Progression from basal to pre-mixed or rapid-acting insulin - Options for intensification and the use of pumps

Initiating insulin therapy is an important step in the management of patients with type 2 diabetes. The insulin regimen prescribed should be physiological and designed to control fasting and post-prandial glucose levels. The primary goals of therapy are achieving and maintaining tight glycemic control. The optimal insulin regimen should be patient-specific, taking the patient's lifestyle into consideration. As their diabetes progresses, an increasing number of patients require insulin therapy. An initial approach is to add basal insulin to oral hypoglycemic agents. When this regimen fails to achieve glycemic control, it should be intensified by either adding a rapid-acting insulin analog to control postprandial hyperglycemia or switching to pre-mixed insulin injection initiated once daily and subsequently up to three times daily. More tools are now available, including injection devices, insulin pens, glucose monitoring devices, and insulin pumps, to overcome the barriers to initiating and intensifying insulin therapy. With new insulin analogs it is possible to intensify insulin therapy to achieve glycemic control targets without increasing the risk for hypoglycemia or causing excessive weight gain.