Initiating and intensifying insulin therapy for type 2 diabetes: why, when, and how.

With the exception of insulin, all diabetes medications have limited glucose-lowering capacity. Therefore, as type 2 diabetes progresses, insulin is often needed to achieve near-normal glycemic targets and avoid complications. Concerns about the initiation of insulin by both clinicians and patients play a major role in poor glycemic control. This article discusses current guidelines for treating type 2 diabetes, exploring when and how insulin therapy should be initiated and intensified, and how barriers to insulin use may be overcome. Advances include the development of novel long-acting, premixed, and rapid-acting insulin analogues and delivery devices. These agents have near-physiological time-action profiles that allow safer, flexible, and more convenient dosing. Many patients find using an insulin pen device easier, more convenient, and more discreet than using a vial and syringe. Nurses and medical assistants can be trained to understand the glucose-lowering capacities and limitations of each class of diabetes medications, including recognizing when insulin therapy is necessary. In addition, by showing patients how easy insulin pens are to use, clinic staff can help empower, educate, and encourage patients with type 2 diabetes to optimize their glycemic control with insulin once oral antidiabetic agents alone have become inadequate.