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Comparisons of Insulin Regimens for Type 2 Diabetes

When insulin therapy becomes necessary for a patient with type 2 diabetes, the exact regimen might be less important than the patient's acceptance of the chosen regimen.

In two new studies, researchers examine options for patients with longstanding type 2 diabetes who have inadequate glycemic control despite treatment with oral antidiabetic drugs.

In a randomized European study, researchers enrolled 371 patients (mean HbA_1c level, 8.8%). One group received two oral drugs (metformin plus the sulfonylurea glimepiride [Amaryl]) plus morning doses of glargine insulin (Lantus); the other group received twice-daily premixed insulin (70% NPH, 30% regular). Medication doses were adjusted according to study protocol. At 24 weeks, the mean decrease in HbA_1c level was significantly greater in the glargine/metformin/glimepiride group than in the 70/30 insulin group (–1.6% vs. –1.3%). Hypoglycemia occurred more often with 70/30 insulin. This study was funded by the maker of Amaryl and Lantus.

In a U.S. study, 233 patients (mean HbA_1c level, 9.7%) were enrolled. All subjects received metformin, and about one third received pioglitazone; in addition, all subjects were randomized to receive either bedtime glargine insulin or twice-daily premixed insulin (Novolog Mix, 70/30), with doses adjusted according to protocol. At 24 weeks, the mean reduction in HbA_1c level was significantly greater in the 70/30 group than in the glargine group (–2.8% vs. –2.4%). Hypoglycemia occurred more often with 70/30 insulin. This study was funded by the maker of Novolog.

Comment: These two studies aren't entirely congruent: The first one pitted a glargine-plus-oral regimen against 70/30 insulin alone, whereas the second compared glargine with 70/30 while all patients continued oral therapy. The glargine group fared slightly better in the first study, and slightly worse in the second. Neither study was blinded, and the results favored the product of the sponsoring drug company in each case. Nevertheless, these studies show us that a variety of regimens can be reasonably effective. Indeed, an editorialist concludes that it doesn't really matter what regimen you choose, as long as your choice works, is safe, and is acceptable to the patient.

— Allan S. Brett, MD

Published in Journal Watch General Medicine March 11, 2005

Citation(s):

Janka HU et al. Comparison of basal insulin added to oral agents versus twice-daily premixed insulin as initial insulin therapy for type 2 diabetes. Diabetes Care 2005 Feb; 28:254-9.

• Original article (Subscription may be required)
• Medline abstract (Free)

Raskin P et al. Initiating insulin therapy in type 2 diabetes: A comparison of biphasic and basal insulin analogs. Diabetes Care 2005 Feb; 28:260-5.

• Original article (Subscription may be required)
• Medline abstract (Free)

Davidson MB. Starting insulin therapy in type 2 diabetic patients: Does it really matter how? Diabetes Care 2005 Feb; 28:494-5.

• Original article (Subscription may be required)
• Medline abstract (Free)