Deciding Among Insulin Therapies for Type 2 Diabetes

Mark Warren, MD: When deciding on a basal insulin for a patient, I would like to give them an insulin that will have less risk of hypoglycemia, less day-to-day variability in the absorption, and less unexplained hyperglycemia. So, I’m always going to use the best insulin if I can, and those insulins are the newer, ultra—long acting insulins. That’s what I would prefer to give my patients, and that’s why I preferentially recommend it to my patients.

The newer, ultra-long basal insulins do offer advantages in that there’s less variability from day to day. And what that will do is prevent unexplained hypoglycemia and unexplained hyperglycemia. In a lot of the insulins we have now, there’s a lot of day-to-day variability in the absorption of the insulin. The newer insulins do offer us less variability and have shown in phase III trials—and some phase IV trials as well—less hypoglycemia compared to some of the older basal insulins.

With the newer, ultra—long acting insulins, we do have the ability to give them at different times of the day without loss of control. I think any time when we can give a patient some options for when they take insulin, it’s very helpful. If we have an insulin that can be dosed at different times of the day from day to day, that’s even better, because they often forget to take it the time that they’re supposed to take it. So, they can simply take it when they remember. That gives a lot of flexibility to the patient, and it does translate into better compliance and better control of their blood sugars. There are a lot of advantages with the longer-acting insulins.

When deciding to change someone from a more conventional long-acting insulin to one of the newer ultra—long acting insulins, I’ll look at their risk and their rates of hypoglycemia. I’ll look to see if they’re compliant with taking it at the time of day they’re taking it. Often, they won’t take it at night if their blood sugar is normal for fear of nocturnal hypoglycemia. So, I’ll ask them about their fear of hypoglycemia and if that is preventing them from getting adequate control. Because often, that is the issue. The patient will often decrease their dose of insulin for fear of nocturnal hypoglycemia. So, that really plays a big role in my decision process. Are they having hypoglycemia or do they have fear of hypoglycemia? Are they adjusting their dose of insulin inappropriately because of their fear of having hypoglycemia?