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Beneficial effects of insulin in new onset type 2 diabetes with severe hyperglycemia
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Insulin therapy in patients with newly diagnosed type 2 diabetes may have benefits beyond improved glycemic control. Several studies have suggested that early insulin therapy may improve beta-cell function. Many of us have observed this in clinical practice.
In the October 2008 issue of Diabetes Care, Chen et al reported the results of a study comparing the effects of insulin to oral antidiabetic agents on new onset type 2 diabetes with severe hyperglycemia (fasting plasma glucose ≥300 mg/dL or random plasma glucose ≥400 mg/dL). The individuals were treated as inpatients with intensive insulin therapy for 10 to 14 days. After hospitalization, 50 patients were randomly assigned to either twice a day neutral protamine hagedorn insulin or oral antidiabetic drugs (metformin or sulfonylurea). An oral glucose tolerance test was obtained immediately after hospitalization and at six months. Long term glycemic control, beta-cell function and insulin sensitivity were also evaluated.
The dose of insulin decreased over the course of the study whereas the dose of oral agents increased. At the end of the six months, the HbA1C was significantly lower in the insulin group than in the oral medication group: 6.78% vs. 7.84% (P=.009). Beta-cell function as measured by oral glucose tolerance testing was improved in both groups but significantly improved in the insulin-treated group compared to the oral medication group. There was no significant difference in the rate of hypoglycemia between groups.
These results are consistent with what I have witnessed in my own practice. I am curious about what the effects of newer antidiabetic medications or a more intensive insulin regimen might have been.
A recent consensus statement on the management of type 2 diabetes released by the American Diabetes Association and European Association for the Study of Diabetes recommended earlier use of insulin, after patients failed therapeutic lifestyle modification and metformin. Although this makes sense in regards to improved glycemic control, it will be challenging to convince our patients of that.
Too many arrive to my office after years and years of uncontrolled diabetes before they finally agree to advance to insulin.
Diabetes Care. 2008;31:1927-1932.