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Insulin for Poorly Controlled Type 2 Diabetes

2020 American Diabetes Association (ADA) guidelines recommend that after a trial of metformin, clinicians add second-line oral drugs based on the presence of cardiovascular and kidney-related comorbidities, risk of weight gain and hypoglycemia, and cost. In this video, Irl B. Hirsch, MD, of the University of Washington in Seattle, explains the rationale for starting insulin as a second drug for patients with persistent HbA1c elevation >9%-9.5% despite lifestyle changes and metformin. Click the related article link for complete details.

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Transcript

Poor longterm control of type 2 diabetes can result in severe complications.

Irl Hirsch: Diabetes is still the leading cause of blindness in adults. It's still the leading cause of end stage renal disease. And all of this is preventable.

That's Dr Irl Hirsch. He thinks earlier use of insulin could be one way to prevent those complications and others.

IH: We feel that if the guidelines were more amenable to starting insulin sooner, it could have a tremendous public health benefit.

Here's what the 2020 American Diabetes Association guidelines currently recommend. All type 2 patients should receive lifestyle education. Adding metformin is the recommended first-line pharmacologic intervention. Then, if the patient has cardiovascular or kidney comorbidities, the guidelines recommend adding a GLP-1 receptor agonist or SGLT2 inhibitor. If there are no such comorbidities, physicians can prescribe drugs based on the risk for hypoglycemia, weight management concerns, or drug cost. Dr Hirsch co-authored an article in JAMA that suggests that after that first step, for patients whose HbA1c is higher than 9 to 9.5%, clinicians should consider prescribing basal insulin, independent of any other considerations.

IH: The problem right now is, quite frankly, if one says you should start a medication, whatever medication, at a level of 9, often it won't be started until 9.5 or 10. That's just the way it is. Having insulin on the mind of the physicians, mostly primary care physicians, earlier, I think, again, over the course of time, could have a dramatic public health impact.

The authors base that recommendation on a few lines of evidence. They cite a 2008 trial demonstrating the benefit of intensive insulin therapy on beta-cell function and glycemic control in patients with newly diagnosed type 2 diabetes. They estimate based on UKPDS data that reducing HbA1c from 9.5 to 8.5% can result in an absolute reduction of microvascular disease by approximately 15% and myocardial infarction by approximately 10%. And they also cite a systematic review in which participants with HbA1c levels above 9 who received insulin had greater reductions in HbA1c than those who received noninsulin drugs.

IH: What's interesting about that study is that when looking at lower A1C levels, the insulin and the non-insulin therapies did the same. It's when you get to these higher A1C levels above 8.5 and 9% that the insulin just did so much better than the non-insulin therapies.

But Dr Hirsch and his coauthor stress the importance of lifestyle in diabetes control, despite their pitch for insulin in type 2 patients.

IH: And anybody who is watching their blood sugars, whether with finger sticks or continuous glucose monitoring, which is we are using more and more, they realize that at the end of the day, no matter what medications they are on, including insulin, what they eat and how they exercise is really going to dictate what their glucose control is.

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