No Need for the Needle (at First)

I n this issue of Diabetes Care, Chen et al. (1) describe an approach to the initial treatment of newly diagnosed type 2 diabetic patients with severe hyperglyce-mia (fasting plasma glucose [FPG] concentrations Ͼ300 mg/dl or random plasma glucose concentrations Ͼ400 mg/ dl) entailing intensive insulin therapy during 10 to 14 days of hospitalization. Following this, half of the patients were randomized to continued insulin treatment and the other half to oral antidiabe-tes drugs (OAD), starting with metformin in overweight and obese patients and a sulfonylurea (SU), gliclazide, in lean patients. If satisfactory control was not obtained with a single OAD, a combination of metformin and the SU was used. Doses of insulin and the OAD were adjusted at each outpatient visit every 2 weeks during the first 2 months and every 4 weeks for another 4 months. Oral glucose tolerance tests were performed after the intensive insulin therapy: once just before random-ization and again 6 months later. At that time, patients in the insulin group were switched to OAD and all patients were followed for another 6 months. As expected, FPG concentrations were no different at randomization: however , they were significantly increased in the OAD group compared with those maintained on insulin. A1C levels were significantly lower at 3 and 6 months in patients maintained on insulin compared with those given OAD. They also remained significantly lower 6 months after the insulin patients were switched to OAD. Glucose and insulin responses among the insulin and OAD groups to the oral glucose tolerance tests were compared at randomization and 6 months later. To their credit, the authors compared only those patients who had achieved an A1C level Ͻ7.0% (22 of 24 in the insulin group and 8 of 18 in the OAD group). As expected, glucose responses were significantly improved in both groups compared with those at randomization, although there were no differences between groups. Conversely, insulin responses (assessed by homeostasis model assessment of ␤-cell function, insulino-genic index, and insulin area under the curve) were all significantly higher not only in both groups at 6 months compared with randomization but also in the insulin group compared with the OAD group at 6 months. So, should there be a rush to insulin as the initial therapy in newly diagnosed type 2 diabetic patients? I think not. Just as one should not rush to judgment, one should carefully examine clinical evidence …