early and Aggressive initiation of insulin therapy for type 2 Diabetes: What is the evidence?

Type 2 diabetes mellitus is a progressive disease in which β-cell function continually declines and eventually fails, ultimately requiring nearly all patients to be placed on insulin therapy. An increasing body of evidence suggests that early intensive glycemic control reduces long-term vascular outcomes and potentially may prolong β-cell lifespan and function. Herein, evidence in favor of early insulin therapy on disease progression and long-term outcomes will be reviewed and placed into clinical context. The importance of good glycemic control to reduce the risk of vascular complications of hyperglycemia is well established. However, type 2 diabetes is a progressive disease, and the need for increasing the intensity of treatment to maintain glycemic control is an indicator of that progression. Ultimately, most patients will require insulin therapy, although insulin is still all too often thought of as “last resort” or “end-stage” therapy. This and other misperceptions frequently limit the early initiation of insulin therapy, even among patients for whom oral agents are no longer adequate. A variety of insulin analogs are now available that lower the risk of hypoglycemia and result in less weight gain, thus providing the tools to overcome barriers commonly associated with insulin therapy. New insulin analogs more closely mimic the kinetic profile of endogenous insulin and allow for flexible dosing in pen devices that are generally well received by patients. Clinical outcome data, together with the safety and convenience of insulin analogs and newer insulin-delivery devices, may make early initiation of insulin therapy more attractive. The objective of this review is to present recent clinical evidence in favor of early and aggressive bloodglucose lowering in patients with type 2 diabetes, and, in this context, to discuss and highlight real-world clinical experiences for type 2 diabetes disease management.