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N Engl J Med. 2009 Oct 29;361(18):1736-47. doi: 10.1056/NEJMoa0905479. Epub 2009 Oct 22.

Three-year efficacy of complex insulin regimens in type 2 diabetes.

Collaborators (163)

Holman R, Darbyshire J, Davies M, Toft AD, Farmer A, Gall M, Levy J, Nelson G, Schou H, del Prato S, Campbell I, Gray R, Hills R, Marshall S, Scarpello J, Davies M, Adler A, Harvey P, Neary G, Bilous M, Farmer J, Gray S, Jones R, Kelly C, Mellor D, Millward A, Moore D, Russell-Jones D, Nolan J, Barrow B, Darbyshire J, Doran Z, Dudley C, Gilligan A, Gregory V, Hartweg J, Harris E, Holman R, Keenan J, Kennedy I, Macdonald K, McLeod D, Motupally S, Roberts R, Paul S, Stratton I, Thorne K, Tse A, Tucker L, Usman M, Carpenter J, Carter R, Fisher K, Islam K, Klyne R, Mansfield L, Platt A, Shine B, Tse A, Waknell T, Aggarwal A, Blakemore J, Brown A, Bryant N, Budwal M, Carrington C, Chambers F, Chubb B, Clemente L, Crawshaw L, Dunmore N, du Preez M, Fenton J, Fitch M, Fox J, Gordon C, Hauff J, Hoppen K, Hutchins D, Lewis R, Lighter D, Lowe L, McQuade S, Mansfield S, Minns I, Monk A, Griffiths N, Patterson M, Peck S, Pike C, Meakin R, Rosenfalck A, Shadbolt J, Shamash S, Sorensen T, Stack M, Stella P, Taylor R, Townshend E, Wilkinson P, Williams S, Young R, Adler A, Akintewe A, Atkin S, Barnett T, Bennett S, Bilous R, Bodmer C, Borthwick L, Davies R, Fox C, Furlong N, Gallen I, Gill G, Gregory R, Harvey P, Hassey A, Heller S, Home P, Hopkins D, Johnson A, Jude E, Kerr D, Kumar S, Litchfield J, Lorains J, McLeod K, McNally P, Mansfield M, Matthews D, Millward A, O'Hare P, Page S, Panahloo A, Robertson D, Rossi M, Rowe R, Russell-Jones D, Sampson M, Scobie I, Stephens W, Strang C, Vora J, Wheatley T, Whitelaw D, Wiles P, Winocour P, Dunne F, Kinsley B, Nolan J, Sreenan S, Andrews J, Henry W, Hunter S, Abraham P, Collier A, Gray S, Jaap A, Leese G, Malik I, Matthews D, Walker J.

Erratum in

  • N Engl J Med. 2010 Nov 18;363(21):2078.



Evidence supporting the addition of specific insulin regimens to oral therapy in patients with type 2 diabetes mellitus is limited.


In this 3-year open-label, multicenter trial, we evaluated 708 patients who had suboptimal glycated hemoglobin levels while taking metformin and sulfonylurea therapy. Patients were randomly assigned to receive biphasic insulin aspart twice daily, prandial insulin aspart three times daily, or basal insulin detemir once daily (twice if required). Sulfonylurea therapy was replaced by a second type of insulin if hyperglycemia became unacceptable during the first year of the study or subsequently if glycated hemoglobin levels were more than 6.5%. Outcome measures were glycated hemoglobin levels, the proportion of patients with a glycated hemoglobin level of 6.5% or less, the rate of hypoglycemia, and weight gain.


Median glycated hemoglobin levels were similar for patients receiving biphasic (7.1%), prandial (6.8%), and basal (6.9%) insulin-based regimens (P=0.28). However, fewer patients had a level of 6.5% or less in the biphasic group (31.9%) than in the prandial group (44.7%, P=0.006) or in the basal group (43.2%, P=0.03), with 67.7%, 73.6%, and 81.6%, respectively, taking a second type of insulin (P=0.002). [corrected] Median rates of hypoglycemia per patient per year were lowest in the basal group (1.7), higher in the biphasic group (3.0), and highest in the prandial group (5.7) (P<0.001 for the overall comparison). The mean weight gain was higher in the prandial group than in either the biphasic group or the basal group. Other adverse event rates were similar in the three groups.


Patients who added a basal or prandial insulin-based regimen to oral therapy had better glycated hemoglobin control than patients who added a biphasic insulin-based regimen. Fewer hypoglycemic episodes and less weight gain occurred in patients adding basal insulin. (Current Controlled Trials number, ISRCTN51125379.)

2009 Massachusetts Medical Society

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