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Zhang P, Chen M, Zhang H, Luo Y, Zhu D, Li X, Ji J, Wang D, Duolikun N, Ji L. Effectiveness and safety of basal insulin therapy in type 2 diabetes mellitus patients with or without metformin observed in a national cohort in China. BMC Endocr Disord 2022; 22:26. [PMID: 35045841 PMCID: PMC8767735 DOI: 10.1186/s12902-021-00892-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 10/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Though many randomized control trials had examined the effectiveness and safety of taking insulin therapy with or without metformin, there are limited real-world data, especially among Chinese type 2 diabetes patients initiating basal insulin (BI) with uncontrolled hyperglycemia by oral agents. This study was designed to assess the effectiveness and safety of BI therapy combined with or without metformin in a real-world national cohort study. METHODS Patients with type 2 diabetes mellitus who initiated BI treatment due to uncontrolled hyperglycemia (HbA1c≥7 %) by oral antidiabetic drugs (OADs) were recruited in Chinese real-world settings between 2011 and 2013. A total of 12,358 patients initiated BI without bolus insulin and completed a 6-month follow-up were selected as the study population and divided into BI with metformin or BI without metformin group based on whether metformin was simultaneously prescribed or not at baseline. Propensity score adjustment was used to balance baseline covariates between two groups. A sub-analysis was also conducted among 8,086 patients who kept baseline treatment regimen during the follow-up. Outcomes were HbA1c, hypoglycemia, weight gain and insulin dose in two groups. RESULTS 53.6 % (6,621 out of 12,358) patients initiated BI therapy concomitant with metformin. After propensity score adjustment, multivariate regression analysis controlled with number of OADs, total insulin dose, physical activity and diet consumption showed that BI with metformin group had a slightly higher control rate of HbA1c <7.0 % (39.9 % vs. 36.4 %, P = 0.0011) at 6-month follow-up, and lower dose increment from baseline to 6-month (0.0064 vs. 0.0068 U/day/kg, P = 0.0035). The sub-analysis with patients remained at same BI therapy further showed that BI with metformin group had higher HbA1c control rate (47.9 % vs. 41.9 %, P = 0.0001), less weight gain (-0.12 vs. 0.15 kg P = 0.0013), and lower dose increment during 6-month follow-up (0.0033 vs. 0.0037 U/day/kg, P = 0.0073) when compared with BI without metformin group. CONCLUSIONS In alliance with current guidelines, the real-world findings also support the insulin initiation together with metformin. Continuous patients' education and clinicians training are needed to improve the use of metformin when initiating BI treatment.
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Affiliation(s)
- Puhong Zhang
- The George Institute for Global Health at Peking University Health Science Center, 100600, Beijing, China
- Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Minyuan Chen
- The George Institute for Global Health at Peking University Health Science Center, 100600, Beijing, China
| | - Heng Zhang
- The George Institute for Global Health at Peking University Health Science Center, 100600, Beijing, China
| | - Yingying Luo
- Department of Endocrinology and Metabolism, Peking University People's Hospital, 100040, Beijing, China
| | - Dongshan Zhu
- The George Institute for Global Health at Peking University Health Science Center, 100600, Beijing, China
| | - Xian Li
- The George Institute for Global Health at Peking University Health Science Center, 100600, Beijing, China
| | - Jiachao Ji
- The George Institute for Global Health at Peking University Health Science Center, 100600, Beijing, China
| | - Du Wang
- The George Institute for Global Health at Peking University Health Science Center, 100600, Beijing, China
| | - Nadila Duolikun
- The George Institute for Global Health at Peking University Health Science Center, 100600, Beijing, China
| | - Linong Ji
- The George Institute for Global Health at Peking University Health Science Center, 100600, Beijing, China.
- Department of Endocrinology and Metabolism, Peking University People's Hospital, 100040, Beijing, China.
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Abdi H, Azizi F, Amouzegar A. Insulin Monotherapy Versus Insulin Combined with Other Glucose-Lowering Agents in Type 2 Diabetes: A Narrative Review. Int J Endocrinol Metab 2018; 16:e65600. [PMID: 30008760 PMCID: PMC6035366 DOI: 10.5812/ijem.65600] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 04/04/2018] [Accepted: 04/04/2018] [Indexed: 12/18/2022] Open
Abstract
CONTEXT Insulin can be prescribed as a monotherapy or a combined therapy with other anti-diabetic medications. In this narrative review, the authors aimed to gather data related to comparison of insulin monotherapy versus combination of insulin and other anti-diabetic treatments with regards to different outcome measures in type 2 diabetes. EVIDENCE ACQUISITION This study searched and focused on the most recently published systematic reviews and their references investigating issues related to the primary aim. RESULTS The current data available on this topic is heterogeneous and suffers from low quality with respect to most combination treatments. Considering the efficacy and safety of combination therapy of insulin with older hypoglycemic agents, in general metformin and pioglitazone have the best and worst profiles, respectively. Compared to insulin monotherapy, combination of insulin and metformin is associated with better glycemic control, reduced daily insulin dose, less hypoglycemia, and weight gain; combination of insulin and pioglitazone results in greater hypoglycemia and weight gain and is associated with increased risk of edema and heart failure. Regarding sulphonylurea, there is some concern regarding hypoglycemia and weight gain. Addition of dipeptidyl peptidase-4 inhibitors to insulin seems to be beneficial with respect to glycemic control without any significant adverse effects. New drugs, including glucagon-like peptide-1 agonists and sodium glucose co-transporter 2 inhibitors, have acceptable profiles with significant benefits regarding weight reduction when added on insulin therapy. CONCLUSIONS Considering the quality and longevity of evidence, compared to insulin monotherapy, insulin combined with metformin and pioglitazone has the best and worst profiles, respectively. New anti-diabetic medications have acceptable profiles yet are expensive. It is important for clinicians to meticulously weigh the advantages of combination therapy against the possible adverse effects with each drug class in every patient, individually.
