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Cucinotta D, Smirnova O, Christiansen JS, Kanc K, le Devehat C, Wojciechowska M, López de la Torre M, Liebl A. Three different premixed combinations of biphasic insulin aspart - comparison of the efficacy and safety in a randomized controlled clinical trial in subjects with type 2 diabetes. Diabetes Obes Metab 2009; 11:700-8. [PMID: 19476479 DOI: 10.1111/j.1463-1326.2009.01035.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To evaluate clinical efficacy and safety of biphasic insulin aspart (BIAsp) 30 twice daily (b.i.d.) vs. BIAsp 50 or BIAsp 70 (high-mix regimens) thrice daily (t.i.d.) all in combination with metformin in a 36-week clinical trial in subjects with type 2 diabetes. METHODS Efficacy measurements included haemoglobin A(1c) (HbA(1c)) and eight-point plasma glucose (PG); safety included adverse events (AEs) and hypoglycaemic episodes. The three treatment groups (approximately 200 subjects in each group) were well matched regarding sex ratio, ethnicity, age and body mass index. RESULTS After 12 weeks, 43% and 54% in the BIAsp 50 and 70 groups, respectively, switched their dinner insulin to BIAsp 30. Both high-mix regimens were non-inferior to BIAsp 30 b.i.d., as measured by change in HbA(1c), and the BIAsp %50 regimen was superior. The odds for meeting the American Diabetes Association and The American Association of Clinícal Endocrinologist HbA(1c) targets of <7% and < or =6.5%, respectively, were significantly higher with the BIAsp 50 regimen than with BIAsp 30. A significantly lower PG level was achieved from lunch until 02:00 hours with both high-mix regimens compared with BIAsp 30 b.i.d. AEs were mild or moderate with all three regimens. Frequency of hypoglycaemic episodes was comparable for the BIAsp 50 and the BIAsp 30 b.i.d. regimens but was significantly higher with BIAsp 70 t.i.d. CONCLUSIONS Glycaemic control improved with BIAsp 50 t.i.d. without higher incidence of hypoglycaemia compared with BIAsp 30 b.i.d.; with BIAsp 70 t.i.d. lower PG levels from lunch to 02.00 hours, but more hypoglycaemic episodes were obtained compared with BIAsp 30 b.i.d.
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Affiliation(s)
- D Cucinotta
- Dipartimento di Medicina Interna, Policlinico Universitario, Via Consolare Valeria, Messina 1 98124, Italy.
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Abstract
The pharmacological advantages of the rapid-acting analog, insulin aspart, over human insulin have contributed to the widespread prescription of the premix, biphasic insulin aspart 30/70 (BIAsp 30), in type 1 (T1DM) and type 2 diabetes (T2DM). This article reviews the available literature on the pharmacology, efficacy and safety of BIAsp 30 in T1DM and T2DM from an online search of the PubMed database. Following injection, BIAsp 30 reaches higher plasma insulin levels more quickly than human premix or basal insulin, giving effective reduction of postprandial hyperglycemia. In T1DM patients, randomized controlled trials (RCTs) have shown that HbA(1c) reduction is similar, but postprandial glycemic control is better, with BIAsp 30 than with human insulin regimens. In T2DM patients, lowering of HbA(1c) and postprandial hyperglycemia with BIAsp 30 compare favorably with optimized oral antidiabetes drug treatment, insulin glargine, and, in obese patients, human premix. An increase in minor hypoglycemia with BIAsp 30 relative to basal insulin has been reported in T2DM patients, but major and nocturnal hypoglycemia rates are generally low. Findings from RCTs in T2DM patients are supported by large observational studies. In summary, BIAsp 30 once to three times daily represents a simple and effective tool for the modern management of diabetes.
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Affiliation(s)
- Paul Valensi
- Department of Endocrinology-Diabetology-Nutrition, Jean Verdier Hospital, AP-HP, Paris Nord University, CRNH-IdF, Bondy, France
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Güler S, Sharma SK, Almustafa M, Kim CH, Azar S, Danciulescu R, Shestakova M, Khutsoane D, Bech OM. Improved Glycaemic Control with Biphasic Insulin Aspart 30 in Type 2 Diabetes Patients Failing Oral Antidiabetic Drugs: PRESENT Study Results. ACTA ACUST UNITED AC 2009; 2:23-33. [PMID: 19684847 PMCID: PMC2721962 DOI: 10.1111/j.1753-5174.2008.00015.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Aims This paper presents the treatment outcomes for patients intiated on biphasic insulin aspart 30 (BIAsp 30) treatment: BIAsp 30-only, BIAsp 30 + sulphonylureas (SU), BIAsp 30 + biguanides (BI), BIAsp 30 + SU + BI, BIAsp 30 + alpha-glucosidase inhibitors (GI), and BIAsp 30 + BI + thiazolidinediones (TZD) after failing oral antidiabetic drugs (OADs) treatment. Methods This was a multi-national, multi-centre, six-month, prospective, open-labelled, uncontrolled, clinical experience evaluation study, with the exception of a three-month study in one country (China) (“all exclude China” and “China”). Initiation and discontinuation of BIAsp 30 treatment were entirely at the discretion of the attending physicians. Results Mean HbA1c, FPG and PPPG were significantly reduced from baseline at three and six months in all groups (P < 0.001). In “all exclude China”, reductions in mean HbA1c, FPG and PPPG at six months were as follows: BIAsp 30-only group (−2.12 ± 1.76% points; −4.82 ± 3.86 mmol/L; −6.89 ± 4.74 mmol/L), BIAsp 30 + BI group (−2.24 ± 1.77% points; −4.48 ± 3.68 mmol/L; −6.66 ± 4.55 mmol/L), BIAsp 30 + SU group (−1.95 ± 1.59% points; −3.98 ± 3.19 mmol/L; −6.25 ± 4.45 mmol/L) and BIAsp 30 + SU + BI group (−1.78 ± 1.20% points; −3.57 ± 2.78 mmol/L; −5.89 ± 3.98 mmol/L). The only serious adverse drug reaction was reported by the BIAsp 30-only group. In the “China” group, reductions in mean HbA1c, FPG and PPPG at three months were: BIAsp 30-only group (−2.16 ± 1.52% points; −3.34 ± 2.49 mmol/L; −6.29 ± 3.92 mmol/L), BIAsp 30 + BI group (−2.44 ± 1.52% points; −4.01 ± 2.50 mmol/L; −7.10 ± 3.96 mmol/L), BIAsp 30 + GI group (−2.33 ± 1.41% points; −4.34 ± 2.52 mmol/L; −7.97 ± 3.99 mmol/L) and BIAsp 30 + BI + TZD group (−1.21 ± 1.60% points; −3.50 ± 2.29 mmol/L; −5.97 ± 3.39 mmol/L). No serious ADR were reported in China. The most frequent hypoglycaemic episodes were diurnal and minor in nature. Conclusions BIAsp 30 treatment in a clinical setting improved glycaemic control in type 2 diabetes patients failing OADs.
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Affiliation(s)
- Serdar Güler
- Ankara Numune Training and Research HospitalAnkara, Turkey
| | | | | | | | - Sami Azar
- American University of BeirutBeirut, Lebanon
| | | | | | | | - Ole Molskov Bech
- Novo Nordisk International Operations Clinical Development CentreBeijing, China
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Ligthelm RJ. Self-titration of biphasic insulin aspart 30/70 improves glycaemic control and allows easy intensification in a Dutch clinical practice. Prim Care Diabetes 2009; 3:97-102. [PMID: 19285933 DOI: 10.1016/j.pcd.2009.01.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2008] [Revised: 01/27/2009] [Accepted: 01/28/2009] [Indexed: 11/23/2022]
Abstract
AIMS This 18-month study assessed the improvement in glycaemic control and proportion of patients reaching glycated haemoglobin (HbA(1c)) targets with biphasic insulin aspart 30/70 (BIAsp 30) in clinical practice. METHODS Type-2 diabetes patients failing on oral antidiabetic drugs (n=90) or existing insulin regimens (n=59) started or switched to BIAsp 30. Thiazolidinediones were stopped, metformin was continued. BIAsp 30 was given once daily (n=41), twice daily (n=96), or three times daily (n=12). Patients were taught self-monitoring and self-titration using an algorithm, adding daily doses of BIAsp 30 when necessary. RESULTS Mean baseline HbA(1c) was 8.4%, weight 85.4 kg, and age 57.9 years. All patients experienced significant reductions in HbA(1c) (mean 1.9%+/-0.1), fasting plasma glucose (mean 2.8 mmol/l), and post-prandial glycaemia (mean 2.9 mmol/l); 91% of patients achieved HbA(1c)<7% and 52% achieved HbA(1c) < or=6.5%. No major or nocturnal hypoglycaemia were reported; 15% of patients reported minor hypoglycaemia. Insulin-naïve patients gained mean 2.7 kg; patients who switched from another insulin lost weight (mean -0.6kg). CONCLUSION The results from this study from routine care suggest that BIAsp 30 may allow a large proportion of type-2 diabetes patients (90%) to improve glycaemic control and reach target HbA(1c)<7%, using self-titration.
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Affiliation(s)
- Robert J Ligthelm
- EHM Clinic, Hoofddorp, 's Gravenweg 53, 3062 ZB Rotterdam, The Netherlands.
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Shah S, Benroubi M, Borzi V, Gumprecht J, Kawamori R, Shaban J, Shestakova M, Wenying Y, Valensi P. Safety and effectiveness of biphasic insulin aspart 30/70 (NovoMix 30) when switching from human premix insulin in patients with type 2 diabetes: subgroup analysis from the 6-month IMPROVE observational study. Int J Clin Pract 2009; 63:574-82. [PMID: 19210701 PMCID: PMC2705824 DOI: 10.1111/j.1742-1241.2009.02012.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
AIMS IMPROVE is an open-label, multinational, non-randomised, 26-week observational study designed to evaluate the safety and effectiveness of biphasic insulin aspart 30 (BIAsp 30) in routine clinical practice. Here, we report data for patients switching to BIAsp 30 from human premixed insulin. METHODS Patients (n = 3856) with type 2 diabetes previously receiving human premixed insulin with or without oral antidiabetic drugs were eligible for inclusion. Demographic data, efficacy end-points (HbA(1c), fasting blood glucose and postprandial blood glucose) and safety end-points (serious adverse drug reactions, hypoglycaemia and adverse events) were collected at baseline and final visit. A subgroup analysis of mean dose change was also undertaken. RESULTS Switching patients to BIAsp 30 resulted in significant improvements in glycaemic control combined with a reduced risk of hypoglycaemia. Patients who reached the HbA(1c) target (< 7%) had shorter diabetes duration, lower HbA(1c) at baseline and needed less insulin. Over 30% of patients were able to reach this target without experiencing hypoglycaemia over the 26-week period. Compared with asymmetric dose switching, unit-for-unit switching resulted in the highest proportion of patients reaching HbA(1c) target and incurred the least amount of dose titration. CONCLUSIONS A unit-for-unit switch is the most effective as well as the simplest approach when transferring patients from biphasic human insulin 30 to BIAsp 30.
