Optimizing Type 2 Diabetes Management in Iraq: Expert Consensus on Initiation and Intensification of Insulin-Based Treatment Options

INTRODUCTION: Type 2 diabetes mellitus (T2DM) prevalence in Iraq is projected to rise significantly by 2045, creating urgent need for optimized use of latest insulin therapies. An expert panel of eleven diabetes specialists convened to assess the evolving landscape of insulin therapies and explore how each option fits into current strategies to optimize T2DM management in Iraq. METHODS: The panel reviewed international guidelines and local practice patterns through pre-meeting surveys. Discussions focused on initiation and intensification of insulin-based treatment in Iraq's context, considering accessibility challenges and patient characteristics. RESULTS: When hemoglobin A1c (HbA1c) is < 2% above target, basal insulin (BI) is recommended for patients with body mass index (BMI) ≤ 30. For BMI > 30, either GLP-1 receptor agonist (GLP-1 RA) monotherapy or a fixed ratio combination (FRC) of GLP-1 RA and BI is preferred. When HbA1c is ≥ 2% above target, initiation with BI and GLP-1 RA is advised across BMI groups. If glycemic targets are not achieved despite reaching 0.5 U/kg of BI, prandial insulin may be added via premixed regimen or basal-bolus regimens based on individual factors. Premix insulin remains an alternative when other options are unavailable. Key barriers in Iraq include high cost and limited availability of GLP-1 RAs, therapeutic inertia, and gaps in healthcare infrastructure. Final treatment decisions should consider disease severity, cardiovascular and renal comorbidities, and weight goals. CONCLUSION: The panel curated clinical practical recommendations about injectable insulin therapies and proposed a structured treatment algorithm tailored to Iraq's healthcare setting, prioritizing simplicity, efficacy, tolerability and accessibility. The panel emphasized the critical role of second-generation BIs and FRCs of BI and GLP-1 RA in Iraq's T2DM treatment algorithm, providing clear guidance on their optimal use and place in therapy, overcoming barriers, alongside enhanced education for healthcare providers and patients.