LETTER TO THE EDITOR

Response to Bloomgarden et al. Insulin treatment of type 2diabetes: a clinical perspectiveAmbika Gopalakrishnan UNNIKRISHNAN1 and Vinay PRUSTY2

1Department of Endocrinology and Diabetes, Amrita Institute of Medical Sciences, Kochi, Kerala, India, and 2Novo Nordisk, Copenhagen

A recent issue of the Journal of Diabetes discussed the

findings of an international, independent expert panel

organized by Novo Nordisk to review the current

guidelines for insulin therapy intensification with bipha-

sic insulin aspart (30 ⁄ 70) (BIAsp 30), with the aim of

developing international practical guidelines for insulin

intensification with BIAsp 30 for clinicians.1 An accom-

panying editorial questioned why the consensus state-

ment did not include the comparisons of BIAsp 30 with

other insulins,2 and also stated that ‘‘initial use of basal

insulin titrated to complex basal–bolus multiple daily

insulin (MDI) regimens’’ may be preferable to premixed

MDI regimens, ‘‘although requiring considerable effort

on the parts of both the clinician and patient.’’

While the authors would like to thank the editorial

for raising a discussion about the choice of insulin reg-

imen for intensification, this question was beyond the

scope of the expert panel, whose primary concern was

to analyze the limited international recommendations

for intensification with premixed insulin analogues

(PIAs). PIAs are a simple and effective tool for insulin

intensification and many physicians worldwide choose

this approach because this therapy can easily be inten-

sified by increasing dosing up to three times a day.

The American Association of Clinical Endocrinolo-

gists ⁄American College of Endocrinology algorithm

for glycemic control3 includes the transition from basal

insulin to a PIA twice daily, or from a once-daily to a

twice-daily PIA, but does not include information

about further intensification or practical information

on dosing. Therefore, the expert panel felt that it

was important to provide clinicians with practical rec-

ommendations for intensification using BIAsp 30.

The editorial also suggested the choice of insulin

intensification in the context of the 4-T study, which

demonstrated comparable glycemic control with less

hypoglycemia and weight gain in patients who transi-

tioned from basal insulin to complex basal–bolus MDI

regimens. This was compared with those on once- or

twice-daily premixed insulin analogues (plus midday

prandial insulin if required) over a 3-year period.4 Inter-

estingly, head-to-head comparison trials of BIAsp 30

with basal insulin have shown that BIAsp 30 offers

superior HbA1c reduction in patients who are inade-

quately controlled with oral antidiabetic therapy, with

comparable hypoglycemic episodes.5 Additionally, in a

randomized study, thrice-daily BIAsp 30 was compara-

ble to a basal–bolus MDI regimen (insulin aspart and

NPH insulin) in terms of glycemic control, frequency of

hypoglycemic episodes, and body weight gain.6

Premixed insulin analogues such as BIAsp 30 admin-

istered up to three times a day can provide a conve-

nient way for clinicians and patients to intensify

insulin therapy. The authors of the consensus would

certainly agree with the view expressed in the editorial

that basal–bolus MDI approaches are superior in that

they offer greater flexibility; however, they are also

more demanding in terms of the number of daily injec-

tions, the need for more intensive glucose monitoring,

and the requirement for titration of both the basal and

bolus insulin doses. Thus, basal–bolus MDI regimens

may not be suitable for all individuals because they

may not be able to cope with, or may be unwilling to

implement, the demanding dosing and titration regi-

mens. The consensus guidelines were developed to pro-

vide practical guidance for clinicians with a simple and

effective algorithm for those who wish to intensify

insulin dosing using BIAsp 30.

References

1. Unnikrishnan AG, Tibaldi J, Hadley-Brown M et al.

Practical guidance on intensification of insulin therapy

with BIAsp 30: a consensus statement. Int J Clin Pract.

2009; 63: 1571–7.

Correspondence

Prof. Dr Ambika G. Unnikrishnan, Department of Endocrinology and

Diabetes, Amrita Institute of Medical Sciences, Kochi,

Kerala 682 026, India.

Tel: +91 484 220 5343; Fax: +91 484 280 2020

Email: unnikrishnanag@gmail.com

doi: 10.1111/j.1753-0407.2010.00092.x

Journal of Diabetes 2 (2010) 136–137

136 ª 2010 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Blackwell Publishing Asia Pty Ltd

2. Bloomgarden Z, Drexler A, Handelsman Y. Insulin

treatment of type 2 diabetes: a clinical perspective.

J Diabetes. 2010; 2: 65–6.

3. Rodbard HW, Jellinger PS, Davidson JA et al. Statement

by an American Association of Clinical Endocrinologists ⁄American College of Endocrinology consensus panel

on type 2 diabetes mellitus: an algorithm for glycemic

control. Endocr Pract. 2009; 15: 540–59.

4. Holman RR, Farmer AJ, Davies MJ et al. Three-year

efficacy of complex insulin regimens in type 2 diabetes.

N Engl J Med. 2009; 361: 1736–47.

5. Strojek K, Bebakar WM, Khutsoane DT et al. Once-daily

initiation with biphasic insulin aspart 30 versus insulin

glargine in patients with type 2 diabetes inadequately con-

trolled with oral drugs: an open-label, multinational

RCT. Curr Med Res Opin. 2009; 25: 2887–94.

6. Ligthelm RJ, Mouritzen U, Lynggaard H et al. Biphasic

insulin aspart given thrice daily is as efficacious as a

basal–bolus insulin regimen with four daily injections:

a randomised open-label parallel group four month

comparison in patients with type 2 diabetes. Exp Clin

Endocrinol Diabetes. 2006; 114: 511–9.

Letter to the Editor

ª 2010 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Blackwell Publishing Asia Pty Ltd 137