Should insulin be started early (prior to optimization of other anti-hyperglycemic medications) in patients with mild-to-moderate diabetes and hypertriglyceridemia refractory to statin and fibrates?  

Not necessarily. The goal should be achieving optimal glucose control to improve triglyceride levels. This can be accomplished with non-insulin agents, such as GLP-1 agonists and others, that can have beneficial effects on triglycerides.

I would agree with the above comment and add that one should not discount the salutary lipid/triglyceride impact of improved cardiorespiratory fitness (CRF). Most patients are significantly sedentary and will be metabolically responsive even to a minor improvement in CRF. Moreover, increased CRF wil...