Optimal initiation of insulin in type 2 diabetes.

Treatment goals for glycemic control in patients with type 2 diabetes are often not achieved or are difficult to maintain as the disease progresses. Too often, insulin therapy is either delayed or is suboptimal. We discuss how the introduction of new insulin analogs may help overcome some of the barriers to insulin use. If combination therapy with oral agents does not achieve glycemic control, the addition of a once-daily intermediate- or long-acting insulin is a simple and highly effective strategy for initiating insulin. If glycemic control is still not achieved, a short- or rapid-acting insulin may be needed prior to meals (basal-prandial approach). A patient's baseline glycosylated hemoglobin (A1C) can guide whether glycemic control can be achieved with basal insulin or will require basal-prandial replacement. In addition to A1C, a patient's age, lifestyle, competence, personal preferences, and comorbidities can be used to help determine the choice of insulin therapy.