Indian reality of managing type 2 diabetes: an expert review of global and national guidelines for optimum insulin use

Abstract

Several guidelines provide recommendations on insulin therapy in people with type 2 diabetes mellitus (T2DM). Major global guidelines have been adapted in multiple countries, and local consensus recommendations have been published giving guidance on insulin therapy considering local realities. This expert review focuses on the recommendations from global and Indian guidelines on insulin therapy in people with T2DM. It emphasizes on a patient-centric approach, including the glycemic parameters, psychosocial aspects, phase of life, and the Indian realities of T2DM management in guiding optimum insulin therapy for initiation and intensification. Therapeutic inertia towards timely insulin initiation needs to be bridged. Owing to the high carbohydrate diet and high postprandial glucose (PPG) excursions, insulin co-formulation and premix insulins offering total glycemic control can be preferred for a timely insulin initiation in Indians with T2DM that is uncontrolled despite multiple oral antidiabetic drugs. They also provide simplicity and convenience for insulin initiation and intensification. Among basal insulins, insulin degludec and glargine U300 are found to be safer, and offer more dosing flexibility than the first-generation basal insulin analogs. Faster-acting insulin aspart has been shown to provide better PPG control and dosing flexibility compared to a rapid-acting insulin analog with a lower risk of hypoglycemia. Thus, based on available evidences, a preferred use of insulin analog over conventional human insulins is suggested, keeping cost considerations in mind. The review also discusses optimum use of concomitant medications with insulin therapy for T2DM management.