Pro's and Con's of the early use of insulin in the management of type 2 diabetes: a clinical evaluation

Purpose of review Recently, there have been increasing calls for insulin to be used as the initial treatment of type 2 diabetes, and if not then, soon after its onset. The underlying reason given is that insulin will slow down the apoptosis of pancreatic beta-cells, which is increased in type 2 diabetes. This review will examine the clinical evidence supporting this recommendation. Recent findings Several observational studies in which newly diagnosed type 2 diabetic patients are intensively treated for a short time with insulin, which is then stopped, have shown that approximately half of these patients retain good control without pharmacological therapy for up to a year. However, HbA1c levels in patients who have to be started on oral antidiabetic drugs are similar to the values in those who do not. HbA1c levels are similar in patients randomized to initial therapy with insulin or oral antidiabetic drug. There is no clinical evidence yet for an effect of insulin on beta-cell apoptosis. Summary The primary goal is to achieve and maintain HbA1c levels of less than 7.0%. Given the extra demands on both patients and physicians when starting insulin compared with oral antidiabetic drug and the many subsequent years in which patients have diabetes, the arguments for using insulin initially, or in patients who have achieved the target HbA1c level, are not convincing. However, as soon as oral antidiabetic drug therapy cannot meet this goal, insulin must be introduced.