The goal of pharmacologic treatment for type 2 diabetes is to achieve and maintain a near-normal glycated hemoglobin (A1C) concentration while minimizing hypoglycemia; an A1C goal of <7% is recommended for most patients to prevent or reduce the microvascular complications of diabetes (retinopathy, nephropathy, neuropathy). An A1C target of <8% may be appropriate for patients who are older, have comorbid conditions, or are at risk for serious hypoglycemia-associated adverse events.

View the Comparison Chart: Some Available Insulins for Type 2 Diabetes

The goal of drug therapy for type 2 diabetes is to achieve and maintain a near-normal glycated hemoglobin (A1C) concentration without inducing hypoglycemia; for most patients, the target A1C is <7%. Metformin is the preferred first-line treatment, but most patients with type 2 diabetes eventually require multidrug therapy and/or insulin to achieve glycemic control.

View the Expanded Table: Some Available Insulins

The goal of drug therapy for type 2 diabetes is to achieve and maintain a near-normal glycated hemoglobin (A1C) concentration without inducing hypoglycemia; the target is generally an A1C of ≤7%. Treating to this target has been shown to prevent microvascular complications (retinopathy, nephropathy, and neuropathy), but whether it prevents macrovascular outcomes is unclear. An A1C target of <8% may be appropriate for older patients and those with underlying cardiovascular disease, a history of severe hypoglycemia, diabetes-related complications or comorbidities, or a long duration of disease.

The FDA has approved Toujeo (Sanofi), a more concentrated form of insulin glargine containing 300 IU/mL compared to the 100 IU/mL in Lantus (Sanofi). Lantus is nearing the end of its patent protection in the US, and biosimilars are expected to become available.

The goal of drug therapy for type 2 diabetes is to achieve and maintain a near-normal A1C concentration without inducing hypoglycemia; the target is generally an A1C of <7.0%. Treating to this target has been shown to prevent the microvascular complications of retinopathy and nephropathy, but whether it prevents macrovascular outcomes remains unclear. Three large trials found that intensive glucose control did not reduce the incidence of macrovascular events. One of these trials (ACCORD) in >10,000 patients with type 2 diabetes, with or at high-risk for cardiovascular disease, found that treating patients intensively with antihyperglycemic drugs to an A1C target of 6.0% for a mean of 3.7 years did not significantly reduce the incidence of major cardiovascular events (the primary endpoint) and was associated with increased all-cause mortality compared to patients treated to an A1C target of 7.0-7.9%. An A1C target of 7-8% may be prudent in older patients and in those with underlying cardiovascular disease, severe hypoglycemia, or multiple diabetes-related complications or co-morbidities.

The development of hyperglycemia in type 2 diabetes results from a combination of metabolic abnormalities that includes insulin resistance, diminished insulin secretion and excess hepatic glucose production. Diet, exercise and weight loss are helpful in improving glucose control, but most patients ultimately require drug therapy.

The development of hyperglycemia in type 2 diabetes results from a combination of metabolic abnormalities including insulin resistance, diminished insulin secretion and excess hepatic glucose production. Diet, exercise and weight loss are helpful in improving glucose control, but most patients ultimately require drug therapy.

The development of hyperglycemia in type 2 diabetes results from a combination of metabolic abnormalities including insulin resistance, excess hepatic glucose production and diminished insulin secretion. In many patients, diet and regular exercise can improve glucose control. Most drugs currently available for management of type 2 diabetes increase insulin supply (sulfonylureas, other secretagogues and insulin itself), decrease insulin resistance (thiazolidinediones) or improve the effectiveness of insulin (biguanides). Alpha-glucosidase inhibitors reduce the rate of glucose absorption. Newer agents such as pramlintide (Symlin) and exenatide (Byetta) have multiple effects to increase satiety and reduce postprandial hyperglycemia.

The development of hyperglycemia in type 2 diabetes results from a combination of metabolic abnormalities including insulin resistance, excess hepatic glucose production and diminished insulin secretion. Most drugs currently available for management of type 2 diabetes fall into 2 categories: those that increase insulin supply (sulfonylureas, other secretagogues and insulin itself) and those that decrease insulin resistance or improve its effectiveness (biguanides, thiazolidinediones). Alpha-glucosidase inhibitors reduce the rate of glucose absorption.

Insulin aspart (Novolog - Novo Nordisk) is the second rapid-acting insulin analog to be approved by the FDA. The first was insulin lispro (Humalog). Insulin aspart differs from human insulin by substitution of aspartic acid for proline in position 28 on the beta-chain.

Insulin Glargine (Lantus) is a new long-acting human insulin analog approved by the FDA for treatment of both type 1 and type 2 diabetes. Synthesized by recombinant DNA technology, it differs from human insulin at position 21 in the A-chain where asparagine is replaced by glycine and at the C-terminus of the B-chain where two arginines are added.

Lispro insulin (Humalog - Lilly), a synthetic insulin analog, has been approved for marketing by the US Food and Drug Administration. Prepared by recombinant DNA methods using E. coli, lispro differs from human insulin in having lysine and proline at positions 28 and 29 on the beta-chain, reversed from their natural position. The new drug has biologic effects similar to unmodified insulin, but is absorbed more rapidly after subcutaneous injection.

The NovolinPen (Squibb - Novo) is a device that uses prefilled cartridges to inject semisynthetic human insulin (Medical Letter, 25:63, 1983). Three formulations are available: regular insulin (Novolin R PenFill), NPH insulin isophane (Novolin N PenFill) and a mixture of 70% NPH and 30% regular (Novolin 70/30 PenFill). The NovolinPen is advertised as more accurate, more convenient and less expensive than conventional syringes and needles. The same device is marketed in Canada as the Novolin-Pen II (Connaught Novo). (An earlier device is also available as the Novolin-Pen in Canada and the NovoPen in the USA.)