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Affiliation(s)
- S Shah
- Department of Endocrinology, BhatiaS. L. Raheja Hospital, Mumbai, India
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Velojic-Golubovic M, Mikic D, Pesic M, Dimic D, Radenkovic S, Antic S. Biphasic insulin aspart 30: better glycemic control than with premixed human insulin 30 in obese patients with Type 2 diabetes. J Endocrinol Invest 2009; 32:23-7. [PMID: 19337010 DOI: 10.1007/bf03345673] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
AIM This 3-month study compared the effect on overall glycemic control of adding biphasic insulin aspart 30 (BIAsp30) and premixed human insulin 30/70 (BHI30) to metformin (met) in insulin-naïve, obese patients (30 males/20 females) with Type 2 diabetes (T2DM). MATERIAL/SUBJECTS: At baseline, patients had a mean age of 58.7 yr, glycated hemoglobin (HbA1c) 9.5%, and body mass index 34+/-2 kg/m2. Patients received either twice-daily BIAsp30 (no.=20) or twice-daily BHI30 (no.=30), and continued to receive maximal doses (2000 mg) of met for the duration of the study, but sulphonylurea oral antidiabetic drugs were discontinued. Primary efficacy endpoint was the change in HbA1c in both groups at study end. Safety endpoints included hypoglycemic episodes and weight gain. RESULTS Both groups reduced HbA1c by end of trial: BIAsp30 + met by 2.5% [2.16-2.86%; 95% confidence interval (CI)]; BHI30 + met by 1.18% (0.98- 1.39%; 95% CI), giving a significantly better HbA1c reduction with BIAsp30 + met (1.33%; p<0.05). Post-prandial plasma glucose decreased in both groups, by 6.38 mmol/l in patients treated with BIAsp30 + met, and by 4.34 mmol/l in those treated with BHI30 + met (p<0.05). Fasting plasma glucose also decreased in both groups, with a slightly larger decrease seen in BIAsp30 patients than in BHI30 patients (7.36 mmol/l at end of study vs 7.82 mmol/l; p=ns). Subjects treated with BIAsp30 gained less weight than those receiving BHI30 (0.3+/-0.1 kg vs 1.2+/-0.4 kg). There was no significant difference in the frequency or number of hypoglycemic episodes between groups. CONCLUSIONS Adding BIAsp30 to met in obese patients with T2DM results in better glycemic control and less weight gain than adding BHI30.
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Gao Y, Guo XH, Vaz JA. Biphasic insulin aspart 30 treatment improves glycaemic control in patients with type 2 diabetes in a clinical practice setting: Chinese PRESENT study. Diabetes Obes Metab 2009; 11:33-40. [PMID: 18494806 DOI: 10.1111/j.1463-1326.2008.00904.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM PRESENT (Physicians' Routine Evaluation of Safety and Efficacy of NovoMix 30 Therapy) is the largest, multinational, open-labelled, uncontrolled and completed observational study of the efficacy and safety of biphasic insulin aspart 30 (BIAsp 30) treatment in clinical practice. We present results of 3 months of treatment in Chinese patients with type 2 diabetes mellitus who were inadequately controlled on current treatment. METHODS Patients received BIAsp 30 treatment with or without oral antidiabetic drugs (OADs). Patients were categorized according to their treatment prior to entering the study: drug-naive (n = 3697), OAD (n = 4754), insulin (n = 2392) or OAD + insulin (n = 817). RESULTS At 3 months, significant reductions from baseline were observed in the mean haemoglobin A(1c) (HbA(1c)) (-2.24 +/- 1.67, -2.04 +/- 1.57, -1.82 +/- 1.49 and -1.86 +/- 1.61%), fasting plasma glucose (-3.93 +/- 3.12, -3.51 +/- 2.55, -2.99 +/- 2.93 and -3.38 +/- 3.16 mmol/l) and postprandial plasma glucose (-7.09 +/- 4.92, -6.51 +/- 4.02, -5.20 +/- 4.31 and -5.50 +/- 4.32 mmol/l) in the drug-naive, OAD, insulin and insulin + OAD groups respectively (p < 0.001). The proportions of patients in each group achieving target HbA(1c) of less than 7% were higher at 3 months (49.5, 51.8, 51.0 and 48.3%) compared with baseline (3.2, 4.2, 7.1 and 8.3%). The rates of hypoglycaemic episodes (events per patient-year) were lower at the end of the study in all the groups compared with baseline. Hypoglycaemic episodes were mostly minor and diurnal in nature. A total of 151 adverse drug reactions were reported, of which five were serious adverse drug reaction (SADRs). These SADRs were all symptoms of local hypersensitivity. CONCLUSIONS The use of BIAsp 30 monotherapy or in combination with OADs in clinical practice was efficacious and safe in Chinese patients with poorly controlled type 2 diabetes.
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Affiliation(s)
- Y Gao
- Department of Endocrinology, Peking University First Hospital, Beijing, China.
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Mannucci E, Monami M, Marchionni N. Short-acting insulin analogues vs. regular human insulin in type 2 diabetes: a meta-analysis. Diabetes Obes Metab 2009; 11:53-9. [PMID: 18671795 DOI: 10.1111/j.1463-1326.2008.00934.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM Short-acting insulin analogues, in comparison with regular human insulin (HRI), provide a greater control of postprandial glucose, while their superiority on haemoglobin A1c (HbA1c) is controversial. METHOD All randomized controlled trials (RCTs) with a duration >4 weeks comparing short-acting insulin analogues (lispro, aspart or glulisine) with HRI in type 2 diabetic patients were retrieved; data on HbA1c and postprandial glucose et end-point and incidence of severe hypoglycaemia were extracted and meta-analysed. RESULTS A total of 13 RCTs (7, 4 and 2 with lispro, aspart and glulisine, respectively) were retrieved and included in the analysis. Short-acting analogues reduced HbA1c by 0.4% (0.1-0.6%) (p = 0.027) in comparison with HRI. A significant improvement was observed also in self-monitored 2 h postbreakfast and dinner blood glucose. The overall rate of severe hypoglycaemia was not significantly different with short-acting analogues and HRI [Mantel-Haenszel odds ratio for 95% confidence interval 0.61 (0.25-1.45)]. CONCLUSION In type 2 diabetic patients, short-acting insulin analogues provide a better control of HbA1c and postprandial glucose than regular human insulin, without any significant reduction of the risk of severe hypoglycaemia.
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Affiliation(s)
- E Mannucci
- Department of Cardiovascular Medicine, Section of Geriatric Cardiology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
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Breum L, Almdal T, Eiken P, Lund P, Christiansen E. Initiating or switching to biphasic insulin aspart 30/70 therapy in subjects with type 2 diabetes mellitus. An observational study. Rev Diabet Stud 2008; 5:154-62. [PMID: 19099087 DOI: 10.1900/rds.2008.5.154] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE To investigate tolerability and glycemic control over 26 weeks in patients with type 2 diabetes (T2D) who initiated insulin with, or switched to, biphasic insulin aspart 30/70 (BIAsp 30) in routine clinical care. METHODS This was a non-randomized, non-interventional, open-label, observational study involving patients under the care of approximately 150 insulin-prescribing physicians in Denmark. All patients enrolled were prescribed BIAsp 30 in routine care. Starting dose, dose titration and injection frequency were determined individually by each physician. Information on serious adverse drug reactions (SADR), glycemic parameters and hypoglycemic events were obtained from patients' notes, patients' diaries and recall, and transferred to case report forms by physicians at baseline (during 4 weeks prior to BIAsp 30 therapy) and after 12 and 26 weeks of treatment. RESULTS 421 subjects were recruited and 392 provided safety data. The age (mean +/- SD) was 62.0 +/- 11.4 years, body mass index (BMI) 30.4 +/- 6.4 kg/m(2), duration of diabetes 9.1 +/- 8.1 years and HbA1c (%) 9.4 +/- 1.7. 199 subjects were prior insulin users and 193 were insulin-naïve patients. Four patients reported a SADR (3 hypoglycemia, 1 severe hypoglycemia). HbA1c was significantly reduced after 26 weeks of BIAsp 30 therapy: prior insulin users -1.2%, insulin-naïve patients -2.2% (both p < 0.001). 28% and 41% of patients, respectively, reached target HbA1c < 7%. Overall the hypoglycemia rate was lower for insulin-naïve patients than for prior insulin users: 5.0 vs. 6.6 episodes/patient-year (p < 0.05). CONCLUSION Initiating insulin with, or switching insulin to, BIAsp 30 in routine care was safe and effective in patients with T2D.
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Affiliation(s)
- Leif Breum
- Department of Medicine, Koge Hospital, Koge, Denmark
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Hermansen K, Mortensen LS, Hermansen ML. Combining insulins with oral antidiabetic agents: effect on hyperglycemic control, markers of cardiovascular risk and disease. Vasc Health Risk Manag 2008; 4:561-74. [PMID: 18827907 PMCID: PMC2515417 DOI: 10.2147/vhrm.s1815] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Patients with type 2 diabetes mellitus (T2DM) have an increased risk of cardiovascular disease (CVD). Unfortunately, several potential barriers exist for CVD risk management in diabetes, including the need for significant lifestyle changes, potential problems with hypoglycemia, weight gain, injection tolerability, treatment complexity with current diabetes therapies and other, unmodifiable factors. Improving glycemic control may impact CVD risk. Treatment of T2DM usually starts with lifestyle changes such as diet and exercise. When these become insufficient, pharmacotherapy is required. Various oral antidiabetic drugs (OADs) are available that reduce hyperglycemia. The first line of therapy is usually metformin, since it does not increase weight and seems to have a beneficial effect on CVD mortality and risk factors. As T2DM progresses, insulin treatment becomes necessary for the majority of patients. The last few years have seen the development of long-acting, rapid-acting, and premixed insulin analog formulations. The treat-to-target algorithms of recent studies combining OADs plus insulin analogs have demonstrated that patients can reach glycemic treatment targets with low risk of hypoglycemia, greater convenience, and – with some analogs – limited weight gain vs conventional insulins. These factors may possibly have a positive influence on CVD risk. Future studies will hopefully elucidate the benefits of this approach.
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Affiliation(s)
- Kjeld Hermansen
- Department of Endocrinology and Metabolism C, Aarhus University Hospital DK-8000 Aarhus, Denmark.
