Expert opinion statement on the use of insulin therapy in patients with type 2 diabetes in primary care

Although the United Kingdom Prospective Diabetes Study (UKPDS) demonstrated the undoubted benefits of tight glycaemic control, over time most patients required oral combination therapy or insulin even to get close to glycaemic targets. Despite this, much confusion remains regarding the place of insulin therapy in management of type 2 diabetes. In this article we provide a series of questions and answers relating to the use of insulin therapy in primary care based on the clinical experience of a multidisciplinary group of health professionals working in this area. We overview the undoubted advantage (and pitfalls) of intensive glycaemic control in preventing/delaying vascular complications and provide recommendations on indications for insulin initiation. We go on to discuss the question of who should prescribe insulin and in what clinical setting. Ideally, initiation should be in a clinical setting where the competence and skills exist in a convenient location for the patient. We then consider which insulin regimens should be used in type 2 diabetes with discussion of insulin in combination with oral agents, further intensified insulin treatment (basal bolus regimens) and twice daily premixed insulins. Insulin start doses are also discussed as well as titration regimens. We also consider the role of the rapid-acting and long-acting analogues in insulin therapy for type 2 diabetes. We conclude that insulin prescribing in primary care is becoming a reality and probably a necessity in view of the increasing number of patients with type 2 diabetes. This will require appropriate training, funding and support at all levels (particularly from secondary care) if this is to be successful. We hope that this article will help to simplify and demystify insulin prescribing in primary care and allow more patients to be appropriately and optimally treated. Copyright © 2003 John Wiley & Sons, Ltd.