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Many patients with type 2 diabetes eventually need insulininsulin.. But which regimen works best for people with poor control despite maximum doses of oral agents? In one trial, none of the options worked particularly well. Only a minority of patients in each group reached their target concentration of glycated haemoglobin during the first year of treatment (16% of all 708 participants). Participants who took their insulin before each meal or had biphasic insulin twice a day did significantly better than those who took basal insulin at bedtime. But both regimens were associated with worse hypoglycaemia and substantial weight gain. Patients on prandial insulin gained more than a 5 kg average. Patients in all three groups needed increasing amounts of insulin as the year progressed.
The authors hesitate to make final recommendations as their study is continuing for another two years and the findings may look very different in the end. An editorial agrees that doctors shouldn't change their practice in response to these interim results (p 1759). Basal insulin is still the best and safest first line option for those who need it. Aggressive management of blood pressure, lipids, platelets, and lifestyles is equally important.