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Qayyum R, Bolen S, Maruthur N, Feldman L, Wilson LM, Marinopoulos SS, Ranasinghe P, Amer M, Bass EB. Systematic review: comparative effectiveness and safety of premixed insulin analogues in type 2 diabetes. Ann Intern Med 2008; 149:549-59. [PMID: 18794553 PMCID: PMC4762020 DOI: 10.7326/0003-4819-149-8-200810210-00242] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Evidence comparing premixed insulin analogues (a mixture of rapid-acting and intermediate-acting insulin analogues) with other antidiabetic agents is urgently required to guide appropriate therapy. PURPOSE To summarize the English-language literature on the effectiveness and safety of premixed insulin analogues compared with other antidiabetic agents in adults with type 2 diabetes. DATA SOURCES The authors searched MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials from inception to February 2008 and sought unpublished data from the U.S. Food and Drug Administration, European Medicines Agency, and industry. STUDY SELECTION Studies with control groups that compared premixed insulin analogues with another antidiabetic medication in adults with type 2 diabetes. DATA EXTRACTION 2 reviewers using standardized protocols performed serial abstraction. DATA SYNTHESIS Evidence from clinical trials was inconclusive for clinical outcomes, such as mortality. Therefore, the review focused on intermediate outcomes. Premixed insulin analogues were similar to premixed human insulin in decreasing fasting glucose levels, hemoglobin A(1c) levels, and the incidence of hypoglycemia but were more effective in decreasing postprandial glucose levels (mean difference, -1.1 mmol/L; 95% CI, -1.4 to -0.7 mmol/L [-19.2 mg/dL; 95% CI, -25.9 to -12.5 mg/dL]). Compared with long-acting insulin analogues, premixed insulin analogues were superior in decreasing postprandial glucose levels (mean difference, -1.5 mmol/L; CI, -1.9 to -1.2 mmol/L [-27.9 mg/dL; CI, -34.3 to -21.5 mg/dL]) and hemoglobin A(1c) levels (mean difference, -0.39% [CI, -0.50% to -0.28%]) but were inferior in decreasing fasting glucose levels (mean difference, 0.7 mmol/L; CI, 0.3 to 1.0 mmol/L [12.0 mg/dL; CI, 6.0 to 18.1 mg/dL]) and were associated with a higher incidence of hypoglycemia. Compared with noninsulin antidiabetic agents, premixed insulin analogues were more effective in decreasing fasting glucose levels (mean difference, -1.1 mmol/L; CI, -1.7 to -0.6 mmol/L [-20.5 mg/dL; CI, -29.9 to -11.2 mg/dL]), postprandial glucose levels (mean difference, -2.1 mmol/L; CI, -3.4 to -0.8 mmol/L [-37.4 mg/dL; CI, -61.0 to -13.7 mg/dL]), and hemoglobin A(1c) levels (mean difference, -0.49% [CI, -0.86% to -0.12%]) but were associated with a higher incidence of hypoglycemia. LIMITATIONS The literature search was restricted to studies published in English. Data on clinical outcomes were limited. The small number of studies for each comparison limited assessment of between-study heterogeneity. CONCLUSION Premixed insulin analogues provide glycemic control similar to that of premixed human insulin and may provide tighter glycemic control than long-acting insulin analogues and noninsulin antidiabetic agents.
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Affiliation(s)
- Rehan Qayyum
- Evidence-based Practice Center, Johns Hopkins University, Baltimore, Maryland, USA.
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Abstract
The PRESENT study was a 6-month multinational observational study in patients with type 2 diabetes receiving biphasic insulin aspart 30 (BIAsp 30). Data from PRESENT were analysed according to predefined subgroups stratified by age, body mass index (BMI) and ethnic origin. Achieved HbA1c levels were similar in each of: four age subgroups (<40 years 7.82%, 40-50 years 7.70%, 50-60 years 7.75%, >or=65 years 7.75%); five BMI subgroups (<25 kg/m(2): 7.78%, 25-30 kg/m(2): 7.58%, 30-35 kg/m(2): 7.57%, 35-40 kg/m(2): 7.74%, >or=40 kg/m(2): 7.93%); and Asian/Pacific Islander, Middle Eastern/Asian, White ethnic-origin subgroups (7.78%, 7.40%, 7.59%, respectively). The Black ethnic-origin subgroup had a higher baseline HbA1c of 11.61% (other groups 9.29-9.63%) and achieved a final HbA1c of 8.59%. Major hypoglycaemia was reported by fewer than 1% of subjects in any subgroup at end of study; overall end of study hypoglycaemia rates were less than four events/subject year (all subgroups). In conclusion, data from subgroups in the PRESENT study indicate that BIAsp 30 can be initiated and titrated effectively to help patients of all ages, of all degrees of obesity, and from a variety of ethnic origins, to achieve clinically relevant improvements in glycaemic control with low rates of hypoglycaemia.
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Affiliation(s)
- Majeed Almustafa
- National Diabetes Center, Al Mstansiriya University, Baghdad, Iraq.
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Gao Y, Li G, Li Y, Guo X, Yuan G, Gong Q, Yan L, Zheng Y, Zhang J. Postprandial blood glucose response to a standard test meal in insulin-requiring patients with diabetes treated with insulin lispro mix 50 or human insulin mix 50. Int J Clin Pract 2008; 62:1344-51. [PMID: 18657196 PMCID: PMC2658027 DOI: 10.1111/j.1742-1241.2008.01850.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
AIM To compare the 2-h postprandial blood glucose (PPBG) excursion following a standard test meal in insulin-requiring patients with diabetes treated twice daily with human insulin mix 50 vs. insulin lispro mix 50 (LM50). METHODS This was a multicentre, randomised, open-label, crossover comparison of two insulin treatments for two 12-week treatment periods in 120 Chinese patients. One- and 2-h PPBG and excursion values were obtained following a standardised test meal. Fasting blood glucose (FBG), haemoglobin A1c (HbA1c), insulin dose, rate of hypoglycaemia and safety data were obtained. A crossover analysis using SAS Proc MIXED was employed. RESULTS Mean 2-h PPBG excursion decreased from 6.32 +/- 3.07 mmol/l at baseline to 3.47 +/- 2.97 mmol/l at end-point in the LM50 group, and from 6.31 +/- 2.88 at baseline to 5.02 +/- 3.32 mmol/l at end-point in the human insulin mix 50 group (p < 0.001). Two-hour PPBG (p = 0.004) and 1-h PPBG excursion (p < 0.001) were significantly lower with LM50 as compared with human insulin mix 50. Both treatment groups were equivalent for HbA1c control, 1-h PPBG and insulin dose requirements. Mean FBG was higher with LM50 than with human insulin mix 50 (p = 0.023). The overall incidence of treatment-emergent adverse events and hypoglycaemia rate per 30 days were similar between treatment groups. CONCLUSIONS Insulin lispro mix 50 provided better postprandial glycaemic control compared with human insulin mix 50 while providing the convenience of injecting immediately before meals. Both treatments were generally well tolerated by all randomly assigned patients.
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Affiliation(s)
- Y Gao
- Department of Endocrinology, Peking University First Hospital, Beijing, China
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Guler S, Vaz JA, Ligthelm R. Intensification lessons with modern premixes: from clinical trial to clinical practice. Diabetes Res Clin Pract 2008; 81 Suppl 1:S23-30. [PMID: 18684540 DOI: 10.1016/j.diabres.2008.06.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This paper aims to underscore the importance of insulin intensification, while highlighting the clinical utility of modern premixes through intensification lessons, by utilising data from key clinical trials, and from the recently published large observational PRESENT Study. Insulin intensification is any change made to an initial insulin regimen to improve glycaemic control. Yet, despite established glycaemic targets, current HbA1c levels in insulin-treated patients suggest that 'real-world' insulin regimens are not optimally intensified. When treatment is intensified as needed, patients are more likely to achieve and maintain glycaemic targets, as evidenced by treat-to-target trials utilising forced titration algorithms. Both clinical and observational studies suggest that modern premixes, such as biphasic insulin aspart 30, represent an effective and well-tolerated option when intensifying a number of existing insulin regimens that no longer maintain optimal glycaemic control. However, physician and patient concerns regarding initiation and intensification of insulin therapy can create barriers to effective patient care, and it is essential that such barriers be resolved. Although it is important to encourage patients to initiate insulin therapy when needed, it is equally important that insulin regimens benefit from ongoing intensification in order to maintain glycaemic control as type 2 diabetes follows its typically progressive course.
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Affiliation(s)
- Serdar Guler
- Ankara Numune Training and Research Hospital, Ankara, Turkey
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Hartman I. Insulin analogs: impact on treatment success, satisfaction, quality of life, and adherence. Clin Med Res 2008; 6:54-67. [PMID: 18801953 PMCID: PMC2572551 DOI: 10.3121/cmr.2008.793] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2008] [Revised: 05/27/2008] [Accepted: 06/25/2008] [Indexed: 01/01/2023]
Abstract
A growing body of medical research has demonstrated that intensive control of serum glucose levels can minimize the development of diabetes-related complications. Success with insulin management ultimately depends on how closely a given regimen can mimic normal physiologic insulin release patterns. The new insulin analogs, including the rapid-acting analogs (aspart, lispro, glulisine), the long-acting basal analogs (glargine, detemir), and the premixed insulin analog formulations (75% neutral protamine lispro, 25% lispro; 50% neutral protamine lispro, 50% lispro; 70% protamine aspart, 30% aspart) have been formulated to allow for a closer replication of a normal insulin profile. The rapid-acting analogs can be administered at mealtimes and produce a rapid and short-lived insulin spike to address postprandial glucose elevations, while the long-acting analogs come close to the ideal of a smooth, relatively flat, 24-hour basal insulin supply, with less variability in action compared to NPH insulin. Despite these clear pharmacologic advantages, measurable clinical benefits in a complex disease such as diabetes can be hard to measure. To date, reviews of insulin analog studies have not found a dramatic overall improvement in glycosylated hemoglobin (HbA1c) outcomes compared to traditional human insulins, although all-analog basal-bolus regimens were associated with significantly lower HbA1c than all-human-insulin basal bolus regimens in some studies. Beyond HbA1c comparisons, however, insulin analogs have been shown in many instances to be associated with lower risks of hypoglycemia, lower levels of postprandial glucose excursions, better patient adherence, greater quality of life, and higher satisfaction with treatment. The long-acting basal analog insulin detemir has the additional advantage of producing less weight gain, which has been considered until now an almost inevitable consequence of insulin replacement.
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Affiliation(s)
- Israel Hartman
- Internal Medicine Department, University of North Texas Health Science Center at Fort Worth, Fort Worth, Texas, USA.
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66
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Velásquez-Mieyer PA, Neira CP. Biphasic insulin aspart 30 for the treatment of type 1 diabetes mellitus. Expert Opin Pharmacother 2008; 9:2377-82. [DOI: 10.1517/14656566.9.13.2377] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Meneghini L. Demonstrating strategies for initiation of insulin therapy: matching the right insulin to the right patient. Int J Clin Pract 2008; 62:1255-64. [PMID: 18705822 DOI: 10.1111/j.1742-1241.2008.01816.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
AIMS To increase awareness regarding the different types of insulin available and provide discussion regarding how each type of insulin can address the needs of diverse patients in terms of their unique requirements, preferences, medical history and lifestyle concerns. SUMMARY New classes of antidiabetes medications, the development of insulin analogues and novel insulin delivery systems, provide more options for the management of type 2 diabetes. Given the inevitable progression of beta-cell dysfunction, along with the relatively limited glucose-lowering capacity of other agents, many patients will eventually require insulin for optimal glycaemic management. However, patients and physicians often fail to initiate insulin early enough during the progression of disease to maintain the recommended levels of glycaemic control. The inherent properties of the new insulin analogues, more physiological and user-friendly time-action profiles compared with older human insulin formulations, may partly address the barriers to insulin use. Insulin analogues include rapid acting (for prandial glycaemic control), long acting (for basal insulin coverage) and premixed insulin analogues, which combine both a rapid acting and an extended duration component in a single insulin formulation. Various case-based scenarios on initiating and intensifying therapy with insulin analogues will be presented. CONCLUSIONS Development of an individualised treatment plan for initiation of insulin is a critical step in achieving target glycaemic levels in patients with type 2 diabetes.
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Affiliation(s)
- L Meneghini
- University of Miami Miller School of Medicine, Eleanor and Joseph Kosow Diabetes Treatment Center, Diabetes Research Institute, Miami, FL 33136, USA.
