We have seen that basal insulin causes
less weight gain than other insulin regimes. In this prospective, multicenter analysis, we see data that suggests initiation of basal
insulin therapy earlier on in disease duration may be beneficial for
therapy on the grounds of concern over weight gain appears to be
counter-productive. This is especially true given the potentially
superior glycemic control also associated with early insulin
initiation, further limiting weight gain. As such, prolonging the
start of insulin.
Peter Bramlage, MD, of the Institute
for Pharmacology and Preventive Medicine in Mahlow, Germany, and
colleagues analyzed data from two groups of patients with type 2
diabetes diagnosed on or after Jan. 1, 2011, identified through the
Diabetes Versorgungs-Evaluation (DIVE) registry, a German multicenter
registry involving 200 physician offices specializing in type 2
diabetes. The first group included insulin-naive patients receiving
basal insulin for the first time (n = 113; concomitant oral
antidiabetic use was permitted); the second group included patients
receiving their first oral antidiabetic therapy without simultaneous
basal or short-acting insulin (n = 408).
Researchers found that, relative to
baseline body weight, patients in the basal insulin group gained an
average of 0.98 kg at 1 year vs. a loss of 1.52 kg for those not
using insulin (P less than .001); results persisted when expressed as
a proportional change from baseline (P less than .001).
In multivariable analysis, researchers
observed that baseline weight (regression coefficient = 0.89; 95% CI,
0.81-0.97) and diabetes duration (regression coefficient = 2.52; 95%
CI, 0.53-4.52) were the only factors that were predictors of weight
gain between baseline and 1 year in the basal insulin group.
The researchers noted that the duration
of diabetes before basal insulin therapy as an independent predictor
of weight gain was “logical,” as early initiation would minimize
HbA1c escalation and avoid the creation of a “BMI deficit.”
The researchers wrote that, “Despite
disagreement over the direction of weight change, findings from prior
and present studies suggest that shorter diabetes duration is
associated with more favorable weight outcomes, and early initiation
of basal insulin therapy may be advantageous
Many of these clinical case studies
exemplify the diversity of patients who may benefit from early
insulin initiation. Ultimately, it is hoped that early initiation of
therapy will not only prevent weight gain and short-term
complications, but also reduce long-term morbidity and mortality by
getting to goal earlier and potentially alter the natural history of
the disease. This latter concept is currently of intense interest.
Although optimal disease management is patient-specific, achieving
and maintaining tight glycemic control are the primary goals of
therapy.
Because many type 2 diabetes patients
will eventually require insulin therapy, overcoming fears and
therapeutic barriers to initiating therapy early as needed are
essential for reducing the vascular comorbidities of this highly
prevalent disease in patients of all ages. Fortunately, a number of
new clinical tools are available, including both prandial and basal
insulin analogs, new insulin-delivery devices, and an ever-improving
knowledge of the pathophysiology and natural history of diabetes.
