Basal insulin in the age of innovation: are diamonds still forever?

Abstract

Introduction: Basal insulin has long served as a cornerstone in the management of type 2 diabetes. However, the emergence of glucose-lowering agents with cardiometabolic benefits - such as glucagon-like peptide 1 receptor agonists, sodium-glucose cotransporter 2 inhibitors, and dual incretin receptor agonists - has prompted a reassessment of insulin's role in the modern therapeutic landscape.

Areas covered: This article reviews recent evidence from cardiovascular outcomes trials and head-to-head studies comparing newer agents to basal insulin. A targeted literature search was conducted using PubMed and major diabetes guidelines to identify high-quality studies and recommendations. The discussion covers clinical scenarios where basal insulin remains essential, the benefits of combination therapy, and the impact of recent innovations such as once-weekly insulin formulations.

Expert opinion: While modern therapies are increasingly prioritized due to superior efficacy, safety, and weight benefits, basal insulin remains indispensable for patients with advanced β-cell failure, symptomatic hyperglycemia, or contraindications to newer agents. Personalized, pathophysiology-driven strategies should guide therapy selection, including the integration of basal insulin where appropriate.