Review of basal‐plus insulin regimen options for simpler insulin intensification in people with Type 2 diabetes mellitus

Abstract

AimsTo identify simple insulin regimens for people with Type 2 diabetes mellitus that can be accepted and implemented earlier in primary and specialist care, taking into consideration each individual's needs and capabilities.MethodsUsing randomized clinical trials identified by a search of the PubMed database, as well as systematic reviews, meta‐analyses and proof‐of‐concept studies, this review addresses topics of interest related to the progressive intensification of a basal insulin regimen to a basal‐plus regimen (one basal insulin injection plus stepwise addition of one to three preprandial short‐acting insulin injections/day) vs a basal‐bolus regimen (basal insulin plus three short‐acting insulin injections per day) in people with Type 2 diabetes. The review explores approaches that can be used to define the meal for first prandial injection with basal‐plus regimens, differences among insulin titration algorithms, and the importance of self‐motivation and autonomy in achieving optimum glycaemic control.ResultsA basal‐plus regimen can provide glycaemic control equivalent to that obtained with a full basal‐bolus regimen, with fewer injections of prandial insulin. The first critical step is to optimize basal insulin dosing to reach a fasting glucose concentration of ~6.7 mmol/l; this allows ~40% of patients with baseline HbA1c >75 mmol/mol (9%) to be controlled with only one basal insulin injection per day.ConclusionsCompared with a basal‐bolus regimen, a basal‐plus insulin regimen is as effective but more practical, and has the best chance of acceptance and success in the real world.

Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

“…Intensified insulin regimens include 1 ) one or more daily injections of rapid- or short-acting insulin before meals (prandial insulin) or 2 ) switching to one to three daily administrations of a fixed combination of short- and long-acting insulin (premixed or biphasic insulins) (229,230). When adding prandial insulin, giving one injection with the largest meal of the day is a simple and safe approach (231). Over time, if glycemic targets are not met with one dose of prandial insulin daily, additional prandial injections can be added to other meals (232).…”

<p>Dipeptidyl peptidase-4 inhibitors as add-on therapy to insulin in patients with type 2 diabetes mellitus: a meta-analysis of randomized controlled trials</p>

“…Although initial treatment with oral antidiabetic drugs (OADs) is effective for glycemic control in T2DM patients, with the deterioration of the β cells of the pancreatic islet during the progression of the disease, exogenous insulin injection is eventually needed 6,7. Currently, multiple regimens of insulin injections are applied in clinical practice, such as basal insulin treatment, basal and premeal bolus insulin injections, and premix insulin treatments, and with which, satisfying glycemic control can be achieved in most T2DM patients 8–10. However, insulin treatment is associated with adverse events including gain of body weight (BW) and hypoglycemia, which are related to the increase of the daily insulin dose 11,12.…”

Practical application of short-term intensive insulin therapy based on the concept of “treat to target” to reduce hypoglycaemia in routine clinical site

“…Many treatment algorithms and clinical trials of T2DM with beta cell death have been proposed so far [31][32][33][34] . Basal-Bolus, Basal plus, Basal supporting oral therapy (BOT), premixed insulins and premixed insulin and GLP-1R agonist were reported to improve safety and efficacy of the patient treated mainly in out-patient clinic [35][36][37][38][39][40][41][42] .…”