Stuart Ross, MB, ChB, FRACP, FRCP(C), Clinical Professor of Medicine, University of Calgary, Calgary, AB.

With glucose targets becoming more stringent, there is a growing need for insulin therapy. The prevalence of diabetes is rising and many of these new diabetic patients will be older and will require insulin as part of their management. When commencing the older patient on insulin, the advantages and concerns of treatment need to be reviewed. Aspects such as physical, mental and visual problems must be carefully assessed; practical and safe glucose targets must be established based on the individual patient's needs and capabilities. Insulin can initially be commenced at nighttime and slowly increased to reach safe morning glucose targets and, if required, fast-acting analog insulins can be added during the day. Complex insulin regimens should be avoided unless essential.
Key words: insulin, analog insulin, glucose targets, hypoglycemia.

Sheldon Singh, BSc
Toronto, ON and

George Fantus, MD, FRCPC,
Diabetology
Mount Sinai Hospital
Toronto, ON and
Director, Banting & Best Diabetes Centre Core Lab

In the USA, the prevalence of type 2 Diabetus Mellitus (T2DM), in individuals over 65 is estimated to be 10%. This is twice the prevalence of the overall USA population. The worldwide prevalence of T2DM is steadily increasing due to factors such as an increase in the elderly population, obesity, and decreased physical activity.

Multiple mechanisms are involved in the pathogenesis of T2DM including impaired insulin secretion by pancreatic b-cells, increased hepatic gluconeogenesis, and reduced glucose uptake by muscles and adipose tissue (see figure 1). These factors lead to hyperglycemia and in the long term, micro- and macrovascular complications. Available evidence indicates that improved glycemic control will decrease the complications of diabetes; this may be achieved with a combination of dietary, exercise and pharmacologic interventions.

Current pharmacologic agents used to treat T2DM include sulphonylureas (glibenclamide, gliclazide), biguanides (metformin), alpha-glucosidase inhibitors (acarbose), or insulin.