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Drug Saf. 1999 Jul;21(1):7-22. doi: 10.2165/00002018-199921010-00002.

Benefits and risks of transfer from oral agents to insulin in type 2 diabetes mellitus.

Drug safety

A Evans, A J Krentz

Affiliations

  1. Southampton General Hospital, England.

PMID: 10433350 DOI: 10.2165/00002018-199921010-00002

Abstract

The treatment of type 2 diabetes mellitus remains controversial. Since most patients are overweight or obese, regimens based on dietary modification and increased physical exercise are logical and safe treatment approaches. However, the long term impact of these interventions is frequently disappointing and pharmacotherapy is therefore required in the majority of patients. Oral antidiabetic agents, principally the sulphonylureas and biguanides, are often only partially effective, even in combination. Insulin is the treatment of choice for certain clinical situations, for example, pregnancy. Often insulin will be a temporary measure. Safety considerations will also point to the preferential use of insulin in other circumstances, for example, in patients with pronounced renal impairment. In addition, a significant proportion of patients with type 2 diabetes mellitus will ultimately require insulin therapy in the long term because of failure of oral agents to provide adequate glycaemic control (i.e. secondary failure). Reservations about insulin therapy in patients with type 2 diabetes mellitus, particularly elderly patients with cardiovascular complications, include hypoglycaemia and bodyweight gain. However, severe hypoglycaemia occurs with considerably lower frequency than in patients with type 1 diabetes mellitus. To date, no clear evidence has emerged implicating exogenous insulin therapy in the promotion of cardiovascular disease. On the contrary, recent clinical and experimental studies suggest anti-atherogenic effects. Insulin therapy can be successful in type 2 diabetes mellitus if patients are carefully selected. Twice daily isophane (neutral protamine Hagedom; NPH) or pre-mixed insulin is used routinely in many centres. The role of combinations of insulin and oral agents remains an area of controversy. Combined therapy with sulphonylureas may be more expensive and clear clinical advantages have not been consistently demonstrated. Bodyweight gain may be lessened by the concomitant use of metformin and troglitazone may improve glycaemic control in obese patients. Procrastination about transfer to insulin is not uncommon. Patient acceptance may be facilitated by a positive attitude from the diabetes care team and discussion of the possibility at a relatively early stage. Adequate support from a multidisciplinary team is important for safe and effective insulin therapy. Even so, in the long term, attainment of glycaemic targets may prove difficult to sustain with present therapeutic strategies.