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Motta M, Bennati E, Ferlito L, Passamonte M, Cardillo E, Malaguarnera M. A review on the actual trends of insulin treatment in elderly with diabetes. Arch Gerontol Geriatr 2008; 47:151-61. [PMID: 17913262 DOI: 10.1016/j.archger.2007.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2007] [Revised: 07/26/2007] [Accepted: 07/30/2007] [Indexed: 01/23/2023]
Abstract
The diabetes of the elderly subjects has two forms: diabetes of long duration, manifesting itself in younger or medium ages, and senile diabetes, appearing above the age of 65 years. The diabetes of the elderly has usually only modest symptoms: it is not ketosic, but in spite of this, in order to avoid the chronic-degenerative complications, it is important to maintain a good, even if not an optimal compensation. The therapeutic intervention cannot neglect a correct alimentary regime and a programmed physical activity in correlation with the clinical conditions of the patient. If the compensation is not achieved only with these tools, one can add oral antidiabetic treatments. In the elderly patients we usually observe primary or secondary failure of the oral antidiabetic treatments, and in such context we have to apply insulin treatment, even in cases of moderate glycometabolic decompensations. While we are waiting for the gene-therapy or the inhalatory insulin preparations, actually there are at disposal only the insulin analogs in rapid, slow and mixed forms. We propose two treatment schemes: (i) The first one consists of three administrations of rapid insulin with the meals, and on dose of slow insulin 2h after the last meal in the evening. (ii) The second scheme consists of one administration of rapid insulin at lunch, one administration of mixed insulin at dinner, with the addition of oral antidiabetics of peripheric action, in the morning and the evening. A better compliance can be obtained, being a fundamental aspect in the elderly diabetics, and a reduction of the number and severity of the hypoglycemia, which are the most important aspects in the elderly diabetes.
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Affiliation(s)
- Massimo Motta
- Department of Aging Sciences, Research Centre The Extreme Senescence, University of Catania, Cannizzaro Hospital, Via Messina 829, I-95124 Catania, Italy.
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Van Gaal LF, Gutkin SW, Nauck MA. Exploiting the antidiabetic properties of incretins to treat type 2 diabetes mellitus: glucagon-like peptide 1 receptor agonists or insulin for patients with inadequate glycemic control? Eur J Endocrinol 2008; 158:773-84. [PMID: 18322302 DOI: 10.1530/eje-07-0804] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Type 2 diabetes mellitus is associated with progressive decreases in pancreatic beta-cell function. Most patients thus require increasingly intensive treatment, including oral combination therapies followed by insulin. Fear of hypoglycemia is a potential barrier to treatment adherence and glycemic control, while weight gain can exacerbate hyperglycemia or insulin resistance. Administration of insulin can roughly mimic physiologic insulin secretion but does not address underlying pathophysiology. Glucagon-like peptide 1 (GLP-1) is an incretin hormone released by the gut in response to meal intake that helps to maintain glucose homeostasis through coordinated effects on islet alpha- and beta-cells, inhibiting glucagon output, and stimulating insulin secretion in a glucose-dependent manner. Biological effects of GLP-1 include slowing gastric emptying and decreasing appetite. Incretin mimetics (GLP-1 receptor agonists with more suitable pharmacokinetic properties versus GLP-1) significantly lower hemoglobin A1c, body weight, and postprandial glucose excursions in humans and significantly improve beta-cell function in vivo (animal data). These novel incretin-based therapies offer the potential to reduce body weight or prevent weight gain, although the durability of these effects and their potential long-term benefits need to be studied further. This article reviews recent clinical trials comparing therapy with the incretin mimetic exenatide to insulin in patients with oral treatment failure, identifies factors consistent with the use of each treatment, and delineates areas for future research.
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Affiliation(s)
- Luc F Van Gaal
- Department of Diabetology, Metabolism and Clinical Nutrition, Antwerp University Hospital, Wilrijkstraat 10 B-2650 Edegem, Antwerp, Belgium.
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Rolla A. Pharmacokinetic and pharmacodynamic advantages of insulin analogues and premixed insulin analogues over human insulins: impact on efficacy and safety. Am J Med 2008; 121:S9-S19. [PMID: 18514090 DOI: 10.1016/j.amjmed.2008.03.022] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Human insulin preparations administered to patients with diabetes mellitus fail to reproduce the normal physiologic pattern of insulin secretion. Modifications have been made in the amino acid sequence of the insulin molecule with the aim of overcoming the pharmacokinetic shortcomings of human insulins. Such modifications have produced long-acting analogues, with relatively flat time-action profiles, for controlling glycemic levels between meals; and rapid-acting analogues with a fast onset and short duration of action, for controlling postprandial hyperglycemia. Premixed formulations of the rapid-acting analogues, containing both rapid-acting soluble and intermediate-acting protaminated forms, are also available. Trials of long-acting insulin analogues have consistently shown efficacy in controlling fasting plasma glucose and glycosylated hemoglobin (HbA1c), as well as a markedly reduced risk of hypoglycemia compared with neutral protamine Hagedorn insulin. The rapid-acting and premixed analogues offer better control of postprandial glucose excursions than do regular human insulin, resulting in similar or lower HbA1c levels. Furthermore, the analogues can offer patients greater flexibility and more convenience in administration compared with human insulins. This review provides an overview of the insulin analogues available today and describes their structure, pharmacokinetics, pharmacodynamics, efficacy, and safety.
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Affiliation(s)
- Arturo Rolla
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02215, USA.
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71
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Rendell MS. Insulin treatment of post-prandial hyperglycemia. Drug Dev Res 2008. [DOI: 10.1002/ddr.20237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Durán García S, de Alaiz RA, Bayort Fernández JA, Hernández Herrero C, Manzano García G, Pumar López A. Efficacy and safety of biphasic insulin aspart 30/70 in the treatment of patients with type 2 diabetes mellitus. ACTA ACUST UNITED AC 2008; 55:159-64. [PMID: 22975451 DOI: 10.1016/s1575-0922(08)70656-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Accepted: 11/26/2007] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess the safety and efficacy of biphasic insulin aspart 30/70 in patients with type 2 diabetes mellitus (DM2). MATERIAL AND METHODS We performed an observational, multicenter, prospective study in 3,054 DM2 patients from primary care and specialized settings, treated with biphasic insulin aspart 30/70 (started within 15 days prior to inclusion). In all patients,the following information was available before starting insulin treatment: HbA(1c) levels, fasting plasma glucose (FPG), 4-point glucose profile (before and 90 minutes after breakfast and dinner) and number of hypoglycemic episodes/week. A total of 2,887 patients completed the study (26 ± 1 week). The variables evaluated were rate of adverse events (AE), number of hypoglycemic episodes/week, HbA(1c), FPG and 4-point glucose profile. RESULTS At least one AE occurred in 10.7% of the patients (2.3% related to the study drug and 1.4% severe). There was a significant decrease (end of study vs baseline; p < 0.0001 for all the comparisons) in HbA(1c) (7.3% and 8.9%, respectively), the mean number of minor (0.3/0.5) and major (0.02/0.07) hypoglycemic episodes/week, FPG (145/207 mg/dl) and postprandial glycemia (162/225 mg/dl). The improvement in metabolic control was achieved both in patients previously treated with oral antidiabetic drugs and in those treated with insulin. The number of hypoglycemic episodes decreased in patients previously treated with insulin. CONCLUSIONS Treatment with biphasic insulin aspart 30/70 in patients with DM2 improves glycemic control, irrespective of previous treatment, with a low rate of AE and fewer hypoglycemic episodes in patients previously treated with insulin.
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Affiliation(s)
- Santiago Durán García
- Servicio de Endocrinología y Nutrición. Hospital Universitario de Valme. Sevilla. España.
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Khutsoane D, Sharma SK, Almustafa M, Jang HC, Azar ST, Danciulescu R, Shestakova M, Ayad NMA, Guler S, Bech OM. Biphasic insulin aspart 30 treatment improves glycaemic control in patients with type 2 diabetes in a clinical practice setting: experience from the PRESENT study. Diabetes Obes Metab 2008; 10:212-22. [PMID: 18269636 DOI: 10.1111/j.1463-1326.2007.00826.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM The Physicians' Routine Evaluation of Safety and Efficacy of NovoMix 30 Therapy (PRESENT) study aims to assess the safety and efficacy of biphasic insulin aspart 30 (BIAsp 30) in patients with type 2 diabetes mellitus in routine clinical practice. METHODS This was a 6-month, prospective, multinational, multiethnic observational study involving 21 977 patients from 13 countries (India, Iraq, Jordan, Kuwait, Lebanon, Qatar, Romania, Russia, Saudi Arabia, South Africa, South Korea, Turkey and the United Arab Emirates). The patients were transferred to BIAsp 30 with or without oral antidiabetic drugs (OADs) from prior treatment with OAD (n = 8583), insulin (n = 5942), OAD + insulin (n = 4673) or diet (i.e. treatment naive) (n = 1707). One thousand and seventy-two patients had incomplete or no information on previous treatment. RESULTS At 3 and 6 months, significant reductions from baseline were observed in the mean haemoglobin A(1c) (HbA(1c)) (-1.33 and -1.81%), fasting plasma glucose (-3.02 and -3.74 mmol/l) and postprandial plasma glucose (-4.76 and -5.82 mmol/l) (p < 0.001). A significantly greater proportion of patients achieved target HbA(1c) of less than 7% at 3 months (15.3%) and 6 months (27.7%) compared with baseline (4.8%) (p < 0.001). Overall, the mean HbA(1c) at 6 months was lowered in patients regardless of prior treatment: -2.15% (OAD), -1.45% (insulin), -1.47% (OAD + insulin) and -2.35% (treatment naive). In the overall cohort, the rate of total hypoglycaemia was reduced from 5.4 events per patient-year at baseline to 2.2 events per patient-year at study end (p < 0.001). Among prior treatment subgroups, the rates of total hypoglycaemia were reduced from 2.5 to 2.1 events per patient-year in the OAD group, from 9.6 to 2.2 events per patient-year in the insulin group and from 7.6 to 2.5 events per patient-year in the OAD + insulin group but were increased from 1.0 to 1.8 events per patient-year in the treatment-naive group (p < 0.001). There were 444 adverse drug reactions (ADRs), including 13 serious ADRs: lipodystrophy (three events), symptoms of generalized hypersensitivity (two events), acute painful neuropathy (one event), worsening of diabetic retinopathy (one event), oedema (one event) and unspecified ADRs (five events). CONCLUSION The use of BIAsp 30 monotherapy or in combination with OADs in clinical practice was effective and safe in patients with poorly controlled type 2 diabetes mellitus.
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Ligthelm R, Davidson J. Initiating insulin in primary care--the role of modern premixed formulations. Prim Care Diabetes 2008; 2:9-16. [PMID: 18684415 DOI: 10.1016/j.pcd.2008.01.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2007] [Revised: 12/11/2007] [Accepted: 01/08/2008] [Indexed: 12/25/2022]
Abstract
Starting insulin therapy earlier can help reduce the risk of micro- and macrovascular complications associated with the progression of type 2 diabetes mellitus (T2DM). However, barriers to the initiation of insulin have been identified. Premixed insulins offer a simpler regimen than basal-bolus therapy for T2DM. Modern premixes, which combine a rapid-acting soluble insulin with a protaminated form of the same insulin, have become increasingly popular. As primary care practitioners and diabetes specialists are encouraged to initiate insulin, premixes that can be used within flexible dosing regimens to improve glycaemic control could be beneficial.
