetes

This suggested approach has not been validated in randomized trials. HbA1c indicates hemoglobin A1c; GLP-1, glucagon-like peptide 1; SGLT-2, sodium glucose cotransporter 2; and DPP-4, dipeptidyl peptidase 4.

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