The primary purpose of the study is demonstration that teaching insulin management in small groups of type 2 diabetes patients in 4 weekly "live" Internet sessions is safe and provides an important resource for rural diabetes care providers who may otherwise, because of lack of time or staff, not be able to put patients on insulin who need it.

The proposed project will test in a limited number of rural and semi-rural sites in the state of Kansas an innovative model of synchronous ("live") Internet initiation and intensification of once daily basal insulin glargine or detemir in type 2 diabetic patients that can be deployed statewide in a subsequent larger study (R18). The study's specific aims are to 1) develop a synchronous ("live") interactive Internet-administered course designed to teach groups of type 2 diabetic patients to safely administer basal insulin without significant support from their usual source of diabetic management and to self-adjust the dose to achieve a HbA1c < 7.0% using a treat-to-target algorithm; and 2) to assess for the Internet patients selected clinical and psychometric outcomes. These will include HbA1c, frequency and severity of hypoglycemia, psychological resistance to insulin treatment, diabetes quality of life, and treatment satisfaction. The study builds upon the findings of the Treat-to-Target and INITIATE trials, as well as on successful Internet interventions for weight management, and both lays the conceptual foundation and gathers the expertise to successfully apply for the R18, which will have as primary aims addressing of delays to insulin therapy documented in the DAWN study and cost effectiveness analysis of the Internet intervention. The study hopes to show that Internet teaching of basal insulin therapy is comparable to traditional insulin management with respect to safety and effectiveness as measured against expected (published) results for frequency of hypoglycemia and percent of patients reaching target. Psychometric outcomes are exploratory - and hypothesis generating with respect to the subsequent R18 application.

Inclusion Criteria:

• T2DM, meets provider criteria for insulin initiation; starting or having started insulin treatment no longer than six months prior to enrollment OR has not yet committed to starting insulin but has agreed to participate in the education
• broadband Internet and experience with logging into a password-protected site (e.g., eCommerce or social networking);
• ability to purchase or otherwise acquire glargine/detemir insulin and testing supplies.

Exclusion Criteria:

• Use of oral glucocorticoids or second generation anti-psychotics;
• previous use of self-administered insulin more than six months prior to enrollment;
• gestational diabetes or other endocrine conditions causing hyperglycemia; treatment for a malignant condition other than basal cell carcinoma in situ within prior two years;
• renal insufficiency (AST/ALT >2 or concurrent liver disease except NASH);
• pregnant or planning to become pregnant within 6 months;
• HbA1c < 7.0% or ongoing weight loss or persistent fasting hyperglycemia > 250 mg/dl.

6 month follow up period post Internet intervention

Adverse events were defined as hypoglycemic events (either a blood glucose reading <70 or symptomatic hypoglycemia). Our formal data collection included only hypoglycemia as an adverse event. Subjects continued to see their primary care providers throughout the study for any medical issues unrelated to the intervention.

This was a pilot study designed to compare rates of hypoglycemia among Internet managed type 2 patients to those from large clinical trials. It was not a placebo controlled trial.