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Fasting glucose and postprandial glycemia: which is the best target for improving outcomes? The Apollo and 4-T Trials

Background: Two studies, the Apollo and 4-T Trials, were conducted in order to determine which insulin regimen (basal or prandial) is the most efficient for the treatment of insulin-requiring type 2 diabetic patients. Methods: Both trials compared treatments using prandial insulins (aspart or lispro) three times daily with more classical insulin strategies using basal insulin given once daily (glargine or detemir) or twice daily if required (detemir in the 4-T Study). Results/conclusion: Both studies showed that a therapeutic regimen involving prandial insulin resulted in equal (Apollo Study) or greater (4-T Study) reductions in patients' HbA1c levels than basal insulin regimens. However, the prandial insulin strategies were accompanied by higher risks of hypoglycemia and greater weight gain. As a consequence, the investigators of the two studies concluded that basal insulin once daily provides a simple and effective option with less adverse effects than prandial insulin three times a day. Expert opinion: Such conclusions are certainly important for guiding strategies in the vast majority of type 2 diabetic patients who require an add-on insulin therapy. However, the authors' opinion is that the choice between either basal or prandial insulin alone and combined insulin regimens with basal and prandial insulin should be tailored according to the patient's clinical status by paying more attention to the respective contributions of basal and prandial hyperglycemia to their overall hyperglycemia. This recommendation seems to be particularly important when insulin treatment is initiated in patients exhibiting HbA1c levels between 7.0 and 8.0%.