A practical approach to the clinical challenges in initiation of basal insulin therapy in people with type 2 diabetes.

Initiating insulin therapy with a basal insulin analogue has become a standard of care in the treatment of type 2 diabetes mellitus (T2DM). Despite increasing choices in pharmacological approaches, intensified glucose monitoring and improvements in quality of care, many patients do not achieve the desired level of glycemic control. Although insulin therapy, when optimized, can help patients reach their glycemic goals, there are barriers to treatment initiation on both the side of the patient and provider. Providers experience barriers based on their perceptions of patients' capabilities and concerns. They may lack the confidence to solve the practical problems of insulin therapy and avoid decisions they perceive as risky for their patients. In this paper we review recommendations for basal insulin initiation, focusing on glycemic targets, titration, monitoring, and combination therapy with non-insulin antihyperglycemic medications. We provide practical advice on how to address some of the key problems encountered in everyday clinical practice and give recommendations where there are gaps in knowledge or guidelines. We also discuss common challenges faced by people with T2DM, such as weight gain and hypoglycemia, and how providers can address and overcome them. This article is protected by copyright. All rights reserved.