Learning Objectives:

• Be able to identify the indications for initiation of insulin therapy in patients with type 2 diabetes, including appropriateness of patient selection
• Be able to compare the different types of insulin preparations available and their regimes
• Be able to select and manage an appropriate initial insulin regimen in patients with type 2 diabetes
• Be able to list the options for insulin therapy advancement when current strategies are no longer adequate
• Be able to identify the need for the implementation of twice daily insulin therapy and devise a plan for achieving glycaemic targets

Expert presenter: Dr Tony Russell
Dr Tony Russell is an endocrinologist and is the Director of the Department of Diabetes and Endocrinology, Princess Alexandra Hospital. He is the Team Leader of Placental Biology at the Diamantina Institute for Cancer, Immunology and Metabolic Medicine at The University of Queensland. Tony is on the Steering Committee for the Diabetes Network, Clinical Practice Improvement Centre, Queensland Health and is actively involved in developing the Inala Chronic Disease Centre, assessing a new model of care for the management of type 2 diabetes mellitus.

References for Dr Russell's presentation:
[1] Altuntas Y, Ozen B, Ozturk B, Sengul A, Ucak S, Ersoy O, Karul S. Comparison of additional metformin or NPH insulin to mealtime insulin lispro therapy with mealtime human insulin therapy in secondary OAD failure. Diabetes Obes Metab. 2003 Nov;5(6):371-8.
[2] Wulffelé MG, Kooy A, Lehert P, Bets D,et al. Ogterop JC, Borger van der Burg B, Donker AJ, Stehouwer CD. Combination of insulin and metformin in the treatment of type 2 diabetes. Diabetes Care. 2002 Dec;25(12):2133-40. Viewed on 14/01/2008, at: http://care.diabetesjournals.org/cgi/reprint/25/12/2133
[3] Tong PC, Chow CC, Jorgensen LN, Cockram CS. The contribution of metformin to glycaemic control in patients with Type 2 diabetes mellitus receiving combination therapy with insulin. Diabetes Res Clin Pract. 2002 Aug;57(2):93-8.
[4] Yki-Järvinen H, Kauppila M, Kujansuu E, Lahti J, Marjanen T, Niskanen L et al. Comparison of insulin regimens in patients with non-insulin-dependent diabetes mellitus. N Engl J Med. 1992 Nov 12;327(20):1426-33.
[5] Hussein Z, Wentworth JM, Nankervis AJ, Proietto J, Colman PG. Effectiveness and side effects of thiazolidinediones for type 2 diabetes: real-life experience from a tertiary hospital. Med J Aust. 2004 Nov 15;181(10):536-9. Viewed on 15/01/2008, at: http://www.mja.com.au/public/issues/181_10_151104/hus10370_fm.html
[6] Gómez-Perez FJ, Fanghänel-Salmón G, Antonio Barbosa J, Montes-Villarreal J, Berry RA, Warsi G, et al. Efficacy and safety of rosiglitazone plus metformin in Mexicans with type 2 diabetes. Diabetes Metab Res Rev. 2002 Mar-Apr;18(2):127-34.
[7] Ovalle F, Bell DS. Effect of rosiglitazone versus insulin on the pancreatic beta-cell function of subjects with type 2 diabetes. Diabetes Care. 2004 Nov;27(11):2585-9. Viewed on 15/01/2008, at: http://care.diabetesjournals.org/cgi/content/full/27/11/2585
[8] McCall A. Insulin Therapy. Leahy J, Cefalu W, editors. New York: Marcel Dekker Inc; 2002. p.193.
[9] Holman RR, Thorne KI, Farmer AJ, Davies MJ, Keenan JF, Paul S et al, for the 4-T Study Group. Addition of biphasic, prandial, or basal insulin to oral therapy in type 2 diabetes. N Engl J Med 2007;357:1716-1730.
[10] Seipke G, Geisen K, Neubauer HP, Pittius C, Rosskamp R, Schwabe D. New insulin preparations with prolonged profiles: A21-modified argine insulins. Diabetologia 1992;35 Suppl 1:A4.
