The underuse of insulin therapy in North America.
At least 8% of the combined population of the United States (US) and Canada have diabetes, and in about one-third of these people, the disease is undiagnosed [1]. Diabetes is not evenly distributed geographically, and there is surprisingly little consensus among categories of medical providers as to when and how intensive insulin therapy should be initiated. Although some physicians worry that insulin therapy may promote insulin resistance or increase the risk of cardiovascular events, the best current clinical evidence suggests that such fears are largely unfounded. Similarly, new evidence shows that the weight gain associated with insulin therapy is by no means always dramatic or progressive. The view that insulin is not effective in type 2 diabetes, although common in the US, is not shared by physicians experienced and skillful in its use and is refuted by recent clinical studies. Promising new patterns of insulin use in type 2 patients are emerging in the US: the availability of insulin as a single dose, rather than moving directly to multiple daily injections; the practice of continuing rather than stopping oral agents when an evening insulin dose is added; and the use of new insulins and insulin-sensitizing agents that facilitate therapy and increase its effectiveness. Several new treatment options are discussed.