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Introduction
Diabetes is a huge and growing global public health problem with an enormous economic burden [1]. According to the International Diabetes Federation (IDF), the number of adults living with diabetes in 2017 is projected to increase from 425 to 629 million in 2045 (a 48% rise) [2]. The loss of the first phase of insulin is the initial pathophysiologic defect in type 2 diabetes mellitus [3]. Insulin, alone or along with other pharmacologic and nonpharmacologic measures of treatment, is widely used in the management of diabetes. Insulin enables adequate glycemic control thus significantly reducing the vascular complications of diabetes. Early insulin use has been associated with reversal of diabetes [4, 5–6].
To tackle the epidemic of diabetes, various countries are scaling up equitable and affordable access to insulin for improved care [2]. Multiple regimens, formulations, and delivery devices of insulin are increasingly being used to individualize treatment and attain the best possible glycemic control in people with diabetes [7, 8]. Available subcutaneous insulins differ in onset, peak, and duration of action and in safety profiles, ranging from ultra-short-acting to ultra-long-acting preparations. With a plethora of formulations, which need to be matched with heterogenous patient profiles, the initiation and intensification of insulin therapy are increasingly becoming challenging [8]. Adult-onset diabetes has been stratified into subgroups to individualize treatment according to patient characteristics, disease progression, and risk of diabetic complications. These subgroups include insulin-deficient and insulin-resistant diabetes as well as mild obesity- and age-related diabetes [9].
Guidelines for the non-pharmacologic and pharmacologic management of diabetes have been formulated by the IDF, American Diabetes Association (ADA), and American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE). The approach to insulin therapy has been described in multiple guidelines for diabetes. The ADA has described an algorithm for the initiation of insulin therapy with basal insulin and the stepwise inclusion of rapid-acting and premixed insulins [10]. The IDF and AACE/ACE have also described a comprehensive algorithm for adding or intensifying insulin in persons with type 2 diabetes [2, 11]. The AACE/ACE explores factors that should be considered when selecting a formulation for insulin initiation, including age, life expectancy, motivation, presence of complications, overall health status, and cost of formulations. In these guidelines, the key disease characteristics...