In a patient with type 2 diabetes, should insulin be always started from once daily administration or can a 2- or 4-injection regimen be used up front?
René Rodríguez-Gutiérrez, MD: I would say keep it easy. The easiest way, and supported by the evidence we have, is to start once-a-day basal insulin. Of course, there are some exceptions to this rule, and that is a patient who comes to us very uncontrolled with long-standing diabetes, in which case you know for sure that using once-a-day basal insulin would not be enough. Even in those cases starting with just basal insulin may be a good idea and trying just to improve glycemic control—maybe not with a regimen, just trying to improve it.
In the end I think it is not about a raise, just trying to improve glycemic control and starting with basal insulin, then titrating basal insulin, and if it is necessary then using a basal plus or a basal-bolus regimen. But I would say most of the time once-a-day basal insulin is quite safe and effective.