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Affiliation(s)
- Hengameh Abdi
- Endocrine Research Centre, Research Institute for Endocrine Science, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | - Fereidoun Azizi
- Endocrine Research Centre, Research Institute for Endocrine Science, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
- Corresponding author: Fereidoun Azizi, MD, Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, P.O. Box 19395-4763, Tehran, IR Iran. E-mail:
| | - Atieh Amouzegar
- Endocrine Research Centre, Research Institute for Endocrine Science, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
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Harman NL, James R, Wilding J, Williamson PR. SCORE-IT (Selecting Core Outcomes for Randomised Effectiveness trials In Type 2 diabetes): a systematic review of registered trials. Trials 2017; 18:597. [PMID: 29246177 PMCID: PMC5732470 DOI: 10.1186/s13063-017-2317-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 11/08/2017] [Indexed: 12/14/2022] Open
Abstract
Background Outcomes measured in clinical trials should be meaningful to patients, healthcare professionals and researchers, yet there is heterogeneity in the outcomes used across trials. This inconsistency impacts on the ability to compare findings and may mean that the results have little importance to healthcare professionals and the patients that they care for. The aim of the present study is to review the outcomes used in registered trials of therapies for type 2 diabetes mellitus as the first step in the development of a core outcome set for effectiveness trials in type 2 diabetes. Methods A systematic review of clinicaltrials.gov entries was completed for randomised, open (actively recruiting or in follow-up period), phase 3 and 4 trials of type 2 diabetes mellitus in adults. Trials of the treatment of diabetes complications, co-morbidities, prevention and surgery were excluded. Each trial was screened for eligibility and outcomes extracted from the primary and secondary outcomes data fields and free text study information. The outcomes were recorded verbatim and classified into core outcome domains according to the COMET taxonomy. Results A total of 354 trial registrations were reviewed for eligibility and 138 trials included. In total, 1444 outcomes were extracted with a median of eight outcomes per trial (range = 1–60). Outcomes were categorised into 30 different outcome domains according to the COMET taxonomy, but no single domain or outcome was measured in 100% of trials. The majority of trials (88%) included outcomes in the ‘metabolism and nutrition’ domain, such as lipids and lipoproteins (21%), HbA1c (18%), hypoglycaemia (14%), fasting plasma/blood glucose (11%), glycaemic variability (8%), postprandial response (8%) and insulin sensitivity (5%). Only 10% of trials included one or more patient reported outcomes; of these, 29% included the Diabetes Treatment Satisfaction Questionnaire. Conclusions There is marked heterogeneity in the outcomes measured in registered therapeutic intervention trials for type 2 diabetes. The use of an agreed set of core outcomes will improve the consistency of reporting in clinical trials for type 2 diabetes. Trial registration The core outcome set study, of which this is a part, is registered in the COMET database, http://www.comet-initiative.org/studies/details/956. Registered on 24 January 2017. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2317-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nicola L Harman
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, L69 3GL, UK.
| | - Rebecca James
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, L69 3GL, UK
| | - John Wilding
- Obesity and Endocrinology Clinical Research Group, Institute of Ageing and Chronic Disease, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK
| | - Paula R Williamson
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, L69 3GL, UK
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Vos RC, van Avendonk MJP, Jansen H, Goudswaard ANN, van den Donk M, Gorter K, Kerssen A, Rutten GEHM. Insulin monotherapy compared with the addition of oral glucose-lowering agents to insulin for people with type 2 diabetes already on insulin therapy and inadequate glycaemic control. Cochrane Database Syst Rev 2016; 9:CD006992. [PMID: 27640062 PMCID: PMC6457595 DOI: 10.1002/14651858.cd006992.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND It is unclear whether people with type 2 diabetes mellitus on insulin monotherapy who do not achieve adequate glycaemic control should continue insulin as monotherapy or can benefit from adding oral glucose-lowering agents to the insulin therapy. OBJECTIVES To assess the effects of insulin monotherapy compared with the addition of oral glucose-lowering agents to insulin monotherapy for people with type 2 diabetes already on insulin therapy and inadequate glycaemic control. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and reference lists of articles. The date of the last search was November 2015 for all databases. SELECTION CRITERIA Randomised controlled clinical trials of at least two months' duration comparing insulin monotherapy with combinations of insulin with one or more oral glucose-lowering agent in people with type 2 diabetes. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, assessed risk of bias, extracted data and evaluated overall quality of the evidence using GRADE. We summarised data statistically if they were available, sufficiently similar and of sufficient quality. We performed statistical analyses according to the statistical guidelines in the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS We included 37 trials with 40 treatment comparisons involving 3227 participants. The duration of the interventions ranged from 2 to 12 months for parallel trials and two to four months for cross-over trials.The majority of trials had an unclear risk of bias in several risk of bias domains. Fourteen trials showed a high risk of bias, mainly for performance and detection bias. Insulin monotherapy, including once-daily long-acting, once-daily intermediate-acting, twice-daily premixed insulin, and basal-bolus regimens (multiple injections), was compared to insulin in combination with sulphonylureas (17 comparisons: glibenclamide = 11, glipizide = 2, tolazamide = 2, gliclazide = 1, glimepiride = 1), metformin (11 comparisons), pioglitazone (four comparisons), alpha-glucosidase inhibitors (four comparisons: acarbose = 3, miglitol = 1), dipeptidyl peptidase-4 inhibitors (DPP-4 inhibitors) (three comparisons: vildagliptin = 1, sitagliptin = 1, saxagliptin = 1) and the combination of metformin and glimepiride (one comparison). No trials assessed all-cause mortality, diabetes-related morbidity or health-related quality of life. Only one trial assessed patients' treatment satisfaction and showed no substantial differences between the addition of either glimepiride or metformin and glimepiride to insulin compared with insulin monotherapy.Insulin-sulphonylurea combination therapy (CT) compared with insulin monotherapy (IM) showed a MD in glycosylated haemoglobin A1c (HbA1c) of -1% (95% confidence interval (CI) -1.6 to -0.5); P < 0.01; 316 participants; 9 trials; low-quality evidence. Insulin-metformin CT compared with IM showed a MD in HbA1c of -0.9% (95% CI -1.2 to -0.5); P < 0.01; 698 participants; 9 trials; low-quality evidence. We could not pool the results of adding pioglitazone to insulin. Insulin combined with alpha-glucosidase inhibitors compared with IM showed a MD in HbA1c of -0.4% (95% CI -0.5 to -0.2); P < 0.01; 448 participants; 3 trials; low-quality evidence). Insulin combined with DPP-4 inhibitors compared with IM showed a MD in HbA1c of -0.4% (95% CI -0.5 to -0.4); P < 0.01; 265 participants; 2 trials; low quality evidence. In most trials the participants with CT needed less insulin, whereas insulin requirements increased or remained stable in participants with IM.We did not perform a meta-analysis for hypoglycaemic events because the included studies used different definitions.. In most trials the insulin-sulphonylurea combination resulted in a higher number of mild episodes of hypoglycaemia, compared to the IM group (range: 2.2 to 6.1 episodes per participant in CT versus 2.0 to 2.6 episodes per participant in IM; low-quality evidence). Pioglitazone CT also resulted in more mild to moderate hypoglycaemic episodes compared with IM (range 15 to 90 episodes versus 9 to 75 episodes, respectively; low-quality evidence. The trials that reported hypoglycaemic episodes in the other combinations found comparable numbers of mild to moderate hypoglycaemic events (low-quality evidence).The addition of sulphonylureas resulted in an additional weight gain of 0.4 kg to 1.9 kg versus -0.8 kg to 2.1 kg in the IM group (220 participants; 7 trials; low-quality evidence). Pioglitazone CT caused more weight gain compared to IM: MD 3.8 kg (95% CI 3.0 to 4.6); P < 0.01; 288 participants; 2 trials; low-quality evidence. Metformin CT was associated with weight loss: MD -2.1 kg (95% CI -3.2 to -1.1), P < 0.01; 615 participants; 7 trials; low-quality evidence). DPP-4 inhibitors CT showed weight gain of -0.7 to 1.3 kg versus 0.6 to 1.1 kg in the IM group (362 participants; 2 trials; low-quality evidence). Alpha-glucosidase CT compared to IM showed a MD of -0.5 kg (95% CI -1.2 to 0.3); P = 0.26; 241 participants; 2 trials; low-quality evidence.Users of metformin CT (range 7% to 67% versus 5% to 16%), and alpha-glucosidase inhibitors CT (14% to 75% versus 4% to 35%) experienced more gastro-intestinal adverse effects compared to participants on IM. Two trials reported a higher frequency of oedema with the use of pioglitazone CT (range: 16% to 18% versus 4% to 7% IM). AUTHORS' CONCLUSIONS The addition of all oral glucose-lowering agents in people with type 2 diabetes and inadequate glycaemic control who are on insulin therapy has positive effects on glycaemic control and insulin requirements. The addition of sulphonylureas results in more hypoglycaemic events. Additional weight gain can only be avoided by adding metformin to insulin. Other well-known adverse effects of oral glucose-lowering agents have to be taken into account when prescribing oral glucose-lowering agents in addition to insulin therapy.