[11] Hilgenfeld R, Dorschug M, Geisen K et al. Controlling insulin bioavailabilty by crystal contact engineering [abstract]. Diabetologia 1992;35 Suppl 1:A193.
[12] Heise T, Nosek L, Draeger E, Ronn BB, Kaptiza C, Heinemann L. Lower within-subject variability of insulin detemir compared to NPH insulin and insulin glargine in subjects with type 1 diabetes. Program and abstracts of the 18th International Diabetes Federation Congress; August 25-29, 2003; Paris, France. Abstract 12.
[13] Heise T, Nosek L, Rønn BB, Endahl L, Heinemann L, Kapitza C, et al. Lower within-subject variability of insulin detemir in comparison to NPH insulin and insulin glargine in people with type 1 diabetes. Diabetes. 2004 Jun;53(6):1614-20. Viewed on 15/01/2008, at: http://diabetes.diabetesjournals.org/cgi/content/full/53/6/1614
[14] Olsson PO, Lindström T. Combination-therapy with bedtime nph insulin and sulphonylureas gives similar glycaemic control but lower weight gain than insulin twice daily in patients with type 2 diabetes. Diabetes Metab. 2002 Sep;28(4 Pt 1):272-7. Viewed on 15/01/2008, at: http://www.masson.fr/masson/portal/bookmark?Global=1&Page=18&
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[15] Riddle MC, Rosenstock J, Gerich J; Insulin Glargine 4002 Study Investigators. The treat-to-target trial: randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients. Diabetes Care. 2003 Nov;26(11):3080-6. Viewed on 15/01/2008, at: http://care.diabetesjournals.org/cgi/content/full/26/11/3080
[16] Aljabri K, Kozak SE, Thompson DM. Addition of pioglitazone or bedtime insulin to maximal doses of sulfonylurea and metformin in type 2 diabetes patients with poor glucose control: a prospective, randomized trial. Am J Med. 2004 Feb 15;116(4):230-5.
[17] López-Alvarenga JC, Aguilar-Salinas CA, Velasco-Perez ML, Arita-Melzer O, Guillen LE, Wong B et al. Acarbose vs. bedtime NPH insulin in the treatment of secondary failures to sulphonylurea-metformin therapy in type 2 diabetes mellitus. Diabetes Obes Metab. 1999 Jan;1(1):29-35.
[18] Stehouwer MH, DeVries JH, Lumeij JA, Adèr HJ, Engbers AM, Iperen Av A et al. Combined bedtime insulin--daytime sulphonylurea regimen compared with two different daily insulin regimens in type 2 diabetes: effects on HbA1c and hypoglycaemia rate--a randomised trial. Diabetes Metab Res Rev. 2003 Mar-Apr;19(2):148-52.
[19] Clauson P, Karlander S, Steen L, Efendic S. Daytime glibenclamide and bedtime NPH insulin compared to intensive insulin treatment in secondary sulphonylurea failure: a 1-year follow-up. Diabet Med. 1996 May;13(5):471-7.
[20] Goudswaard AN, Stolk RP, Zuithoff NP, de Valk HW, Rutten GE. Long-term effects of self-management education for patients with Type 2 diabetes taking maximal oral hypoglycaemic therapy: a randomized trial in primary care. Diabet Med. 2004 May;21(5):491-6.
[21] Senfalck AM, Thorsby P, Kjems L, Birkeland K, Dejgaard A, Hanssen KF et al. Improved postprandial glycaemic control with insulin Aspart in type 2 diabetic patients treated with insulin. Acta Diabetol. 2000 Mar;37(1):41-6.
[22] Tamás G, Marre M, Astorga R, Dedov I, Jacobsen J, Lindholm A; Insulin Aspart Study Goup. Glycaemic control in type 1 diabetic patients using optimised insulin aspart or human insulin in a randomised multinational study. Diabetes Res Clin Pract. 2001 Nov;54(2):105-14.
[23] Korytkowski M. When oral agents fail: practical barriers to starting insulin. Int J Obes Relat Metab Disord. 2002 Sep;26 Suppl 3:S18-24.

Quiz reference:
[24] Expert lecture. Dr Anthony Russell. Advanced skills in management of type 2 diabetes.