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Affiliation(s)
- Robert Ligthelm
- EHM Clinic Hoofddorp's-Gravenweg 53, Rotterdam 3062 ZB, The Netherlands.
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76
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Efendic S, Alvarsson M, Brismar K, Wagner H. Pathophysiology and treatment of patients with type 2 diabetes exhibiting failure to oral drugs. Acta Physiol (Oxf) 2008; 192:117-25. [PMID: 18171434 DOI: 10.1111/j.1748-1716.2007.01789.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
It is generally accepted that a poor glycaemic control increases the risk for development of vascular complications in diabetic patients. This advocates for early introduction of insulin treatment in patients with type 2 diabetes exhibiting a secondary failure to oral treatment. This strategy is facilitated by introduction of long-acting insulin glargine and biphasic insulin aspart 70/30. The introduction of Glucagon-like peptide-1 (GLP-1) mimetics and dipeptidyl peptidase 4 (DPP-4) inhibitors in treatment of type 2 diabetes will however, to a large extent, influence therapeutic policy. Thus we suggest that DPP-4 inhibitors or long-acting GLP-1 mimetics will be used as either first-line therapy or as an early addition to metformin. The already generated results in animal and clinical studies suggest that these two classes of antidiabetic drugs may in addition to improving glycaemic control protect islet beta-cell mass and thereby postpone development of a secondary failure. When patients treated with metformin, sulfonylurea (SU), tiazolidinediones or a combination of these drugs fail, the GLP-1 mimectics may be preferred to insulin treatment. First, the risk of hypoglycaemia is less if not combined with SU. Secondly, the body weight is usually decreased while insulin treatment increases weight. Patients not responding to GLP-1 mimetics or experiencing significant side effects will be treated with insulin. Irrespective of the policy used for the drug treatment of type 2 diabetes, exercise and proper diet will remain important for optimization of metabolic control.
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Affiliation(s)
- S Efendic
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
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Hirao K, Arai K, Yamauchi M, Takagi H, Kobayashi M. Six-month multicentric, open-label, randomized trial of twice-daily injections of biphasic insulin aspart 30 versus multiple daily injections of insulin aspart in Japanese type 2 diabetic patients (JDDM 11). Diabetes Res Clin Pract 2008; 79:171-6. [PMID: 17919762 DOI: 10.1016/j.diabres.2007.08.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2007] [Accepted: 08/21/2007] [Indexed: 10/22/2022]
Abstract
To evaluate glycemic control using convenience-oriented biphasic insulin analog compared with intensified insulin therapy, we conducted a 6-month multicentric, open-label, randomized trial in Japanese insulin-naive patients with type 2 diabetes mellitus. A total of 160 adult patients at 19 centers were randomized into two groups: those who received twice-daily injections of biphasic insulin aspart 30 and those on three-times-daily injections of insulin aspart with or without NPH insulin (multiple daily injections). At 6 months, mean HbA(1c) decreased by approximately 2.5% in both groups. Reduction of HbA(1c) on both regimens was better in patients whose prior therapy before starting the study was only diet and exercise (-5.0%) than in patients who were previously taking oral antidiabetic agents (-1.0%). No incidence of major hypoglycemia was observed in either regimen. These results suggest that convenience-oriented insulin therapy using biphasic insulin analog is as useful as intensified insulin therapy with insulin analog for the treatment of type 2 diabetes mellitus over 6 months. Furthermore, early induction of insulin therapy in individuals hitherto using only diet and exercise may provide good glycemic control. This study suggests that convenience-oriented biphasic insulin aspart 30 might be a useful option for the treatment of type 2 diabetes mellitus, especially for insulin-naive patients over 6 months, although it should be changed to another regimen when expected efficacy is not obtained.
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78
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Bell DSH. Insulin therapy in diabetes mellitus: how can the currently available injectable insulins be most prudently and efficaciously utilised? Drugs 2007; 67:1813-27. [PMID: 17722952 DOI: 10.2165/00003495-200767130-00002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The era of animal source insulins has passed and human recombinant DNA insulins are gradually being replaced because of the superior efficacy of insulin analogues. Analogue insulins are available in both rapid- and long-acting preparations. Currently available rapid-acting insulins are lispro, aspart and glulisine, and the currently available long-acting analogue basal insulins are detemir and glargine. The rapid-acting insulin analogues are also available in combination with protamine in fixed-dose pre-mixed insulins to provide a more sustained action. The chemical structure, subcutaneous behaviour, time of onset, maximal effect and duration of action of both analogue and human insulins, and how these actions can be best utilised in the diabetic patient are discussed in this review. In addition, strategies where efficacy of the available analogue insulins can be maximally utilised in both type 1 and type 2 diabetes mellitus are described. Maximal utilisation of analogue insulins will result not only in better glycaemic control, but will also minimise the frequency and severity of hypoglycaemic episodes. In addition, maximisation of glycaemic control will result in prevention, delay of onset or amelioration of both the microvascular and perhaps the macrovascular complications of diabetes.
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Affiliation(s)
- David S H Bell
- University of Alabama at Birmingham Medical School, Birmingham, Alabama, USA.
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Shestakova M, Sharma SK, Almustafa M, Min KW, Ayad N, Azar ST, Danciulescu R, Khutsoane D, Guler S. Transferring type 2 diabetes patients with uncontrolled glycaemia from biphasic human insulin to biphasic insulin aspart 30: experiences from the PRESENT study. Curr Med Res Opin 2007; 23:3209-14. [PMID: 18005503 DOI: 10.1185/030079907x253636] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIM The Physician's Routine Evaluation of Safety and Efficacy of NovoMix* 30 Therapy (PRESENT) aims to assess the safety and efficacy of biphasic insulin aspart (BIAsp30) used in routine clinical practice. METHODS This was a large, multi-national, multi-centre, prospective, 6-month study in type 2 diabetes mellitus patients who were prescribed BIAsp30. Efficacy endpoints included changes in HbA(1c), fasting plasma glucose (FPG), postprandial plasma glucose (PPPG), and proportion who achieved target HbA(1c) < 7%. Changes from baseline were analysed using paired t-test. Safety endpoints were incidence and rate of hypoglycaemic episodes. A subgroup of patients previously uncontrolled (HbA(1c) > or = 7.0%) on biphasic human insulin (BHI) were analysed. RESULTS Glycaemia improved significantly (mean +/- SD): HbA(1c) by 1.58 +/- 1.69% points (from 9.32 +/- 1.64% to 7.70 +/- 1.29%), FPG by 2.92 +/- 3.71 mmol/L and PPPG by 4.75 +/- 4.87 mmol/L. The incidence of hypoglycaemic episodes decreased over time, from 38.7% (baseline) to 20.8% (6 months). Episodes were mostly minor (reduced from 37.7 to 20.6% at 6 months), occurring during the day (reduced from 31.5 to 17.1% at 6 months). Major episodes were less frequently reported (reduced from 5.0 to 0.4% at 6 months). The rate of hypoglycaemia (episodes/patient year) from baseline to end of study decreased over time for overall (8.9-2.2), major (0.7-0.1), minor (8.2-2.2) and nocturnal (2.9-0.5) episodes. CONCLUSIONS In this observational study, in the type 2 diabetes mellitus patients who were poorly controlled on BHI, glycaemia improved when transferred to BIAsp30, and a lower incidence or rate of hypoglycaemia was observed in these patients.
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Affiliation(s)
- M Shestakova
- Institute of Diabetes, Federal Scientific Centre of Endocrinology, Federal Agency of Rosmedtechnology, Dmitryia Uljanova, Moscow, Russia.
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Tibaldi JT. Biphasic insulin aspart 70/30 three times a day in older patients with type 2 diabetes not achieving optimal glycemic control on a twice-daily regimen: a retrospective case series analysis from clinical practice. Adv Ther 2007; 24:1348-56. [PMID: 18165218 DOI: 10.1007/bf02877782] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
This retrospective study was conducted to determine whether the addition of a third injection of biphasic insulin aspart 70/30 (BIAsp 30) just before lunch in older patients with type 2 diabetes who did not achieve goals with a twice-daily (BID) regimen would optimize glycemic control in a clinical practice setting. A retrospective chart analysis was conducted. In 12 patients aged 52 to 80 y with type 2 diabetes that had been diagnosed between 5 and 24 y earlier and who remained on oral antidiabetes agents, a third injection of BIAsp 30 was added because optimal glycemic control (glycosylated hemoglobin [HbA1c]<7%) was not achieved on a BID regimen. Changes in HbA1c, body weight, total insulin dose, and frequency of hypoglycemia were analyzed after 6 mo of three times daily (TID) treatment. Mean HbA1c decreased from 8.4% to 7.2%. An HbA1c goal of <7% was attained by 58% of patients. Although the total insulin dose increased by 11% with the TID regimen, pre-breakfast and predinner doses decreased by 15%. No patient experienced major hypoglycemia on BID or TID dosing. With the TID regimen, no minor hypoglycemic events were reported by patients and mean body weight decreased by 2.25 lb. The addition of a third injection of BIAsp 30 substantially improved HbA1c and decreased body weight and the incidence of hypoglycemia in 12 patients with type 2 diabetes who did not achieve optimal glycemic control on a BID regimen.
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Heller S, Kozlovski P, Kurtzhals P. Insulin's 85th anniversary--An enduring medical miracle. Diabetes Res Clin Pract 2007; 78:149-58. [PMID: 17482306 DOI: 10.1016/j.diabres.2007.04.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2006] [Accepted: 04/02/2007] [Indexed: 10/23/2022]
Abstract
In 1922, the discovery of insulin led to a revolution in diabetes management. Since then, many improvements have been made to insulin preparations: early preparations of bovine and porcine insulins were purified and their duration of action prolonged, giving rise to the introduction of Neutral Protamine Hagedorn (NPH) insulin and monocomponent insulins. Then, with the advances in genetic engineering in the 1980s, it became possible to produce recombinant human insulin. Nowadays, modern molecular biology techniques enable the production of insulin analogues, which have several advantages over human insulin preparations including a reduced risk of hypoglycaemia. Insulin delivery is still predominantly via subcutaneous injections, but alternative routes of insulin administration are being investigated. Pulmonary delivery has emerged as the most feasible option thus far but oral delivery is an ultimate goal, although basic problems of insulin stability in the gut and absorption from the gastrointestinal tract still need to be resolved. The availability of a true artificial pancreas by means of a closed-loop system, linking continuous glucose monitoring with insulin-pump technology, would also constitute a significant advance, but major technological problems still need to be overcome.
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Affiliation(s)
- Simon Heller
- Academic Unit of Diabetes, Endocrinology and Metabolism, University of Sheffield, Royal Hallamshire Hospital, Glossop Road, Sheffield, South Yorkshire S10 2JF, UK.