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Affiliation(s)
- Rimke C Vos
- University Medical Center UtrechtJulius Center for Health Sciences and Primary CarePO Box 85500UtrechtNetherlands3508 AB
| | - Mariëlle JP van Avendonk
- Guideline Development and ResearchDutch College of General PractitionersPO Box 3231UtrechtNetherlands3502 GE
| | - Hanneke Jansen
- University Medical Center UtrechtJulius Center for Health Sciences and Primary CarePO Box 85500UtrechtNetherlands3508 AB
| | | | - Maureen van den Donk
- Guideline Development and ResearchDutch College of General PractitionersPO Box 3231UtrechtNetherlands3502 GE
| | | | - Anneloes Kerssen
- University Medical Center UtrechtJulius Center for Health Sciences and Primary CarePO Box 85500UtrechtNetherlands3508 AB
| | - Guy EHM Rutten
- University Medical Center UtrechtJulius Center for Health Sciences and Primary CarePO Box 85500UtrechtNetherlands3508 AB
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Holden SE, Jenkins-Jones S, Currie CJ. Association between Insulin Monotherapy versus Insulin plus Metformin and the Risk of All-Cause Mortality and Other Serious Outcomes: A Retrospective Cohort Study. PLoS One 2016; 11:e0153594. [PMID: 27152598 PMCID: PMC4859474 DOI: 10.1371/journal.pone.0153594] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 03/31/2016] [Indexed: 01/08/2023] Open
Abstract
AIMS To determine if concomitant metformin reduced the risk of death, major adverse cardiac events (MACE), and cancer in people with type 2 diabetes treated with insulin. METHODS For this retrospective cohort study, people with type 2 diabetes who progressed to insulin with or without metformin from 2000 onwards were identified from the UK Clinical Practice Research Datalink (≈7% sample of the UK population). The risks of all-cause mortality, MACE and incident cancer were evaluated using multivariable Cox models comparing insulin monotherapy with insulin plus metformin. We accounted for insulin dose. RESULTS 12,020 subjects treated with insulin were identified, including 6,484 treated with monotherapy. There were 1,486 deaths, 579 MACE (excluding those with a history of large vessel disease), and 680 cancer events (excluding those in patients with a history of cancer). Corresponding event rates were 41.5 (95% CI 39.4-43.6) deaths, 20.8 (19.2-22.5) MACE, and 21.6 (20.0-23.3) cancer events per 1,000 person-years. The adjusted hazard ratios (aHRs) for people prescribed insulin plus metformin versus insulin monotherapy were 0.60 (95% CI 0.52-0.68) for all-cause mortality, 0.75 (0.62-0.91) for MACE, and 0.96 (0.80-1.15) for cancer. For patients who were propensity-score matched, the corresponding aHRs for all-cause mortality and cancer were 0.62 (0.52-0.75) and 0.99 (0.78-1.26), respectively. For MACE, the aHR was 1.06 (0.75-1.49) prior to 1,275 days and 1.87 (1.22-2.86) after 1,275 days post-index. CONCLUSIONS People with type 2 diabetes treated with insulin plus concomitant metformin had a reduced risk of death and MACE compared with people treated with insulin monotherapy. There was no statistically significant difference in the risk of cancer between people treated with insulin as monotherapy or in combination with metformin.
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Affiliation(s)
- Sarah E. Holden
- The Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, United Kingdom
- Global Epidemiology, Pharmatelligence, Cardiff, United Kingdom
| | | | - Craig J. Currie
- The Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, United Kingdom
- Global Epidemiology, Pharmatelligence, Cardiff, United Kingdom
- * E-mail:
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[Insulin therapy of diabetes]. Wien Klin Wochenschr 2016; 128 Suppl 2:S54-61. [PMID: 27052221 DOI: 10.1007/s00508-015-0925-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Hyperglycemia contributes to morbidity and mortality in patients with diabetes. Thus, reaching treatment targets with regard to control of glycemia is a central goal in the therapy of diabetic patients. The present article represents the recommendations of the Austrian Diabetes Association for the practical use of insulin according to current scientific evidence and clinical studies.
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Roy S, Sherman A, Monari-Sparks MJ, Schweiker O, Jain N, Sims E, Breda M, Byraiah GP, Belecanech RG, Coletta MD, Barrios CJ, Hunter K, Gaughan JP. Association of Comorbid and Metabolic Factors with Optimal Control of Type 2 Diabetes Mellitus. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2016; 8:31-9. [PMID: 27011945 PMCID: PMC4784181 DOI: 10.4103/1947-2714.175197] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background: Type 2 diabetes mellitus (T2DM) is a poorly controlled epidemic worldwide that demands active research into mitigation of the factors that are associated with poor control. Aims: The study was to determine the factors associated with suboptimal glycemic control. Materials and Methods: Electronic medical records of 263 adult patients with T2DM in our suburban internal medicine office were reviewed. Patients were divided into two groups: Group 1 [optimal diabetes control with glycosylated hemoglobin (HbA1c) of 7% or less] and Group 2 (suboptimal diabetes control with HbA1c greater than 7%). The influence of factors such as age, gender, race, social history, comorbid conditions, gestational diabetes, family history of diabetes, diabetes management, statin use, aspirin use, angiotensin convertase enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) use, body mass index (BMI), blood pressures, lipid profile, and urine microalbumin level were analyzed in the two groups. Results: In the suboptimal diabetes control group (N = 119), the majority (86.6%) of the patients were 41-80 years old. Factors associated with the suboptimal control were male gender [odds ratio (OR) 2.6, 95% confidence interval (CI), 1.579-4.321], Asian ethnicity (OR 1.4, 95% CI, 0.683-3.008), history of peripheral arterial disease (PAD; OR 3.9, 95% CI, 1.017-14.543), history of congestive heart failure (CHF; OR 3.9, 95% CI, 1.017-14.543), elevated triglycerides (OR 1.004, 95% CI, 1.000-1.007), and elevated urine microalbumin level of 30 mg/24 h or above (OR 4.5, 95% CI, 2.446-8.380). Patients with suboptimal diabetes control had a 3.8 times greater odds (95% CI, 1.493-6.885) of receiving the insulin and oral hypoglycemic agent together. Conclusions: In adult patients with T2DM, male gender, Asian ethnicity, CHF, PAD, management with insulin along with oral hypoglycemic agents, hypertriglyceridemia, and microalbuminuria were associated with suboptimal control.
