Indian National Consensus Group: National Guidelines on Initiation and Intensification of Insulin Therapy with Premixed Insulin Analogs

Abstract

Currently, physicians across the world are striving to practice medicine based on evidence. Evidence-based medicine refers to the incorporation of the most recent clinical research physicians’ experience and patients’ wishes and needs into clinical practice. The treating physician is often confronted with the dilemma of which insulin to use and currently the use of a patient-centered approach for attaining the glycemic goals is being widely recommended. In 2009, the Indian National Consensus Group (INCG) published the “Premix Insulin: Initiation and Continuation Guidelines for Management of Diabetes in Primary Care” with the aim of providing primary care physicians (PCPs) a simplified regimen based on the patients’ and physicians’ needs and expectations. This guideline recommended the use of premix insulin regimen for its convenience, safety and efficacy. This was probably one of the first guidelines on insulin therapy in India, which provided a simple guide for initiation and intensification of insulin therapy. Subsequently, the improving management practices and clinical outcomes in type 2 diabetes (IMPACT) study were planned with the objective of validating this guideline and providing insights for further improvement and revision. The purpose of this paper is to contextualize the existing Indian insulin guidelines (IIGs) through evidence-based recommendations for appropriate management and its use in Indian scenario. We propose a systematic approach intended to assist PCPs in developing strategies that can effectively assist in providing optimal glycemic control in type 2 diabetes. Recommendations based on comparative effectiveness and safety of premixed insulin analogs over other regimens have been developed besides focusing on the role of highratio premixes, diabetes management in special populations and during periods of fasting. A systemic literature review was conducted covering peerreviewed studies and publications in the field of management of diabetes with premixed insulin analog based therapies. Although each recommendation has been designed and graded by the weight it should have in clinical practice and by the degree of support from literature, logic and clinical judgment and decisions of individual physicians remain critical for successful implementation of any guideline. It is also worthwhile to note that evidence-based medicine keeps evolving every day and so will guidelines. It is recommended that this guideline may be used for optimizing premixed insulin analog therapy. However, individualization of therapy based on patients’ preferences, needs and attitude remain most critical while treating diabetes.