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Hirao K, Maeda H, Urata S, Takisawa Y, Hirao S, Sasako T, Sasaki T. Comparison of the pharmacokinetic and pharmacodynamic profiles of biphasic insulin aspart 50 and 30 in patients with type 2 diabetes mellitus: a single-center, randomized, double-blind, two-period, crossover trial in Japan. Clin Ther 2007; 29:927-934. [PMID: 17697911 DOI: 10.1016/j.clinthera.2007.05.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2007] [Indexed: 11/28/2022]
Abstract
BACKGROUND To overcome the complicated mixing procedures required in the use of insulin formulations, premixed formulations consisting of rapid-acting and intermediate-type insulin in various mixing proportions have been developed. Biphasic insulin aspart 50 (BIAsp50) and 30 (BlAsp30) are 2 premixed formulations containing the active ingredient insulin aspart (IAsp) and consisting of a rapid-acting component soluble IAsp) and intermediate-acting component (protamine-crystallized protracted IAsp) in ratios of 50/50 and 30/70, respectively. These formulations are provided with the expectation that BIAsp30 and BIAsp50 will be beneficial for patients needing to improve their postprandial blood glucose control without changing their dietary habits and lifestyles. BIAsp30 has been widely used in medical practice, whereas BIAsp50 is being investigated in clinical trials. OBJECTIVE The aim of this study was to compare the pharmacokinetic (PK) and pharmacodynamic (PD) profiles of BIAsp50 (test) and BIAsp30 (reference) after single-dose SC injection in patients with type 2 diabetes mellitus. METHODS This single-center, randomized, doubleblind, 2-period, crossover trial was conducted at the H.E.C. Science Clinic, Yokohama, Japan. Male and female patients aged > or = 20 years with a > or = 1 year history of type 2 diabetes were eligible. Patients were randomly assigned to 1 of 2 treatment sequences: group A received BIAsp30 in period 1 and BIAsp50 in period 2; group B received BIAsp50 in period 1 and BIAsp30 in period 2. All treatments were administered as an SC injection of a single dose (0.3 U/kg). The study periods were separated by a washout period of 4 to 21 days. For PK analysis of IAsp (maximum serum IAsp concentration [C(max,IAsp); primary end point], AUC of serum IAsp 0 to 120, 240, and 480 minutes after administration [AUC(0-120 min,IAspl), AUC(0-240 min,IAsp), and AUC(0-480 min,IAsp5) respectively], and time to (Cmax,IAsp) [T(max,IAsp)] ), blood samples were drawn immediately before (baseline) and at prespecified time points over 480 minutes after administration. The PD profiles of BIAsp50 and BIAsp30 were also examined by comparing the time course of the glucose infusion rate (GIR) using the euglycemic clamp technique. The PD end points were AUC of GIR 0 to 120 minutes after administration (AUC(0-120 min,GIR)), maximum GIR (GIR(max)), and time to GIRmax (T(max,GIR)). Tolerability was assessed using physical examination, including vital sign measurement, electrocardiography, body weight, adverse events (AEs), and clinical laboratory analysis (hematology and serum biochemistry). RESULTS Six men and 4 women were enrolled in the study (mean age, 62.4 years; mean body weight, 58.3 kg; mean body mass index, 22.22 kg/m(2); mean duration of diabetes, 9.53 years; and mean glycosylated hemoglobin concentration, 6.07%). Mean(Cmax,IAsp) with BIAsp50 was 63% higher than that for BIAsp30 (P < 0.002). The BIAsp50/BIAsp30 ratio with AUC(0-120 min,IAsp) was 1.68 (95% CI, 1.31-2.14). The BIAsp50/BIAsp30 ratiofor AUC(0-120 min,GIR) was 1.31 (95% CI, 1.02-1.68). A total of 9 AEs were reported in 5 patients, but none of the AEs were considered related to the study drug. CONCLUSION In this small PK/PD study in adults with type 2 diabetes in Japan, mean C(max,IAsp) was significantly higher with BIAsp50 than with BIAsp30, and AUC(0-120 min,IAsp) and AUC(0-120 min,GIR) were higher with BIAsp50 than with BIAsp30.
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Affiliation(s)
- Koichi Hirao
- Department of Internal Medicine, H. E C. Science Clinic, Yokohama, Japan
| | - Hajime Maeda
- Department of Internal Medicine, H. E C. Science Clinic, Yokohama, Japan
| | - Shinichi Urata
- Department of Internal Medicine, H. E C. Science Clinic, Yokohama, Japan
| | - Yukiko Takisawa
- Department of Internal Medicine, H. E C. Science Clinic, Yokohama, Japan
| | - Setsuko Hirao
- Department of Internal Medicine, H. E C. Science Clinic, Yokohama, Japan
| | - Tatsuya Sasako
- Development Division, Department of Diabetes Clinical Development, Novo Nordisk Pharma Ltd., Tokyo, Japan
| | - Tomio Sasaki
- Development Division, Department of Diabetes Clinical Development, Novo Nordisk Pharma Ltd., Tokyo, Japan.
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84
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Abstract
The progressive nature of type 2 diabetes makes insulin initiation a necessary therapeutic step for many patients. Premixed insulin formulations containing both basal and prandial insulin (so called biphasic insulin) are often prescribed because they are superior to long- or intermediate-acting insulin in obtaining good metabolic control. In addition, they are considered as an attractive alternative to classical basal-bolus therapy as fewer daily injections are required. Premixed insulin formulations include conventional (e.g. biphasic human insulin 70/30, or 30/70 in European countries, BHI 30) and newer premixed human analogues (e.g. biphasic insulin aspart 70/30, or 30/70 in Europe, BIAsp 30; insulin lispro mix 75/25-Mix 75/25, or Mix 25/75 in Europe). Like conventional premixed human insulin, premixed insulin analogues contain a fixed proportion of soluble, rapid-acting insulin analogue, with protaminated analogue comprising the remainder. Unlike conventional premixes, analogue premixes have more physiological pharmacokinetic and therapeutically more desirable pharmacodynamic profiles than premixed human insulin. Consequently, postprandial glycaemic control is better with premixed insulin analogues than with premixed human insulin. In nontreat-to-target registration trials, the lowering of haemoglobin A(1c) with premixed insulin analogues was not inferior to that seen with premixed human insulin. Minor hypoglycaemia was similar for premixed analogue and premixed human insulins, while major hypoglycaemia appears to be rare with either formulation. The occurrence of adverse events, other than hypoglycaemia, was also similar between various premix insulins. The premixed insulin analogues, BIAsp 30 and Mix 75/25, like the fast-acting analogues from which they are derived, also allow flexible injection timing, relative to meal timing, thus improving adherence, compliance and quality of life compared with premixed human insulin. Overall, the evidence suggests that premixed insulin analogues are cost effective and have useful advantages over premixed human insulin for the treatment of type 2 diabetes.
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Affiliation(s)
- Alan J Garber
- Baylor College of Medicine, Faculty Center, Houston, TX 77030, USA.
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85
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Mitrović M, Pantelinac P, Radosavljević J, Bajkin I, Todorović-Dilas L. [The role of insulin analogues in the current treatment of diabetes mellitus]. MEDICINSKI PREGLED 2007; 59:539-44. [PMID: 17633894 DOI: 10.2298/mpns0612539m] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Ever since insulin was discovered by Banting and Best in 1921, all further researches in this field had been conducted with one goal: to find new insulin molecules which would provide better glycemic control with fewer side effects i.e. to mimic endogenous physiological insulin secretion. NORMAL INSULIN SECRETION In healthy individuals, endogenous insulin secretion can be classified as basal (which provides basal glucose homeostasis) and stimulated (as a response to a meal). Conventional insulin preparations--human insulin, have time-action profiles that cannot fully immitate endogenous insulin secretion, thus leading to postprandial hyperglicemia and high glycemic oscilations during the day. RAPID-ACTING ANALOGUES: Rapid acting analogues should have a time-action profile with onset of less than one hour, duration less than four hours, hypoglycemic potency equal or greater than that of human insulin, and similar effects in all patients. Two rapid action analogues, lispro and aspart are available. BASAL INSULIN ANALOGUES The ideal basal insulin should provide slow and constant absorption, long half-life that would provide once daily dosing (or every other day), and peakless effect. Insulin glargine led to solubility at pH 4 and to slow absorption in neutral pH environment. Insulin detemir is a soluble insulin analogue with neutral pH and affinity to bind to serum albumin, thus gaining prolonged action. MITOGENIC INFLUENCE The mitogenic influence of insulin is due to the affinity to bind to IGF-I receptors. Following two-year administration of glargine in mice and rats, systemic carcinogenic potential was not found, though there were reports of hepatocellular carcinomas, which are frequently found in these animals. CONCLUSION In the last two decades, many trials have shown that unsatisfactory glycemic control leads to chronic complications in both types of diabetes. Using basal glucose level, postprandial glycemy and HbA1c as metabolic parameters, it has been proven that only strict glycemic control can lower the risk of developing complications. Discovery of insulin analogues (both rapid acting and basal) enables physicians to provide better glycoregulation and less hypoglycemic incidents to their patients.
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86
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Cobden D, Lee WC, Balu S, Joshi AV, Pashos CL. Health Outcomes and Economic Impact of Therapy Conversion to a Biphasic Insulin Analog Pen Among Privately Insured Patients with Type 2 Diabetes Mellitus. Pharmacotherapy 2007; 27:948-62. [PMID: 17594200 DOI: 10.1592/phco.27.7.948] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To evaluate claims-related treatment adherence, health care resource utilization, and associated costs of therapy conversion from an insulin vial and syringe to a premixed biphasic insulin analog pen device among privately insured patients with type 2 diabetes mellitus. DESIGN Retrospective, longitudinal, intrapatient (before and after) analysis. DATA SOURCE PharMetrics database of medical and pharmaceutical claims from 57 commercial health plans across the United States. PATIENTS Four hundred eighty-six adult patients with a confirmed diagnosis of type 2 diabetes who converted from an insulin analog vial and syringe (233 patients) or a human insulin vial and syringe (253 patients) to a biphasic insulin analog pen device between July 1, 2001 and December 31, 2002. MEASUREMENTS AND MAIN RESULTS All patients had no previous use of the pen device. Primary end points were medication possession ratio (MPR), a measure of adherence; hypoglycemic events; associations between treatment adherence and hypoglycemic events, and adherence and all-cause health care costs; and all-cause-attributable, hypoglycemia-attributable, and other diabetes-attributable costs. After conversion, MPR increased significantly from 59% to 68% (p<0.01). A significant decrease in the likelihood of experiencing a hypoglycemic event was also observed after conversion (odds ratio [OR] 0.40, 95% confidence interval [CI] 0.27-0.61, p<0.05), with hypoglycemic occurrences reduced nearly two thirds among subjects with optimal adherence indicated by an MPR of 80% or greater (incidence rate ratio 0.36, 95% CI 0.11-0.76, p<0.05). Significant decreases in hypoglycemia-attributable emergency department visits (OR 0.36, 95% CI 0.16-0.84, p<0.05) and physician visits (OR 0.39, 95% CI 0.20-0.77, p<0.05) were observed. Total mean all-cause annual treatment costs were reduced by $1748/patient (p<0.01), hypoglycemia-attributable costs were reduced by $908/patient (p<0.01), and other diabetes-attributable costs were reduced by $643/patient (p<0.01). Patients with an MPR of 80% or greater were associated with significant reductions in all-cause health care costs (OR 0.55, 95% CI 0.31-0.80, p<0.05). CONCLUSION Privately insured patients with type 2 diabetes may exhibit considerable improvements in clinical and economic outcomes after insulin therapy conversion from vial and syringe to a premixed biphasic insulin analog pen device.
