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Insulin in the therapeutic scheme for type 2 diabetes mellitus


Authors: Emil Martinka
Authors‘ workplace: Národný endokrinologický a diabetologický ústav, n. o., Ľubochňa
Published in: Forum Diab 2017; 6(2): 69-77
Category: Topic

Overview

Insulin treatment in patients with type 2 diabetes mellitus (DM2T) is naturally needed as a result of their disease causing gradual reduction of their own insulin secretion. Although own insulin secretion in these patients only exceptionally falls below the limit that we still consider normal, a relative insufficiency of insulin in relation to the degree of insulin resistance already appears in the earlier stages of the disease. Insulin is a “medicine” with the strongest effect of lowering glycemia. The HbA1c target levels are attained in a greater number of patients as compared to OAD and the effect is long-term. Insulin can be used for patients with DM2T in the following ways: (1) As initial treatment for DM2T (with HbA1c > 9 %, or the clinical manifestations of hyperglycemia, or with glycemia levels > 14 mmol/l); (2) In combination with metformin (preferentially basal analogue); (3) In combination with all the groups of oral antidiabetics after preceding monotherapy or dual therapy of OAD; (4) As the ultimate treatment when the treatment with non-insulin antidiabetic drugs has failed. Insulin analogues (basal as well as prandial) have more advantageous pharmacokinetic properties, which is also why they are preferred. The most widespread method of initiating insulin treatment following OAD treatment is through basal insulin (preferentially the basal analogues glargine, detemir, degludec). An alternative initial regimen with HbA1c > 8.5 % is one using biphasic insulin. Intensification of basal insulin treatment was only possible by adding prandial insulin until recently. Currently it is also possible with the use of GLP1 receptor agonist, however only with a fixed combination of insulin degludec and liraglutide. Besides its impact on glycemia, insulin has also demonstrated numerous other effects. It affects the metabolism of fats, proteins, electrolytes and minerals. It has also demonstrated anti-inflammatory, antioxidant and endothelial protective effects. With regard to a cardiovascular risk/benefit it is neutral and it is safe as far as cancer risk is concerned. An early insulin treatment received by patients with newly diagnosed DM2T can lead to remission. The main undesirable effects include hypoglycemia and weight gain. A potentially increased morbidity and mortality risk associated with very high insulin doses has been a discussed topic.

Key words:
degludec, detemir, diabetes type 2 – DM2T, glargine, GLP1, insulin, insulin analogues, metformine, oral antidiabetic drugs

Received:
18. 4. 2017

Accepted:
2. 5. 2017


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Diabetology Endocrinology Internal medicine
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