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Affiliation(s)
- Satyajeet Roy
- Department of Medicine, Cooper University Hospital, Camden, New Jersey, USA
| | - Anthony Sherman
- Department of Medicine, Cooper University Hospital, Camden, New Jersey, USA
| | | | - Olga Schweiker
- Department of Medicine, Cooper University Hospital, Camden, New Jersey, USA
| | - Navjot Jain
- Department of Medicine, Cooper University Hospital, Camden, New Jersey, USA
| | - Etty Sims
- Department of Medicine, Cooper University Hospital, Camden, New Jersey, USA
| | - Michelle Breda
- Department of Medicine, Cooper University Hospital, Camden, New Jersey, USA
| | - Gita P Byraiah
- Department of Medicine, Cooper University Hospital, Camden, New Jersey, USA
| | | | | | | | - Krystal Hunter
- Department of Biostatistics, Cooper Research Institute, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - John P Gaughan
- Department of Biostatistics, Cooper Research Institute, Cooper Medical School of Rowan University, Camden, New Jersey, USA
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Floyd JS, Wiggins KL, Christiansen M, Dublin S, Longstreth WT, Smith NL, McKnight B, Heckbert SR, Weiss NS, Psaty BM. Case-control study of oral glucose-lowering drugs in combination with long-acting insulin and the risks of incident myocardial infarction and incident stroke. Pharmacoepidemiol Drug Saf 2015; 25:151-60. [PMID: 26547662 DOI: 10.1002/pds.3914] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 10/05/2015] [Accepted: 10/20/2015] [Indexed: 01/14/2023]
Abstract
BACKGROUND The use of oral glucose-lowering therapies with insulin is common, but the cardiovascular effects are largely unknown. Among users of long-acting insulin, we conducted a population-based case-control study to evaluate the incident myocardial infarction (MI) and incident stroke risks associated with the use of sulfonylureas and the use of metformin. METHODS Cases were Group Health Cooperative enrollees with type 2 diabetes who used long-acting insulin at the time of diagnosis with a first MI (n = 413) or first stroke (n = 247) from 1995 to 2010. Controls (n = 443) with type 2 diabetes who used long-acting insulin were matched to cases on age, sex, and calendar year. Sulfonylurea and metformin use was classified as current, past, or never using electronic pharmacy records. MI and stroke diagnoses were validated by medical record review. Analyses were adjusted for potential confounders. RESULTS Current use of sulfonylureas compared with never use was associated with a higher risk of MI (odds ratio [OR] 1.67; 95% confidence interval [CI], 1.10-2.55) but not stroke (OR 1.22; 95%CI, 0.74-2.00). Current use of metformin compared with never use was associated with a lower risk of stroke (OR 0.54; 95%CI, 0.31-0.95) but not MI (OR 0.77; 95%CI, 0.44-1.33). Past use of sulfonylureas and past use of metformin were not associated with either outcome. CONCLUSIONS Sulfonylureas in combination with long-acting insulin may increase the risk of MI compared with the use of insulin alone. Metformin may be an important cardiovascular disease prevention therapy for patients on insulin therapy. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- James S Floyd
- Cardiovascular Health Research Unit, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - Kerri L Wiggins
- Cardiovascular Health Research Unit, University of Washington, Seattle, WA, USA
| | - Mark Christiansen
- Cardiovascular Health Research Unit, University of Washington, Seattle, WA, USA
| | - Sascha Dublin
- Department of Epidemiology, University of Washington, Seattle, WA, USA.,Group Health Research Institute, Seattle, WA, USA
| | - William T Longstreth
- Department of Epidemiology, University of Washington, Seattle, WA, USA.,Department of Neurology, University of Washington, Seattle, WA, USA
| | - Nicholas L Smith
- Cardiovascular Health Research Unit, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA.,Group Health Research Institute, Seattle, WA, USA.,Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs, Office of Research and Development, Seattle, WA, USA
| | - Barbara McKnight
- Cardiovascular Health Research Unit, University of Washington, Seattle, WA, USA.,Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Susan R Heckbert
- Cardiovascular Health Research Unit, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA.,Group Health Research Institute, Seattle, WA, USA
| | - Noel S Weiss
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Bruce M Psaty
- Cardiovascular Health Research Unit, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA.,Group Health Research Institute, Seattle, WA, USA
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Danne T, Bluhmki T, Seufert J, Kaltheuner M, Rathmann W, Beyersmann J, Bramlage P. Treatment intensification using long-acting insulin -predictors of future basal insulin supported oral therapy in the DIVE registry. BMC Endocr Disord 2015; 15:54. [PMID: 26446863 PMCID: PMC4597397 DOI: 10.1186/s12902-015-0051-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 09/22/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND In patients with type-2 diabetes receiving oral antidiabetic drugs (OADs), the addition of insulin is frequently required to achieve sufficient control over blood glucose levels. It is, however, difficult to predict if, when and in which patients insulin therapy will be needed. We aimed to identify patient related variables associated with the addition of basal insulin to oral therapy resulting in a basal supported oral therapy (BOT). METHODS DIVE (DIabetes Versorgungs-Evaluation) is a prospective, observational, multi-centre diabetes registry established in Germany in 2011. For the present explorative analysis, 31,008 patients with type-2 diabetes prescribed at least one OAD were included. Patients who had previously received insulin and those over 90 years old were excluded. The event of interest was defined as the initiation of BOT during the observational period. Cause-specific Cox proportional hazards models based on a competing risk framework were applied for risk quantification. RESULTS Multivariable adjusted hazard ratios demonstrated that longer diabetes duration, higher BMI, poorer glycaemic control, documentation of any micro- or macrovascular comorbidity, the presence of concomitant non-antidiabetic pharmacotherapies, and greater numbers of prescribed OADs increased the likelihood of BOT initiation. On the other hand BOT initiation was less likely in patients with older age and female gender. Analysing the likelihood of OAD termination without initiation of BOT provided supportive evidence for the variables predictive of BOT initiation. DISCUSSION Analysis of the DIVE registry has resulted in the identification of a number of factors that may be predictive for the initiation of BOT for type-2 diabetes patients initially prescribed one or more OADs. Poor glycaemic control, the presence of vascular comorbidities and concomitant medications, and a greater number of OADs were all detected to increase the risk of a switch to BOT. Female gender and younger age showed protective properties. CONCLUSIONS The close monitoring of patients displaying these characteristics may help to identify individuals who might benefit from early addition of insulin therapy to their oral treatment regimen.
