Starting insulin in type 2 diabetes

David Kinshuck


Targets for glucose control

When first starting insulin in type 2 diabetes, once daily insulins may be recommended, such as Degludec. If the diabetes is controlled with this regime, then the once daily injection may be enough. Dose of the insulin has to be increased until fasting sugars are controlled, and other sugars are controlled as opposite.


Once daily insulin not keeping target: twice daily mixtures

If the once daily injection does not work, then multiple dose insulin (MDI, basal bolus regime, flexible insulin regime) is needed. Multiple dose insulin injection treatment will help patients keep their target HbA1c and glucose levels, and thereby prevent diabetic retinopathy.

Many patients are offered twice daily insulin mixtures, but this is realy only ideal for older patents or for those who struggle with their diabetes, with a few exceptions. It often does not achieve the best control to stop the retinopathy progressing.

I and many others believe twice daily insulin is best reserved for patients with disabilities or very ill from diabetes, when tight diabetic control may be harmful. This is for both type1 and type 2 patients.

However, there is certainly a percentage of patients with type 2 diabetes who can be very well controlled with a twice daily insulin mixture, especially when insulin is begun for the first time.

Multiple dose insulin

Such complex insulin regimes do lead to better glucose control, fewer hypos, and better weight control than twice daily insulin (NEJM 2009). As treatment is changing so quickly, I have not discussed this here.