Introduction

The clinical milieu of type 2 diabetes mellitus (T2DM) is undoubtedly one of the most challenging faced by family physicians. The association of T2DM with other chronic diseases, such as hypertension, dyslipidemia, cardiovascular disease, and obesity, speaks to the complex issues that must be addressed. Considering the complexity of these issues, it is important to recognize that, as a chronic disease, T2DM is largely self-managed and patients mostly control their own DM-related health outcomes. To assist patients with T2DM to successfully take on this responsibility, family physicians should raise and discuss the treatment options available to achieve agreed upon goals, and, in consultation with the patient, recommend treatment options that best address the patient’s clinical issues and meet the patient’s needs. These steps are important to help motivate the patient and promote long-term treatment adherence. Among the treatment options available for T2DM, the challenges of self-management are perhaps greatest with insulin.

Insulin is the most physiologic and effective glucose-lowering agent available, and is recommended as glucose-lowering therapy over the spectrum of T2DM.^1,2 Yet studies show that the initiation of insulin treatment is often delayed, sometimes for years, following loss of glycemic control with oral glucose-lowering agents.^3,4 Once initiated, adherence to insulin tends to be moderate at best.^5,6 It is crucial that family physicians address the issues that contribute to low levels of acceptance and adherence to insulin treatment. In addition, physicians need a firm understanding of how to initiate, modify, and intensify insulin therapy. The primary goal of this supplement is to provide the family physician with a detailed understanding of the current recommendations for, and advances in, insulin treatment.

This supplement includes three articles; the first of which is a historical review of the discovery of insulin. Also included in that article, by Michael Heile, MD, and Doron Schneider, MD, FACP, is a review of the evolution of insulin, including a comparison of the clinical pharmacology of human and analog insulins. The second article begins with a discussion of the conceptual strategies to address patient barriers that have a dramatic impact on the acceptance of, and self-management with, insulin. Building on that foundation, Luigi Meneghini, MD, MBA, and Timothy Reid, MD, present 4 case studies that detail how to assist patients in the implementation of these strategies when initiating or intensifying insulin therapy. The case studies also provide practical considerations with respect to dosing basal, basal-bolus, and premixed insulin. The third article examines advances in insulin, with a focus on the investigational agent, ultra–long-acting insulin degludec. Allen King, MD, provides a solid foundation of the clinical pharmacology of insulin degludec and the clinical experience to date regarding the use of insulin degludec in patients with type 1 DM or T2DM.

It is hoped that the information in this supplement will prove helpful for the practicing family physician in managing patients with this increasingly common disease and its associated clinical dilemmas.