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Affiliation(s)
- Thomas Danne
- Kinder- und Jugendkrankenhaus "AUF DER BULT", Hannover, Germany.
| | - Tobias Bluhmki
- Institute of Statistics, University of Ulm, Ulm, Germany.
| | - Jochen Seufert
- Division of Endocrinology and Diabetology, Department of Internal Medicine II, University Hospital of Freiburg, Freiburg, Germany.
| | - Matthias Kaltheuner
- Gemeinschaftspraxis Kaltheuner - v. Boxberg, Leverkusen, Germany.
- winDiab GmbH, Kehler Straße 24, 40468, Düsseldorf, Germany.
| | - Wolfgang Rathmann
- Institut für Biometrie und Epidemiologie, Deutsches Diabetes Zentrum Düsseldorf, Düsseldorf, Germany.
| | - Jan Beyersmann
- Institute of Statistics, University of Ulm, Ulm, Germany.
| | - Peter Bramlage
- Institut für Pharmakologie und Präventive Medizin, Mahlow, Germany.
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Stoekenbroek R, Rensing K, Bernelot Moens S, Nieuwdorp M, DeVries J, Zwinderman A, Stroes E, Currie C, Hutten B. High daily insulin exposure in patients with type 2 diabetes is associated with increased risk of cardiovascular events. Atherosclerosis 2015; 240:318-23. [DOI: 10.1016/j.atherosclerosis.2015.03.040] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 03/12/2015] [Accepted: 03/24/2015] [Indexed: 01/28/2023]
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Abstract
OBJECTIVE To investigate the impact associated with mild hypoglycemia among patients with type 2 diabetes (T2DM) in the United States and to identify risk factors among different subpopulations. METHODS We performed a literature search to gather available data allowing estimation of rates of mild hypoglycemia. Because risk factors are interdependent, risk factors included in the model were based on those reported within multivariate analyses or judged to be biologically plausible by the medical community. Based on literature search results, we built a mathematical model predicting the rates of mild hypoglycemia in individual patients as a function of the patient's antidiabetic medications, hemoglobin A1c levels, duration of diabetes, kidney function, and body mass index. RESULTS We estimated an overall average rate of mild hypoglycemia among US patients with T2DM of 2.2 ± 0.8 events per person per year. Patients taking oral antidiabetic medications only had an average rate of 1.9 ± 0.8 events per person per year. The average rate for all patients taking insulin, including those combining it with other antidiabetic medications, was 4.9 ± 2.0 events per person per year. Mild hypoglycemia rates increased with age, with 80-year-old patients experiencing 1.5 times the risk of 40-year-old patients. Based on published values for direct and indirect medical costs for mild hypoglycemia events, we determined that the economic impact in the US of mild hypoglycemic events is approximately $900 million per year, roughly equal to that of severe hypoglycemic events. One of the key limitations to our model is that it applies to the US population under standard medical care and not to clinical trials and does not include certain known risk factors such as rigorous exercise. CONCLUSIONS Understanding the benefit versus risk of glycemic control and hypoglycemia is fundamental to the successful management of patients with T2DM. Our validated hypoglycemia model is an important step in addressing this issue and may be helpful to researchers, clinicians, and payers to determine the patients who are at the highest risk for hypoglycemia, whether a patient is experiencing events at 'higher-than-expected' rates, and the corresponding economic burden.
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12
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Lu Y, Ma D, Xu W, Shao S, Yu X. Effect and cardiovascular safety of adding rosiglitazone to insulin therapy in type 2 diabetes: A meta-analysis. J Diabetes Investig 2014; 6:78-86. [PMID: 25621136 PMCID: PMC4296706 DOI: 10.1111/jdi.12246] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 04/11/2014] [Accepted: 04/28/2014] [Indexed: 11/30/2022] Open
Abstract
AIMS/INTRODUCTION Recently, the use of rosiglitazone has been limited or withdrawn from the market as a result of cardiovascular risk. However, theoretically adding rosiglitazone to insulin could help insulin to decrease the glucose level. The present meta-analysis was designed to investigate the effect and safety of adding rosiglitazone to insulin therapy in type 2 diabetes. MATERIALS AND METHODS We searched published and unpublished databases through to March 2012. Randomized controlled trials (RCTs) comparing rosiglitazone in combination with insulin (RSG + INS) vs insulin alone (INS) in type 2 diabetes with outcomes including glycated hemoglobin levels, insulin dose, lipid parameters, blood pressure, edema and cardiovascular adverse events were selected. RESULTS Nine RCTs with durations of 24-26 weeks involving 1,916 patients were included. The RSG + INS group showed significantly decreased glycated hemoglobin levels by 0.89% (P < 0.00001) with an 8.48-U reduction in daily insulin dose (P <0.00001). However, the risks of hypoglycemia and edema were more frequent in the RSG+INS group (P < 0.0001; P = 0.03, respectively). Total cholesterol level was significantly increased in the RSG+INS group (P < 0.00001), but none of the high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, very low-density lipoprotein cholesterol or triglyceride levels were significantly different between groups. There were no significant differences between groups with regard to the risks of myocardial infarction, heart failure, cardiovascular death or all-cause death. CONCLUSIONS Rosiglitazone could help type 2 diabetes patients with poorly controlled glucose with insulin therapy to decrease glucose levels and reduce their daily insulin dose, but at the cost of increased total cholesterol level, hypoglycemia and edema risk. Compared with insulin therapy, adding rosiglitazone to insulin did not increase the risks of myocardial infarction, heart failure, cardiovascular death or all-cause death.
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Affiliation(s)
- Yu Lu
- Department of Endocrinology, Tongji Hospital, Tongji Medical College of Huazhong University of Science & Technology Wuhan, China ; Department of Endocrinology, Taizhou People's Hospital, Nantong University Jiangsu, China
| | - Delin Ma
- Department of Endocrinology, Tongji Hospital, Tongji Medical College of Huazhong University of Science & Technology Wuhan, China
| | - Weijie Xu
- Department of Endocrinology, Tongji Hospital, Tongji Medical College of Huazhong University of Science & Technology Wuhan, China
| | - Shiying Shao
- Department of Endocrinology, Tongji Hospital, Tongji Medical College of Huazhong University of Science & Technology Wuhan, China
| | - Xuefeng Yu
- Department of Endocrinology, Tongji Hospital, Tongji Medical College of Huazhong University of Science & Technology Wuhan, China
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13
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Anderson M, Powell J, Campbell KM, Taylor JR. Optimal management of type 2 diabetes in patients with increased risk of hypoglycemia. Diabetes Metab Syndr Obes 2014; 7:85-94. [PMID: 24623984 PMCID: PMC3949696 DOI: 10.2147/dmso.s48896] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
With the number of individuals diagnosed with type 2 diabetes on the rise, it has become more important to ensure these patients are effectively treated. The Centers for Disease Control and Prevention estimated that 8.3% of all Americans were diagnosed with diabetes in 2011 and this number will likely continue to rise. With lifestyle interventions, such as proper diet and exercise, continuing to be an essential component of diabetes treatment, more patients are requiring medication therapy to help them reach their therapeutic goals. It is important for the clinician, when determining the treatment strategy for these individuals, to find a balance between reaching treatment goals and limiting the adverse effects of the treatments themselves. Of all the adverse events associated with treatment of diabetes, the risk of hypoglycemia is one that most therapies have in common. This risk is often a limiting factor when attempting to aggressively treat diabetic patients. This manuscript will review how hypoglycemia is defined and categorized, as well as discuss the prevalence of hypoglycemia among the many different treatment options.
