A Real-World Approach to Insulin Therapy in Primary Care Practice

Irl B. Hirsch; Richard M. Bergenstal; Christopher G. Parkin; Eugene Wright; John B. Buse

doi:10.2337/diaclin.23.2.78

Departments

A Real-World Approach to Insulin Therapy in Primary Care Practice

Irl B. Hirsch, MD,
Richard M. Bergenstal, MD,
Christopher G. Parkin, MS,
Eugene Wright, Jr., MD and
John B. Buse, MD, PhD

Clinical Diabetes 2005 Apr; 23(2): 78-86. https://doi.org/10.2337/diaclin.23.2.78

Type 2 diabetes is a progressive disease characterized by relentless deterioration of pancreatic β-cell function.¹ With the increasing incidence of type 2 diabetes, especially among younger individuals who will live longer with their disease, more patients will develop severe insulin deficiency and require insulin replacement. Because primary care providers see the vast majority of patients with type 2 diabetes, they may soon find themselves overwhelmed with insulin-requiring patients.

This article provides some practical guidelines for initiating insulin therapy in primary care practice. It is important to remember, however, that these are general guidelines and that management should be individualized for each patient.

WHY INSULIN THERAPY?

Some primary care providers may be apprehensive about using insulin in patients with type 2 diabetes. Wallace and Matthews² have gone so far as to suggest that patients and providers have often “colluded in implicit and unspoken contracts to continue oral agents for as long as possible.”

Concerns about hypoglycemia and patient willingness and/or ability to inject insulin are good reasons why many providers may approach insulin therapy with caution. Compounding this reluctance is the perception that insulin therapy is too complex to manage in a busy primary care practice; prescribing information provided by manufacturers has been somewhat vague regarding initial dosing and titration. Because of these factors, providers may delay in making the necessary transition from oral agents to insulin. Indeed, recent evidence suggests that the hemoglobin A_1c (A1C) result that triggers glucose-lowering action is ≥ 9%.³ This is unfortunate because numerous studies have shown that excellent glycemic control can be achieved with insulin therapy in patients with type 2 diabetes.^4-7 Moreover, there is an increasing body of evidence showing that early and effective intervention with insulin is more important than had been previously believed.^8-10