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87
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Abstract
A recent meta-analysis evaluated trials of the rapid-acting analogues insulin lispro and insulin aspart, performed before the introduction of the basal analogues, insulin glargine and insulin detemir. This article reviews the effect of rapid-acting and basal insulin analogues separately and in combination, relative to human insulin. Outcomes evaluated include HbA(1c), hypoglycaemia, postprandial glucose (PPG), and weight changes. Results from trials that matched defined criteria are presented in tables. In type 1 diabetes, compared with human insulin, the rapid-acting analogues generally reduced hypoglycaemia and postprandial glucose, whereas the basal analogues tended to reduce hypoglycaemia -- particularly nocturnal hypoglycaemia. Weight gain may also be reduced with basal analogues, compared with human basal insulin. In type 2 diabetes, premix rapid-acting analogues controlled postprandial glucose better than human insulin mixes; basal analogues used as basal-only therapy reduced hypoglycaemia compared with NPH insulin; and some advantages were apparent with analogues in basal-bolus therapy. Whilst the benefits on individual metabolic and clinical outcomes appear modest, almost all studies report some advantage when using insulin analogues in type 1 and type 2 diabetes. Significant benefits, including PPG lowering with the rapid-acting analogues and the potential for reduction in cardiovascular risk, should be investigated further.
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Affiliation(s)
- Stephen C L Gough
- Institute of Biomedical Research, The Medical School, University of Birmingham, Birmingham, UK.
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88
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Meneghini L, Hirsch IB. Pharmacotherapies for diabetes management: an update for the practicing clinician. Semin Thorac Cardiovasc Surg 2007; 18:379-89. [PMID: 17395035 DOI: 10.1053/j.semtcvs.2007.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2007] [Indexed: 01/08/2023]
Abstract
Over the past several years, the pharmacologic options for the management of glycemic control have tremendously expanded. Whereas prior to the introduction of metformin therapy in 1995 the only alternatives were human insulin therapies and sulfonylurea drugs, we now have the option of using several different classes of oral antidiabetic drugs, injectable non-insulin therapies, and insulin analogs. In this article we present a functional classification of glycemic therapies available for the treatment of diabetes in an attempt to provide the clinician with a practical framework which optimize blood glucose management. Patients with diabetes, especially type 2 diabetes, are often managed with a wide variety of injectable and non-injectable options in the attempt to improve glycemic control and glycemic variability, minimize hypoglycemia (as well as weight gain) and prevent both micro- and macrovascular complications. We specifically focus on novel therapies and present macrovascular complications. We specifically focus on novel therapies and present information about their efficacy and safety, as well as potential contraindications. The last section of this paper will present some suggestions for how to manage glycemia in the in-patient setting, including the use of rapid and long-acting insulin preparations to cover fasting and nutritional needs, as well as the proper use of insulin scales.
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Affiliation(s)
- Luigi Meneghini
- University of Miami Miller School of Medicine, Diabetes Research Institute, Miami, Florida 33136, USA.
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89
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Abstract
Type 2 diabetes is characterised by insulin resistance and progressive beta-cell deterioration. As beta-cell function declines, most patients with type 2 diabetes will require insulin therapy. Clinical studies show that tight control of blood glucose levels prevents the development of the microvascular and macrovascular complications caused by diabetes. Insulin is the most potent drug currently available to achieve tight glycaemic control; however, often it is not used early or aggressively enough for patients to achieve the glycaemic targets needed to prevent chronic complications. New basal insulin analogues and premixed insulin analogues, which have more physiological time-action profiles compared with human insulin formulations, offer flexibility and convenience, thereby improving quality of life. It is crucial that doctors initiate insulin therapy as soon as other diabetes therapies are no longer effective. This article reviews the improvements provided by basal insulin analogues, premixed insulin analogues, and insulin delivery systems; provides sample algorithms for initiating and titrating the various insulin analogue preparations; and discusses how to individualise treatment regimens to maximise outcomes in patients with type 2 diabetes.
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Affiliation(s)
- J Tibaldi
- Department of Medicine, Flushing Hospital Medical Center, Flushing, NY, USA.
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90
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Abstract
Most patients with type 2 diabetes are inadequately controlled on their current therapy. Suboptimal glycemic control can have devastating consequences, such as retinopathy, nephropathy, neuropathy, and cardiovascular disease that may ultimately lead to mortality. Most patients eventually need insulin therapy, and initiating insulin earlier in the course of type 2 diabetes may lead to optimal glycemic control and prevent or delay diabetes-related complications. Although insulin therapy is the most effective method of managing hyperglycemia, it is often delayed owing to concerns about the complexity and inconvenience of treatment regimens; fear of injections, hypoglycemia or weight gain; and the time required to learn how to effectively manage insulin therapy. The development of insulin analogs, biphasic insulin analogs, and more convenient insulin delivery systems may make insulin therapy more manageable and help more patients achieve their treatment goals.
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Affiliation(s)
- Luigi Meneghini
- Eleanor and Joseph Kosow Diabetes Treatment Center, Diabetes Research Institute, Miami, FL 33136, USA.
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91
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Matching Insulin to Patient: How to Make the Best Use of Premixed Insulin Analog Formulations. J Nurse Pract 2007. [DOI: 10.1016/j.nurpra.2006.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Ray JA, Valentine WJ, Roze S, Nicklasson L, Cobden D, Raskin P, Garber A, Palmer AJ. Insulin therapy in type 2 diabetes patients failing oral agents: cost-effectiveness of biphasic insulin aspart 70/30 vs. insulin glargine in the US. Diabetes Obes Metab 2007; 9:103-13. [PMID: 17199725 DOI: 10.1111/j.1463-1326.2006.00581.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To project the long-term clinical and economic outcomes of treatment with biphasic insulin aspart 30 (BIAsp 70/30, 30% soluble and 70% protaminated insulin aspart) vs. insulin glargine in insulin-naïve type 2 diabetes patients failing to achieve glycemic control with oral antidiabetic agents alone (OADs). METHODS Baseline patient characteristics and treatment effect data from the recent 'INITIATE' clinical trial served as input to a peer-reviewed, validated Markov/Monte-Carlo simulation model. INITIATE demonstrated improvements in HbA1c favouring BIAsp 70/30 vs. glargine (-0.43%; p < 0.005) and greater efficacy in reaching glycaemic targets among patients poorly controlled on OAD therapy. Effects on life expectancy (LE), quality-adjusted life expectancy (QALE), cumulative incidence of diabetes-related complications and direct medical costs (2004 USD) were projected over 35 years. Clinical outcomes and costs were discounted at a rate of 3.0% per annum. Sensitivity analyses were performed. RESULTS Improvements in glycaemic control were projected to lead to gains in LE (0.19 +/- 0.24 years) and QALE (0.19 +/- 0.17 years) favouring BIAsp 70/30 vs. glargine. Treatment with BIAsp 70/30 was also associated with reductions in the cumulative incidences of diabetes-related complications, notably in renal and retinal conditions. The incremental cost-effectiveness ratio was $46 533 per quality-adjusted life year gained with BIAsp 70/30 vs. glargine (for patients with baseline HbA1c >/= 8.5%, it was $34 916). Total lifetime costs were compared to efficacy rates in both arms as a ratio, which revealed that the lifetime cost per patient treated successfully to target HbA1c levels of <7.0% and </= 6.5% were $80 523 and $93 242 lower with BIAsp 70/30 than with glargine, respectively. CONCLUSIONS Long-term treatment with BIAsp 70/30 was projected to be cost-effective for patients with type 2 diabetes insufficiently controlled on OADs alone compared to glargine. Treatment with BIAsp 70/30 was estimated to represent an appropriate investment of healthcare dollars in the management of type 2 diabetes.
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Affiliation(s)
- J A Ray
- CORE - Center for Outcomes Research, A unit of IMS, Binningen/Basel, Switzerland
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93
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Yamada S, Watanabe M, Kitaoka A, Shiono K, Atsuda K, Tsukamoto Y, Kawana Y, Irie J. Switching from premixed human insulin to premixed insulin lispro: a prospective study comparing the effects on glucose control and quality of life. Intern Med 2007; 46:1513-7. [PMID: 17878636 DOI: 10.2169/internalmedicine.46.0236] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
AIM To evaluate the clinical effects of switching from premixed human insulin to a premixed rapid-acting insulin analogue in type 2 diabetic patients. RESEARCH DESIGN AND METHODS Thirty patients, who were treated with a twice-daily injection of premixed human insulin, were enrolled and randomized to (i) 50/50 premixed insulin lispro twice-daily at the same daily dose as premixed human insulin (analogue mix group), or (ii) continued premixed human insulin (control group). The doses of insulin were adjusted every month by registered diabetologists to achieve adequate blood glucose levels. At the beginning of the study, and again 4 months later, HbA1c and blood glucose levels were measured, and the amount of insulin required and BMI were recorded in both groups. Insulin therapy-related quality of life (ITR-QOL) and the diabetes treatment satisfaction questionnaire (DTSQ) were also assessed in the analogue mix group at the beginning of the study and again 4 months later. RESULTS Although HbA1c levels did not change significantly over the duration of the study in the control group (7.33 +/- 0.58 vs 7.29 +/- 0.65%), HbA1c did improve significantly in the analogue mix group (7.59 +/- 0.44 vs 7.24 +/- 0.49%; p<0.05). The dose of insulin required in the analogue mix group did not change significantly (0.37 +/- 0.11 vs 0.38 +/- 0.14 U/kg/day), but increased in the control group from 0.34 +/- 0.15 to 0.37 +/- 0.16 U/kg/day (p<0.05). The switch to the premixed insulin analogue did not affect ITR-QOL and DTSQ scores. CONCLUSIONS This study showed that switching from premixed human insulin to 50/50 premixed insulin lispro improved blood glucose control without compromising QOL. This finding suggests that a premixed rapid-acting insulin analogue is more effective than human insulin for Japanese type 2 diabetic patients.
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Affiliation(s)
- Satoru Yamada
- Department of Internal Medicine, Kitasato Institute Hospital, Tokyo.
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94
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Chen JW, Lauritzen T, Bojesen A, Christiansen JS. Multiple mealtime administration of biphasic insulin aspart 30 versus traditional basal-bolus human insulin treatment in patients with type 1 diabetes. Diabetes Obes Metab 2006; 8:682-9. [PMID: 17026493 DOI: 10.1111/j.1463-1326.2005.00557.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM The aim of this study was to compare the effect of multiple mealtime injections of biphasic insulin aspart 30 (30% fast-acting insulin aspart in the formulation, BIAsp30) to traditional basal-bolus human insulin regimen (HI) on glycaemic control in patients with type 1 diabetes. METHODS Twenty-three patients (eight women and 15 men) aged 44.8 (20.6-62.5) years (median and range) with a diabetes duration of 19.5 (1.6-44.6) years completed the study. All eligible patients were randomly assigned to BIAsp30 thrice daily supplied with bedtime NPH insulin when necessary, or basal-bolus HI for 12 weeks and then switched to the alternative regimen for another 12 weeks. The insulin dose adjustments were made by patients on the basis of advice from a diabetes nurse. At end of each treatment period, the patients attended two profile days, 1 week apart for pharmacodynamic and pharmacokinetic assessments. HbA1C was measured at baseline and at the end of each treatment period. A seven-point self-monitored blood glucose (SMBG) was obtained twice weekly. RESULTS In comparison with HI, multiple mealtime injections of BIAsp30 resulted in a significant reduction in HbA1C[HI vs. BIAsp30 (%, geometric mean and range): 8.6 (7.4-11.4) vs. 8.3 (6.7-9.8), p = 0.013]. During treatment with BIAsp30, nighttime glycaemic control was significantly improved. Day-to-day variation in pharmacodynamics and pharmacokinetics and the rate of hypoglycaemia were not increased with BIAsp30 compared with HI. CONCLUSIONS In type 1 diabetics, multiple mealtime administration of BIAsp30 compared with traditional basal-bolus human insulin treatment significantly improves long-term glycaemic control without increasing the risk of hypoglycaemia. Despite a higher proportion of intermediate-acting insulin, thrice-daily injections with BIAsp30 do not increase the day-to-day variations in insulin pharmacokinetics and pharmacodynamics.