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Affiliation(s)
- Morgan Anderson
- North Florida/South Georgia Veterans Health System, Malcom Randall VAMC, Gainesville, FL, USA
| | - Jason Powell
- University of Florida, College of Pharmacy, Gainesville, FL, USA
| | - Kendall M Campbell
- The Center for Underrepresented Minorities in Academic Medicine, The Florida State University College of Medicine Tallahassee, FL, USA
| | - James R Taylor
- University of Florida, College of Pharmacy, Gainesville, FL, USA
- Correspondence: James R Taylor, University of Florida, College of Pharmacy, 1225 Center Drive HPNP Bulding, Room 3309 Gainesville, FL 32610, USA, Tel +1 352 273 6239, Fax +1 352 273 6242, Email
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14
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Abstract
Hyperglycemia contributes to morbidity and mortality in patients with diabetes. Thus, reaching treatment targets with regard to control of glycemia is a central goal in the therapy of diabetic patients. The present article represents the recommendations of the Austrian Diabetes Association for the practical use of insulin according to current scientific evidence and clinical studies.
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15
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Yki-Järvinen H, Kotronen A. Is there evidence to support use of premixed or prandial insulin regimens in insulin-naive or previously insulin-treated type 2 diabetic patients? Diabetes Care 2013; 36 Suppl 2:S205-11. [PMID: 23882047 PMCID: PMC3920773 DOI: 10.2337/dcs13-2026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Hannele Yki-Järvinen
- Division of Diabetes, Department of Medicine, University of Helsinki, Helsinki, Finland.
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16
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McBrien KA, Manns BJ, Chui B, Klarenbach SW, Rabi D, Ravani P, Hemmelgarn B, Wiebe N, Au F, Clement F. Health care costs in people with diabetes and their association with glycemic control and kidney function. Diabetes Care 2013; 36:1172-80. [PMID: 23238665 PMCID: PMC3631826 DOI: 10.2337/dc12-0862] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Accepted: 10/18/2012] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine the association between laboratory-derived measures of glycemic control (HbA1c) and the presence of renal complications (measured by proteinuria and estimated glomerular filtration rate [eGFR]) with the 5-year costs of caring for people with diabetes. RESEARCH DESIGN AND METHODS We estimated the cumulative 5-year cost of caring for people with diabetes using a province-wide cohort of adults with diabetes as of 1 May 2004. Costs included physician visits, hospitalizations, ambulatory care (emergency room visits, day surgery, and day medicine), and drug costs for people >65 years of age. Using linked laboratory and administrative clinical and costing data, we determined the association between baseline glycemic control (HbA1c), proteinuria, and kidney function (eGFR) and 5-year costs, controlling for age, socioeconomic status, duration of diabetes, and comorbid illness. RESULTS We identified 138,662 adults with diabetes. The mean 5-year cost of diabetes in the overall cohort was $26,978 per patient, excluding drug costs. The mean 5-year cost for the subset of people >65 years of age, including drug costs, was $44,511 (Canadian dollars). Cost increased with worsening kidney function, presence of proteinuria, and suboptimal glycemic control (HbA1c >7.9%). Increasing age, Aboriginal status, socioeconomic status, duration of diabetes, and comorbid illness were also associated with increasing cost. CONCLUSIONS The cost of caring for people with diabetes is substantial and is associated with suboptimal glycemic control, abnormal kidney function, and proteinuria. Future studies should assess if improvements in the management of diabetes, assessed with laboratory-derived measurements, result in cost reductions.
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Affiliation(s)
- Kerry A. McBrien
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Braden J. Manns
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Betty Chui
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Doreen Rabi
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Pietro Ravani
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Brenda Hemmelgarn
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Natasha Wiebe
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Flora Au
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Fiona Clement
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
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17
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Liebl A. [Insulin therapy of type 2 diabetes: from simple to flexible--three strategies are available]. MMW Fortschr Med 2012; 154 Spec No 3:66-73. [PMID: 23724722 DOI: 10.1007/s15006-012-1298-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Andreas Liebl
- Diabetes- und Stoffwechselzentrum, m&i-Fachklinik Bad Heilbrunn.
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18
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Gorter KJ, van de Laar FA, Janssen PGH, Houweling ST, Rutten GEHM. Diabetes: glycaemic control in type 2 (drug treatments). BMJ CLINICAL EVIDENCE 2012; 2012:0609. [PMID: 23862772 PMCID: PMC3462437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Diabetes mellitus is a progressive disorder of glucose metabolism. It is estimated that about 285 million people between the ages of 20 and 79 years had diabetes worldwide in 2010, or 5% of the adult population. Type 2 diabetes may occur with obesity, hypertension, and dyslipidaemia (the metabolic syndrome), which are powerful predictors of cardiovascular disease. Without adequate blood-glucose-lowering treatment, blood glucose levels may rise progressively over time in people with type 2 diabetes. Microvascular and macrovascular complications may develop. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical question: What are the effects of blood-glucose-lowering medications in adults with type 2 diabetes? We searched: Medline, Embase, The Cochrane Library, and other important databases up to February 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS We found 194 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS In this systematic review we present information relating to the effectiveness and safety of the following interventions: alpha-glucosidase inhibitors (AGIs), combination treatment (single, double, and triple), dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) analogues, insulins (including conventional [human] and analogue, different regimens, different length of action), meglitinides, metformin, sulphonylureas, and thiazolidinediones.
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19
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Cai X, Han X, Luo Y, Ji L. Analysis of insulin doses of Chinese type 2 diabetic patients with intensive insulin treatment. PLoS One 2012; 7:e38962. [PMID: 22720003 PMCID: PMC3377710 DOI: 10.1371/journal.pone.0038962] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Accepted: 05/16/2012] [Indexed: 11/19/2022] Open
Abstract
Background To investigate the daily insulin doses and the ratio of basal insulin to total daily insulin in Chinese type 2 diabetic patients who received basal bolus insulin therapy. Methodology/Principal Findings Totally 2480 patients prescribed with pre-meal bolus insulin and bedtime basal insulin were included. The mean daily insulin doses was 38.22±14.92 IU/day, the mean daily insulin doses per weight was 0.58±0.22 IU/kg, the mean bolus insulin dose was 0.44±0.17 IU/kg and the mean basal insulin dose was 0.13±0.08 IU/kg. The mean basal/total daily insulin ratio (BD/TDD) was 0.23±0.08. In most patients (47.94%), the BD/TDD was between 0.20 and 0.30. Diabetic duration, BMI, HbA1c, fasting and postprandial blood glucose level were positively associated with daily insulin dose, while age was negatively associated with daily insulin dose. Diabetic duration, BMI, HbA1c, fasting blood glucose level, and using metformin were positively associated with BD/TDD ratio, while age, postprandial C peptide, postprandial blood glucose level and CRE level were negatively associated with BD/TDD ratio. Conclusions/Significance The daily insulin doses of intensive treatment in Chinese type 2 diabetic patients was 38.22 IU/day, the mean daily insulin doses per weight was 0.58 IU/kg, mean BD/TDD ratio was 0.23.
