Type 2 diabetes is the most common type of diabetes in adults and   is characterized by both peripheral  insulin resistance and impaired insulin secretion.   Treatment   of   type   2   diabetes   include   education,   lifestyle changes and oral medications to maintain good glycemic control. As the disease progresses with worsening hyperglycemia and deterioration in beta cell function and loss of beta cell mass most T2DM  patients will eventually   require   insulin   to   reach   glycemic   target.     Most   common indication of insulin initiation is when glycemic control has deteriorated despite  maximally tolerated oral agents.

Aim
The aim of our study was to examine the following:1. Indications for insulin initiation 2. Initial insulin regimen prescribed 3. Effect on glycemic control

Method
This   was   a   prospective   study   conducted   at   an   Endocrine   Center   in Kathmandu, Nepal . A total of 101 patients( 55 male and 101 female)with type   2 diabetes  were   enrolled in our   study. Patients already   on insulin use, not willing for insulin therapy and type 1 diabetic patients were   excluded   from   this   study.   Baseline   FBS,   PP  blood   sugar   and HbA1c  were analyzed at the time  of  initiation  and compared after 3 months using paired t test. 

Results
In total 101 eligible adults (55 males, 46 females; mean age 55.02 ± 12.7; mean baseline HbA1c 10.68 ± 3.44)  initiated insulin. Premixed insulin(55.4%) was the  most   common prescribed insulin followed   by   basal insulin (28.43%) and basal bolus insulin (15.8%). The most common indication of insulin initiation was poorly controlled diabetes (72.2%)followed by high HbA1c   at diagnosis (11.8%), diabetes complications 8.9% and OHA failure 6.9%. The mean HbA1c at 3 months follow up was 7.72±1.506.

Conclusion
In our study poorly controlled diabetes was the most common indication for insulin initiation and premixed insulin was the most common insulin prescribed insulin followed by basal insulin. Patients who were started on insulin therapy achieved good glycemic control at 3 months followup. Initiating insulin therapy in type 2 diabetes patients can lead to good glycemic control and reduce risk for long term complications.

Insulin initiation in Nepalese patients with type 2 diabetes: types, indications and outcomes