References

  1. Diabetes Care. 1998 Apr;21(4):574-9 - PubMed
  2. Diabetes. 1995 Apr;44(4):369-74 - PubMed
  3. Diabet Med. 1993 Apr;10(3):231-7 - PubMed
  4. Arch Intern Med. 1997 Jan 27;157(2):181-8 - PubMed
  5. Diabetes Res Clin Pract. 1995 May;28(2):103-17 - PubMed
  6. N Engl J Med. 1998 Mar 26;338(13):861-6 - PubMed
  7. Endocr Pract. 1998 Sep-Oct;4(5):259-67 - PubMed
  8. Diabetes. 1997 Jan;46(1):3-10 - PubMed
  9. Circulation. 1996 May 15;93(10):1780-3 - PubMed
  10. Diabetes. 1996 Dec;45(12):1661-9 - PubMed
  11. Diabetologia. 1996 Dec;39(12):1577-83 - PubMed
  12. Diabetologia. 1997 Oct;40 Suppl 3:B89-93 - PubMed
  13. Ann Intern Med. 1999 Mar 2;130(5):389-96 - PubMed
  14. Diabet Med. 1995 Jul;12 (7):619-21 - PubMed
  15. Diabetologia. 1994 Sep;37(9):945-7 - PubMed
  16. Diabetes Care. 1993 Jan;16(1):21-31 - PubMed
  17. Diabet Med. 1996 Sep;13(9 Suppl 6):S16-8 - PubMed
  18. N Engl J Med. 1992 Sep 3;327(10):707-13 - PubMed
  19. Lancet. 1997 Nov 1;350(9087):1288-93 - PubMed
  20. Diabetes Care. 1993 Jun;16(6):896-901 - PubMed
  21. Diabetologia. 1996 May;39(5):503-14 - PubMed
  22. Lancet. 1994 Jan 8;343(8889):91-5 - PubMed
  23. Lancet. 1998 Sep 12;352(9131):854-65 - PubMed
  24. Lancet. 1998 Sep 12;352(9131):837-53 - PubMed
  25. Diabetes. 1996 Jul;45 Suppl 3:S45-6 - PubMed
  26. Diabetes Care. 1996 Dec;19(12):1326-32 - PubMed
  27. Arch Intern Med. 1998 Jan 26;158(2):134-40 - PubMed
  28. Diabetes. 1996 Jul;45 Suppl 3:S87-90 - PubMed
  29. J R Coll Physicians Lond. 1993 Jul;27(3):259-66 - PubMed
  30. N Engl J Med. 1992 Nov 12;327(20):1426-33 - PubMed
  31. Diabetes Care. 1992 Jul;15(7):831-4 - PubMed
  32. Diabetes. 1995 Feb;44(2):165-72 - PubMed
  33. Arteriosclerosis. 1988 Mar-Apr;8(2):168-77 - PubMed
  34. Diabet Med. 1997 Feb;14(2):123-31 - PubMed
  35. Diabetes Care. 1997 Jul;20(7):1183-97 - PubMed
  36. N Engl J Med. 1996 Apr 11;334(15):952-7 - PubMed
  37. Diabetologia. 1993 Nov;36(11):1175-84 - PubMed
  38. Diabet Med. 1993 Jan-Feb;10(1):27-32 - PubMed
  39. J Hypertens. 1993 Mar;11(3):319-25 - PubMed
  40. Eur J Clin Pharmacol. 1993;44(2):107-12 - PubMed
  41. Diabetes Care. 1995 Aug;18(8):1113-23 - PubMed
  42. Diabetes. 1997 Sep;46 Suppl 2:S101-3 - PubMed
  43. Diabetes Care. 1996 Mar;19(3):204-10 - PubMed
  44. BMJ. 1997 May 24;314(7093):1497 - PubMed
  45. Diabetes. 1994 Aug;43(8):960-7 - PubMed
  46. BMJ. 1996 Nov 30;313(7069):1385-9 - PubMed
  47. Ann Intern Med. 1996 Jan 1;124(1 Pt 2):90-6 - PubMed
  48. Diabetologia. 1997 May;40(5):512-20 - PubMed
  49. Diabetologia. 1971 Oct;7(5):323-7 - PubMed
  50. Ann Intern Med. 1996 Jan 1;124(1 Pt 2):136-45 - PubMed
  51. Diabetes Care. 1990 Sep;13(9):1011-20 - PubMed
  52. Ann Intern Med. 1996 Jan 1;124(1 Pt 2):123-6 - PubMed
  53. Drug Saf. 1994 Oct;11(4):223-41 - PubMed
  54. N Engl J Med. 1993 Sep 30;329(14 ):977-86 - PubMed
  55. Br Med J (Clin Res Ed). 1988 Apr 9;296(6628):1015-6 - PubMed
  56. Diabetes Care. 1995 Mar;18(3):307-14 - PubMed
  57. Ann Intern Med. 1996 Jan 1;124(1 Pt 2):104-9 - PubMed
  58. Diabet Med. 1997 Jul;14(7):611-21 - PubMed
  59. Diabetes Care. 1992 Aug;15(8):953-9 - PubMed
  60. Lancet. 1998 Sep 12;352(9131):832-3 - PubMed
  61. Diabetes. 1995 May;44(5):483-8 - PubMed
  62. Diabetes. 1972 Sep;21(9):976-9 - PubMed
  63. BMJ. 1997 Nov 1;315(7116):1105-6 - PubMed
  64. Diabetologia. 1997 Jul;40(7):749-57 - PubMed
  65. Diabetes. 1980 Jan;29(1):41-9 - PubMed
  66. Diabetologia. 1987 Mar;30(3):123-31 - PubMed
  67. Lancet. 1996 Apr 6;347(9006):949-50 - PubMed
  68. Diabetes Care. 1997 Mar;20(3):292-8 - PubMed
  69. Diabetes Care. 1998 Jun;21(6):919-24 - PubMed
  70. BMJ. 1998 Sep 12;317(7160):703-13 - PubMed
  71. Diabet Med. 1988 Apr;5(3):275-81 - PubMed
  72. Diabetes Care. 1997 Mar;20(3):258-64 - PubMed
  73. Diabetes. 1988 Dec;37(12):1595-607 - PubMed
  74. BMJ. 1997 May 24;314(7093):1512-5 - PubMed
  75. Baillieres Clin Endocrinol Metab. 1993 Oct;7(4):1079-103 - PubMed
  76. Diabetes. 1994 Jun;43(6):735-40 - PubMed
  77. Diabetes Care. 1998 Sep;21(9):1389-90 - PubMed
  78. Diabetes. 1989 May;38(5):580-8 - PubMed
  79. Diabetes. 1997 Oct;46(10):1601-6 - PubMed
  80. Diabetologia. 1997 Nov;40(11):1334-40 - PubMed

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