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Affiliation(s)
- Xiaoling Cai
- Endocrinology and Metabolism Department, Peking University People’s Hospital, Beijing, China
| | - Xueyao Han
- Endocrinology and Metabolism Department, Peking University People’s Hospital, Beijing, China
| | - Yingying Luo
- Endocrinology and Metabolism Department, Peking University People’s Hospital, Beijing, China
| | - Linong Ji
- Endocrinology and Metabolism Department, Peking University People’s Hospital, Beijing, China
- * E-mail:
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20
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Hardman TC, Dubrey SW. Development and potential role of type-2 sodium-glucose transporter inhibitors for management of type 2 diabetes. Diabetes Ther 2011; 2:133-45. [PMID: 22127823 PMCID: PMC3173594 DOI: 10.1007/s13300-011-0004-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Indexed: 12/25/2022] Open
Abstract
There is a recognized need for new treatment options for type 2 diabetes mellitus (T2DM). Recovery of glucose from the glomerular filtrate represents an important mechanism in maintaining glucose homeostasis and represents a novel target for the management of T2DM. Recovery of glucose from the glomerular filtrate is executed principally by the type 2 sodium-glucose cotransporter (SGLT2). Inhibition of SGLT2 promotes glucose excretion and normalizes glycemia in animal models. First reports of specifically designed SGLT2 inhibitors began to appear in the second half of the 1990s. Several candidate SGLT2 inhibitors are currently under development, with four in the later stages of clinical testing. The safety profile of SGLT2 inhibitors is expected to be good, as their target is a highly specific membrane transporter expressed almost exclusively within the renal tubules. One safety concern is that of glycosuria, which could predispose patients to increased urinary tract infections. So far the reported safety profile of SGLT2 inhibitors in clinical studies appears to confirm that the class is well tolerated. Where SGLT2 inhibitors will fit in the current cascade of treatments for T2DM has yet to be established. The expected favorable safety profile and insulin-independent mechanism of action appear to support their use in combination with other antidiabetic drugs. Promotion of glucose excretion introduces the opportunity to clear calories (80-90 g [300-400 calories] of glucose per day) in patients that are generally overweight, and is expected to work synergistically with weight reduction programs. Experience will most likely lead to better understanding of which patients are likely to respond best to SGLT2 inhibitors, and under what circumstances.
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Affiliation(s)
- Timothy Colin Hardman
- Niche Science & Technology Ltd., London House, 243-253 Lower Mortlake Road, London, TW9 2LL, UK,
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21
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Lechleitner M, Hoppichler F. Insulin therapy. Wien Med Wochenschr 2011; 161:300-4. [PMID: 21584767 DOI: 10.1007/s10354-011-0889-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Accepted: 02/08/2011] [Indexed: 12/01/2022]
Abstract
Insulin therapy is a vital hormone replacement therapy in type 1 diabetes mellitus. In type 2 diabetes, insulin is indicated if glycaemic goals are not reached by oral anti diabetics, as well as for metabolic detoriation, co-morbidities, surgery, pregnancy or contradictions against oral anti diabetics. Insulin preparations are characterized by the onset of the insulin action, the peak profile and duration of action. Available are short acting, long-acting and premixed preparations of human insulin, and insulin analogues. The gold standard of insulin therapy in type 1 diabetes is functional insulin therapy with a basal-bolus insulin regimen and control and adaption of the therapy by the patient. Various insulin regimens are available for treating patients with type 2 diabetes, including basal insulin supported oral therapy, supplementary mealtime injection of short acting insulin or insulin analogues, conventional insulin therapy or a basal bolus procedure. The various insulin preparations and regimens make it possible to adapt the therapy according to the patient's individual need.
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Danchin N, Eschwège E, Bekka S, Krempf M. [Weight change, cardiometabolic risk and the impact of antidiabetic medications in type 2 diabetic patients]. Ann Cardiol Angeiol (Paris) 2010; 59:214-220. [PMID: 20691966 DOI: 10.1016/j.ancard.2010.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2010] [Accepted: 06/28/2010] [Indexed: 05/29/2023]
Abstract
In the first part of this review article, the prognostic impact of weight and weight changes in terms of clinical outcomes and metabolic control is reviewed, through the analysis of the results of several large cohorts and prospective studies of diabetic patients followed in "real world" settings. The second part of the review focuses on the impact of antidiabetic medications on weight, emphasising the importance of a comprehensive approach, taking into account weight, in the management of diabetic patients.
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Affiliation(s)
- N Danchin
- Division maladies coronaires et soins intensifs, faculté Paris Descartes, hôpital européen Georges-Pompidou, AP-HP, 20, rue Leblanc, 75015 Paris, France.
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Abstract
The treatment of type 2 diabetes is shifting from secondary specialist centres to the primary care setting. However, for this shift to be sustainable and successful, primary care physicians (PCPs) must effectively provide aspects of diabetes care traditionally supplied by specialists. In particular, the early and appropriate use of insulin in type 2 diabetes will increasingly become the responsibility of PCPs. This review examines how patients with type 2 diabetes are currently managed across several European countries, and explores the evidence around insulin use in type 2 diabetes and the implications for primary care.
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Hemmingsen B, Lund SS, Gluud C, Vaag A, Almdal T, Wetterslev J. Targeting intensive glycaemic control versus targeting conventional glycaemic control for type 2 diabetes mellitus. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2009. [DOI: 10.1002/14651858.cd008143] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Lasserson DS, Glasziou P, Perera R, Holman RR, Farmer AJ. Optimal insulin regimens in type 2 diabetes mellitus: systematic review and meta-analyses. Diabetologia 2009; 52:1990-2000. [PMID: 19644668 DOI: 10.1007/s00125-009-1468-7] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Accepted: 06/15/2009] [Indexed: 12/27/2022]
Abstract
AIMS/HYPOTHESIS We compared the effect of biphasic, basal or prandial insulin regimens on glucose control, clinical outcomes and adverse events in people with type 2 diabetes. METHODS We searched the Cochrane Library, MEDLINE, EMBASE and major American and European conference abstracts for randomised controlled trials up to October 2008. A systematic review and meta-analyses were performed. RESULTS Twenty-two trials that randomised 4,379 patients were included. Seven trials reported both starting insulin dose and titration schedules. Hypoglycaemia definitions and glucose targets varied. Meta-analyses were performed pooling data from insulin-naive patients. Greater HbA(1c) reductions were seen with biphasic and prandial insulin, compared with basal insulin, of 0.45% (95% CI 0.19-0.70, p = 0.0006) and 0.45% (95% CI 0.16-0.73, p = 0.002), respectively, but with lesser reductions of fasting glucose of 0.93 mmol/l (95% CI 0.21-1.65, p = 0.01) and 2.20 mmol/l (95% CI 1.70-2.70, p < 0.00001), respectively. Larger insulin doses at study end were reported in biphasic and prandial arms compared with basal arms. No studies found differences in major hypoglycaemic events, but minor hypoglycaemic events for prandial and biphasic insulin were inconsistently reported as either higher than or equivalent to basal insulin. Greater weight gain was seen with prandial compared with basal insulin (1.86 kg, 95% CI 0.80-2.92, p = 0.0006). CONCLUSIONS/INTERPRETATION Greater HbA(1c) reduction may be obtained in type 2 diabetes when insulin is initiated using biphasic or prandial insulin rather than a basal regimen, but with an unquantified risk of hypoglycaemia. Studies with longer follow-up are required to determine the clinical relevance of this finding.