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Affiliation(s)
- J-W Chen
- Department of Endocrinology and Diabetes, Aarhus University Hospital, Aarhus, Denmark.
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95
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Abstract
Insulin aspart, an analogue of human insulin, which is approved for use in people with diabetes, is more rapidly absorbed and achieves higher plasma concentrations than human soluble insulin following subcutaneous injection. Hence, it has a faster and more effective glucose-lowering action, with superior control of postprandial hyperglycaemia compared with human soluble insulin. Its shorter duration of action makes interprandial and nocturnal hypoglycaemia less of a problem than with human soluble insulin. Insulin aspart is approved for use in continuous subcutaneous infusion and offers a valuable treatment option during pregnancy.
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Affiliation(s)
- David Owens
- Diabetes Research Unit, First Floor, Academic Centre, Llandough Hospital, Penlarn Road, Penarth, South Glamorgan, CF64 2FX, Wales, UK. owens
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96
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Soliman AT, Omar M, Rizk MM, El Awwa A, AlGhobashy FM. Glycaemic control with modified intensive insulin injections (MII) using insulin pens and premixed insulin in children with type-1 diabetes: a randomized controlled trial. J Trop Pediatr 2006; 52:276-81. [PMID: 16410276 DOI: 10.1093/tropej/fmk005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The objective of this study was to compare glycemic control and insulin dosage in children with type 1 diabetes treated by a modified intensified insulin therapy MII using insulin pens (and premixed and regular insulin) with those on conventional insulin therapy. This was a longitudinal, randomized controlled trial for 6 months or more. From a cohort of 125 children with previously diagnosed type-1 diabetes (more than a year after diagnosis) two groups were randomly selected Group AI (n=20) and Group B (n=20). Group AI children and 10 children with recently diagnosed type 1 diabetes (Group AII) were allocated to MII using regular insulin and premixed insulin (30/70 and 40/60 and 50/50). Group B patients continued their conventional insulin therapy for the whole period of the trial. The main outcome measures were glycemic control measured by mean blood glucose concentration and percentage of glycated haemoglobin and total daily insulin dose. Mean blood glucose concentrations before the three main meals, and at midnight, (148, 147, 179 and 127 mg/dl, respectively) were lower in children receiving intensified MII compared with those receiving conventional insulin therapy (192, 174, 194 and 179 mg/dl, respectively) (standardized mean difference 34+/-15 mg/dl), equivalent to a difference of 1.9+/-0.8 mmol/l. This improved control during MII was achieved with no change in the average daily insulin dose in group-AI. In group-AII insulin dose decreased significantly during their first 6 moths of treatment (honeymooning). Glycemic control is better during MII using insulin pens and premixed and regular insulin compared with conventional insulin therapy, without any significant change in insulin dose needed to achieve this level of control. The difference in glycemic control between the two methods is significant and could reduce the risk of micro-vascular complications.
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Affiliation(s)
- Ashraf T Soliman
- Department of Pediatrics, Alexandria University Children's Hospital, El-Chatby, Alexandria, Egypt.
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97
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Siebenhofer A, Plank J, Berghold A, Jeitler K, Horvath K, Narath M, Gfrerer R, Pieber TR. Short acting insulin analogues versus regular human insulin in patients with diabetes mellitus. Cochrane Database Syst Rev 2006:CD003287. [PMID: 16625575 DOI: 10.1002/14651858.cd003287.pub4] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Short acting insulin analogue use for diabetic patients is still controversial, as reflected in many scientific debates. OBJECTIVES To assess the effects of short acting insulin analogues versus regular human insulin. SEARCH STRATEGY The Cochrane Library (Issue 3, 2005), MEDLINE, EMBASE until September 2005. SELECTION CRITERIA Randomised controlled trials with an intervention duration of at least 4 weeks. DATA COLLECTION AND ANALYSIS Trial selection and evaluation of study quality was done independently by two reviewers. MAIN RESULTS Altogether 8274 participants took part in 49 randomised controlled studies. Most studies were of poor methodological quality. In patients with type 1 diabetes, the weighted mean difference (WMD) of HbA1c was -0.1% (95% CI: -0.2 to -0.1) in favour of insulin analogue, whereas in patients with type 2 diabetes the WMD was 0.0% (95% CI: -0.1 to 0.0). In subgroup analyses of different types of interventions in type 1 diabetic patients, the WMD in HbA1c was -0.2% (95% CI: -0.3 to -0.1) in favour of insulin analogue in studies using continuous subcutaneous insulin injections (CSII), whereas for conventional intensified insulin therapy (IIT) studies the WMD in HbA1c was -0.1% (95% CI: -0.1 to 0.0). The WMD of the overall mean hypoglycaemic episodes per patient per month was -0.2 (95% CI: -1.1 to 0.7) and -0.2 (95% CI: -0.5 to 0.1) for analogues in comparison to regular insulin in patients with type 1 diabetes and type 2 diabetes, respectively. For studies in type 1 diabetes patients the incidence of severe hypoglycaemia ranged from 0 to 247.3 (median 21.8) episodes per 100 person-years for insulin analogues and from 0 to 544 (median 46.1) for regular insulin, in type 2 the incidence ranged from 0 to 30.3 (median 0.3) episodes per 100 person-years for insulin analogues and from 0 to 50.4 (median 1.4) for regular insulin. No study was designed to investigate possible long term effects (e.g. mortality, diabetic complications), in particular in patients with diabetes related complications. AUTHORS' CONCLUSIONS Our analysis suggests only a minor benefit of short acting insulin analogues in the majority of diabetic patients treated with insulin. Until long term efficacy and safety data are available we suggest a cautious response to the vigorous promotion of insulin analogues. For safety purposes, we need a long-term follow-up of large numbers of patients and well designed studies in pregnant women to determine the safety profile for both the mother and the unborn child.
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Affiliation(s)
- A Siebenhofer
- Leopold Auenbrugger Medical University of Graz, University of Medicine, Auenbruggerplatz 15, Graz, Austria, 8036.
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98
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Abstract
Premixed insulin analogues, consisting of rapid-acting and intermediate-acting insulin analogues, were developed to more closely mimic physiological endogenous insulin secretion and meet the needs of patients who require both basal and prandial insulin but wish to limit the number of daily injections. There is considerable variability in onset and duration of action, as well as peak insulin levels, obtained with human insulin formulations such as premixed human insulin 70/30. To overcome these limitations, premixed insulin analogues were developed. Peak insulin levels are twice as high and reached in half the time with the rapid-acting insulin component of a premixed insulin analogue. In the US, two premixed insulin analogue formulations are currently available: insulin lispro 75/25 (75% insulin lispro protamine suspension and 25% insulin lispro) and biphasic insulin aspart 70/30 (BIAsp 70/30; 70% insulin aspart protamine suspension and 30% insulin aspart). They are generally administered twice daily, just before breakfast and dinner. Data from various randomised trials show that both insulin lispro 75/25 and BIAsp 70/30 provide more effective postprandial control of blood glucose than premixed human insulin 70/30 or human insulin isophane suspension (NPH insulin). Longer-term glycaemic control, evaluated as changes in glycosylated haemoglobin, is comparable for premixed insulin analogues and premixed human insulin 70/30 in most studies. Three comparative, randomised trials have shown that patients with type 2 diabetes mellitus using premixed insulin analogues twice daily are more likely to reach glycaemic goals than those using only insulin glargine once daily. Some patients can also reach glycaemic goals with once-daily administration of a premixed insulin analogue. Although the incidence of hypoglycaemia is low, direct comparison across trials of premixed insulin analogues is difficult because of inconsistencies in reporting. Within trials, the incidence of both major (rare) and minor hypoglycaemic episodes during treatment with premixed insulin analogues is low and comparable with rates found with human insulin 70/30. Premixed insulin analogues can be safely used, and are effective and convenient for achieving overall glycaemic control in patients with diabetes. In addition, given the convenience of mealtime dose administration, compliance with insulin therapy may increase with premixed insulin analogues.
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Affiliation(s)
- Alan J Garber
- Department of Medicine, Baylor College of Medicine, Houston, Texas 77030, USA
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99
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Sridhar GR. Two regimens of twice-daily premix insulin analogue: an observational study. Diabetes Res Clin Pract 2006; 71:105-7. [PMID: 16171886 DOI: 10.1016/j.diabres.2005.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2005] [Accepted: 08/13/2005] [Indexed: 11/23/2022]
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Kvapil M, Swatko A, Hilberg C, Shestakova M. Biphasic insulin aspart 30 plus metformin: an effective combination in type 2 diabetes. Diabetes Obes Metab 2006; 8:39-48. [PMID: 16367881 DOI: 10.1111/j.1463-1326.2005.00492.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM This study compared glycaemic control achieved with biphasic insulin aspart 30 (BIAsp 30) monotherapy, BIAsp 30 plus metformin and glibenclamide plus metformin in patients with type 2 diabetes not adequately controlled with metformin. METHODS In this multinational, open-labelled, parallel group, 16-week trial, 341 patients (patients not adequately controlled with metformin for at least 1 month) with type 2 diabetes were studied. Patients were randomized to receive BIAsp 30, twice daily (n = 107 exposed to treatment), or BIAsp 30, twice daily, plus metformin (n = 108) or glibenclamide plus metformin (n = 114). The primary endpoint was HbA(1c) at end of trial; adverse events, hypoglycaemia episodes, blood lipids and weight were also monitored. RESULTS In the total population (HbA(1c) 7.5-13.0% at screening), end-of-trial HbA(1c) levels were lower in patients receiving BIAsp 30 plus metformin compared with those receiving BIAsp 30 only [mean treatment difference (+/-s.e.m), 0.39 +/- 0.15%, p = 0.007]. In a subpopulation (HbA(1c) > or = 9.0% at baseline, n = 193), patients receiving BIAsp 30 plus metformin had significantly lower HbA(1c) levels at the end of the trial compared with those receiving glibenclamide plus metformin (treatment difference, 0.46 +/- 0.21%, p = 0.027). Mean body weight (+/-s.d) at the end of the trial was significantly lower in patients receiving glibenclamide plus metformin compared with those receiving BIAsp 30 only (84.3 +/- 13.3 kg vs. 88.9 +/- 16.9 kg, p < 0.001). No major hypoglycaemic episodes were recorded during the trial, and incidence rates for minor and symptoms-only hypoglycaemia were low and similar between treatment groups (0.03-0.04 events/patient/week). CONCLUSION BIAsp 30 added to metformin could be an appropriate therapeutic option for achieving good glycaemic control, compared with the addition of a second oral agent, particularly where HbA(1c) > or = 9%.
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Affiliation(s)
- M Kvapil
- Internal Clinic 2nd Medical Faculty, Prague, Czech Republic.
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