Starting insulin in type 2 diabetes

David Kinshuck


Targets for glucose control

When first starting insulin in type 2 diabetes, once daily Levemir (detemir) or Lantus (glargine) long acting insulins may be recommended. 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. NEJM 09.

Many patients are offered twice daily insulin mixtures. If control is good with a twice daily regime then such departments advise patients to continue to use twice daily insulin, then this is reasonable. But often, whilst they may be effective for a while, they do not keep the diabetes controlled for long.

Therefore, for everyone not controlled on twice daily insulin mixtures, unless they are very elderly or are in very poor health, this author and many others do not recommend twice daily mixtures.  Multiple dose regimes over more flexibility and better control for many people.

At present many people in the UK are using twice daily insulin treatment, and this study indicated they have 3 times the chance of developing retinopathy, renal failure, and neuropathy compared to patients using MDI.

Of course, if you are using multiple dose insulin, you will need to test your sugar and adjust your insulin dose to achieve good control. The best insulin injection regime at present is based on twice daily Levemir and a rapid acting insulin, and is covered here: lantus dose & rapid acting.

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

See. Such complex insulin regimes do lead to better glucose control, fewer hypos, and better weight control than twice daily insulin (NEJM 2009).