The number of people worldwide with diabetes is predicted to exceed 370 million by the year 2030. Over 90% of these will have type 2 diabetes with a twofold greater risk of heart disease and stroke than in the general population, and a reduction in life expectancy of five or more years.
Type 2 diabetes is a condition of relative insulin deficiency. Insulin secretory responses to meal challenges are delayed and prolonged and, although fasting insulin levels may be normal or elevated, they are insufficient to meet the metabolic demand or overcome the decreased insulin sensitivity which develops in many patients prior to diagnosis. Insulin is the oldest medication available for the treatment of diabetes and in many ways is a logical choice, providing hormone replacement therapy for an endocrine deficiency disease.
First-line therapy with a basal insulin in UKPDS was associated with a reduced risk of diabetic complications, with only modest weight gain (~2.5 kg over 10 years) and low levels of hypoglycaemia (~5% of patients per year). Early addition of basal insulin in UKPDS patients with fasting plasma glucose levels >6.0 mmol/l on maximum sulfonylurea therapy resulted in more of them achieving HbA1c levels <7.0% (<53 mmol/mol), with no greater weight gain and fewer hypoglycaemic episodes.
The recent treating to target in type 2 diabetes (4-T) trial confirmed that early addition of a basal insulin, in patients with inadequate glycaemic control on maximum metformin and sulfonylurea therapy, achieved similar or lower HbA1c values than adding biphasic or prandial insulin, and with less hypoglycaemia or weight gain. The ADA/EASD consensus algorithm for the management of hyperglycaemia in type 2 diabetes continue to recommend the addition of basal insulin to metformin therapy, or to metformin plus sulfonylurea therapy, whenever glycaemic targets are not met.
09 - 11 Nov 2011
British Society for Paediatric Endocrinology and Diabetes