Early Insulin Initiation—A Review of the Literature and Case Studies

The prevalence of type 2 diabetes (T2D) in the United States has increased in the last decade. Clinical guidelines direct patients with newly diagnosed T2D to a stepwise approach to glycemic management that includes diet, exercise, sequential oral antidiabetic drug (OAD) treatment (from monotherapy to combination therapy), and insulin treatment in order to help prevent microvascular and macrovascular complications. Studies have shown that patients with T2D benefit from early initiation of glycemic therapy to reduce glycated hemoglobin (A1C); however, OADs have been associated with limited A1C reductions leading to patients requiring insulin. Therefore, early initiation of insulin may help more patients to achieve and maintain longterm glycemic control. Insulin initiation is, however, frequently hindered by patient anxiety, clinician inertia, and patient and physician misconceptions about the role of insulin in glycemic control. This review examines the literature on insulin therapy in patients with T2D, focusing on the efficacy and advantages of early basal insulin analog therapy and real-life clinical experience that is illustrated in 3 case studies of patients with T2D. Early insulin initiation should be considered for a wide range of patients, from those with slightly elevated A1C to those with frank diabetic ketoacidosis.