Early insulin: an important therapeutic strategy.

The issue of when and how to initiate insulin in type 2 diabetes is one that has engendered much debate (1). Some recent evidence may aid in this discussion. First, the desirable glycemic targets are largely agreed upon, with only a few minor disagreements (2,3). Data from the U.K. Prospective Diabetes Study (UKPDS) and the Diabetes Control and Complications Trial (DCCT) have demonstrated a strong correlation between glycemic burden and microvascular complications in both type 1 and type 2 diabetes, with no evidence of a threshold below which complications do not occur. Further, the follow-up analysis of the DCCT, the EDIC (Epidemiology of Diabetes Interventions and Complications), has shown a “legacy effect” of improved glycemic control persisting for at least 5 years in the previously intensively treated group, even after some rise in HbA1c (4). This increases the urgency to achieve and maintain good control as early as possible. Therefore, many authors on this subject agree that the target HbA1c should be “as close to normal as possible while minimizing the risks of treatment” (3). Herein lies the rub or debate regarding the later caveat. That is, what is the risk and burden of treatment in terms of economic, mental, and physical aspects? Analysis of the quality of life for subjects in the intensively treated groups, in both the UKPDS and DCCT, showed no adverse effects on quality of life.