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Competing Interests: CAB was supported by the Dutch Research Council's Rubicon programme (project number 452022313). MKA reported a past grant from Merck & Co to Emory University and past consulting fees from Bayer and Eli Lilly and Company outside the scope of the submitted work. All other authors declare no competing interests.

Competing Interests: No support was received for writing this manuscript. Authors declare the following support or relationships within 36 months of submitting the work. DF reports a Pilot and Feasibility Grant funded by the Michigan Center for Diabetes Translational Research (US National Institutes of Health grant P30-DK092926) and a grant from the Swinmurn Foundation to implement a sustainable diabetes clinic in Guatemala. DF also reports volunteer affiliations with Wuqu' Kawoq and GlucoSalud. DF has received research fellowship funding from the National Clinician Scholars Program at the University of Michigan Institute for Healthcare Policy and Innovation. TB reports grants from the Alexander von Humboldt Foundation, Wellcome Trust, and US National Institutes of Health. RA reports contracts with Novo Nordisk, the Union for International Cancer Control, Novo Nordisk, Hoffman-La Roche, and Sloan Memorial Kettering Hospital. RA also reports payments or honorario from Merck and Hoffmann-La Roche. JD reports grants from UK MRC and National Institute for Health Research, and US National Institute of Health. All other authors declare no competing interests.

Background: The amount of insulin needed to effectively treat type 2 diabetes worldwide is unknown. It also remains unclear how alternative treatment algorithms would affect insulin use and disability-adjusted life-years (DALYs) averted by insulin use, given that current access to insulin (availability and affordability) in many areas is low. The aim of this study was to compare alternative projections for and consequences of insulin use worldwide under varying treatment algorithms and degrees of insulin access., Methods: We developed a microsimulation of type 2 diabetes burden from 2018 to 2030 across 221 countries using data from the International Diabetes Federation for prevalence projections and from 14 cohort studies representing more than 60% of the global type 2 diabetes population for HbA 1c , treatment, and bodyweight data. We estimated the number of people with type 2 diabetes expected to use insulin, international units (IU) required, and DALYs averted per year under alternative treatment algorithms targeting HbA 1c from 6·5% to 8%, lower microvascular risk, or higher HbA 1c for those aged 75 years and older., Findings: The number of people with type 2 diabetes worldwide was estimated to increase from 405·6 million (95% CI 315·3 million-533·7 million) in 2018 to 510·8 million (395·9 million-674·3 million) in 2030. On this basis, insulin use is estimated to increase from 516·1 million 1000 IU vials (95% CI 409·0 million-658·6 million) per year in 2018 to 633·7 million (500·5 million-806·7 million) per year in 2030. Without improved insulin access, 7·4% (95% CI 5·8-9·4) of people with type 2 diabetes in 2030 would use insulin, increasing to 15·5% (12·0-20·3) if insulin were widely accessible and prescribed to achieve an HbA 1c of 7% (53 mmol/mol) or lower. If HbA 1c of 7% or lower was universally achieved, insulin would avert 331 101 DALYs per year by 2030 (95% CI 256 601-437 053). DALYs averted would increase by 14·9% with access to newer oral antihyperglycaemic drugs. DALYs averted would increase by 44·2% if an HbA 1c of 8% (64 mmol/mol) were used as a target among people aged 75 years and older because of reduced hypoglycaemia., Interpretation: The insulin required to treat type 2 diabetes is expected to increase by more than 20% from 2018 to 2030. More DALYs might be averted if HbA 1c targets are higher for older adults., Funding: The Leona M and Harry B Helmsley Charitable Trust., (Copyright © 2019 Elsevier Ltd. All rights reserved.)