Abstract
Brazil is expected to have 19.6 million patients with diabetes by the year 2030. A key concept in the treatment of type 2 diabetes mellitus (T2DM) is establishing individualized glycemic goals based on each patient’s clinical characteristics, which impact the choice of antihyperglycemic therapy. Targets for glycemic control, including fasting blood glucose, postprandial blood glucose, and glycated hemoglobin (A1C), are often not reached solely with antihyperglycemic therapy, and insulin therapy is often required. Basal insulin is considered an initial strategy; however, premixed insulins are convenient and are equally or more effective, especially for patients who require both basal and prandial control but desire a more simplified strategy involving fewer daily injections than a basal-bolus regimen. Most physicians are reluctant to transition patients to insulin treatment due to inappropriate assumptions and insufficient information. We conducted a nonsystematic review in PubMed and identified the most relevant and recently published articles that compared the use of premixed insulin versus basal insulin analogues used alone or in combination with rapid-acting insulin analogues before meals in patients with T2DM. These studies suggest that premixed insulin analogues are equally or more effective in reducing A1C compared to basal insulin analogues alone in spite of the small increase in the risk of nonsevere hypoglycemic events and nonclinically significant weight gain. Premixed insulin analogues can be used in insulin-naïve patients, in patients already on basal insulin therapy, and those using basal-bolus therapy who are noncompliant with blood glucose self-monitoring and titration of multiple insulin doses. We additionally provide practical aspects related to titration for the specific premixed insulin analogue formulations commercially available in Brazil.
Highlights
In 2011, the prevalence of diabetes mellitus worldwide was approximately 366 million people [1]
This finding suggests that patients required a higher insulin dose or needed to be switched to a more intensive treatment. Another recent study [33], which reviewed strategies of intensification of glucose control with different treatment options for type 2 diabetes mellitus (T2DM), concluded that the type of treatment used to achieve glycemic control can focus on fasting BG (FBG) or postprandial blood glucose (BG). These findings suggest that if lowering FBG is the treatment goal, FBG would contribute to approximately 34% of A1C and postprandial BG to approximately 66% of A1C
Premixed insulin analogues provide both the basal and prandial coverage in a single formulation, which may explain the better glycemic control achieved with BID and times daily (TID) dosing regimens with premixed analogues compared with a basal only or basal-bolus approach
Summary
In 2011, the prevalence of diabetes mellitus worldwide was approximately 366 million people [1]. This finding suggests that patients required a higher insulin dose or needed to be switched to a more intensive treatment Another recent study [33], which reviewed strategies of intensification of glucose control with different treatment options for T2DM, concluded that the type of treatment used to achieve glycemic control can focus on FBG or postprandial BG. Patients already on basal insulin therapy Some patients taking 1 daily dose of basal insulin (NPH, detemir, or glargine) may not achieve the proposed A1C targets due to postprandial hyperglycemia despite appropriate fasting BG levels In such cases, a prandial insulin can be added or premixed analogues can be used. Nutritional guidance with the purpose of encouraging patients to eat meals low in carbohydrates and to eliminate highglycemic-index foods altogether from their diet, as well as encouraging patients to maintain a physical activity program, are helpful in controlling weight gain
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