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Demssie YN, Younis N, Soran H. The role of insulin detemir in overweight type 2 diabetes management. Vasc Health Risk Manag 2009; 5:553-60. [PMID: 19590589 PMCID: PMC2704896 DOI: 10.2147/vhrm.s4326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2009] [Indexed: 01/31/2023] Open
Abstract
The recent evidence-based shift towards an algorithm of early initiation and aggressive titration of insulin therapy in the management of type 2 diabetes requires the use of an effective insulin formulation that is both safe and acceptable to patients and physicians alike. The advent of the long-acting insulin analogues, insulin detemir and glargine, in the last decade has revolutionized insulin therapy in type 2 diabetes. Their unique pharmacokinetic and pharmacodynamic properties have offered tangible advantage over the conventional intermediate and long-acting insulin preparations in terms of improving glucose control as well as reducing risk of hypoglycemia and weight gain. This review focuses on the pharmacodynamic properties of the long-acting insulin analogue detemir, the outcome of studies on its relative efficacy and safety as well as its proposed place in the management of type 2 diabetes.
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Affiliation(s)
- Yared N Demssie
- Department of Diabetes and Endocrinology, Salford Royal Foundation NHS Trust, Salford, UK
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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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Abstract
Obesity is a major risk factor for diabetes and cardiovascular disease, and most people with diabetes are overweight or obese. Weight reduction has been shown to improve glycemic control and reduce cardiovascular risk in the diabetic population. While physicians strive to achieve better glycemic control for their patients with diabetes, they are faced with the problem of weight gain that is commonly encountered with the use of antidiabetic agents, particularly insulin, insulin secretagogues, and thiazolidinediones. Weight gain in this population could offset the beneficial effects of good glycemic control and discourage patients from adhering to treatment. In this review, we discuss the effects of the various antidiabetic agents on body weight, highlighting the potential mechanisms and the implications of weight gain in this population. We also present the available therapeutic modalities that have the potential of achieving better glycemic control without adverse effects on body weight.
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Affiliation(s)
- Samy I McFarlane
- Division of Endocrinology, Diabetes and Hypertension, College of Medicine, SUNY-Downstate/Kings County Hospital Center, Brooklyn, NY 11203, USA.
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Abstract
AIM To systematically review the literature regarding insulin use in patients with type 2 diabetes mellitus METHODS A Medline and Embase search was performed to identify randomized controlled trials (RCT) published in English between 1 January 2000 and 1 April 2008, involving insulin therapy in adults with type 2 diabetes mellitus. The RCTs must comprise at least glycaemic control (glycosylated haemoglobin (HbA1c), postprandial plasma glucose and /or fasting blood glucose (FBG)) and hypoglycaemic events as outcome measurements. RESULTS The Pubmed search resulted in 943 hits; the Embase search gave 692 hits. A total of 116 RCTs were selected by title or abstract. Eventually 78 trials met the inclusion criteria. The studies were very diverse and of different quality. They comprised all possible insulin regimens with and without combination with oral medication. Continuing metformin and/or sulphonylurea after start of therapy with basal long-acting insulin results in better glycaemic control with less insulin requirements, less weight gain and less hypoglycaemic events. Long-acting insulin analogues in combination with oral medication are associated with similar glycaemic control but fewer hypoglycaemic episodes compared with NPH insulin. Most of the trials demonstrated better glycaemic control with premix insulin therapy than with a long-acting insulin once daily, but premix insulin causes more hypoglycaemic episodes. Analogue premix provides similar HbA1c, but lower postprandial glucose levels compared with human premix, without increase in hypoglycaemic events or weight gain. Drawing conclusions from the limited number of studies concerning basal-bolus regimen seems not possible. Some studies showed that rapid-acting insulin analogues frequently result in a better HbA1c or postprandial glucose without increase of hypoglycaemia than regular human insulin. CONCLUSION A once-daily basal insulin regimen added to oral medication is an ideal starting point. All next steps, from one to two or even more injections per day should be taken very carefully and in thorough deliberation with the patient, who has to comply with such a regimen for many years.
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Affiliation(s)
- Mariëlle J P van Avendonk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
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van Avendonk MJP, Gorter KJ, van den Donk M, Rutten GEHM. Insulin therapy in type 2 diabetes is no longer a secondary care activity in the Netherlands. Prim Care Diabetes 2009; 3:23-28. [PMID: 19095513 DOI: 10.1016/j.pcd.2008.10.007] [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: 03/20/2008] [Revised: 09/25/2008] [Accepted: 10/24/2008] [Indexed: 11/17/2022]
Abstract
AIM Because Dutch health care organisations did want to establish well-defined diabetes shared care groups, we investigated the organisation of insulin therapy in general practice in the Netherlands and assessed factors that were associated with providing insulin therapy in type 2 diabetes (DM2) patients. METHODS Questionnaire to half of the Dutch general practitioners (GPs) (n=3848). We compared GPs who both start insulin treatment and monitor the dosages with those who always refer patients requiring insulin therapy or only monitor insulin dosages. RESULTS Total response was 42% (n=1621). 67% of the GPs start insulin therapy in patients with DM2, especially male GPs and those above the age of 40, as well as GPs working in a health centre and those working together with a practice nurse. GPs working in urban regions less often start insulin. The most often mentioned barriers for starting and/or monitoring insulin therapy are lack of knowledge of insulin therapy, lack of time and insufficient financial incentives. CONCLUSION This nation-wide overview shows that insulin therapy is no longer a secondary care based activity. However, there is still need to enlarge the practice staff and to overcome the perceived skills deficit.
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Affiliation(s)
- Mariëlle J P van Avendonk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands.
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Baxter MA. The role of new basal insulin analogues in the initiation and optimisation of insulin therapy in type 2 diabetes. Acta Diabetol 2008; 45:253-68. [PMID: 18766296 DOI: 10.1007/s00592-008-0052-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2007] [Accepted: 07/25/2008] [Indexed: 02/07/2023]
Abstract
Intensive insulin therapy aimed at achieving normoglycaemia is becoming increasingly accepted in the treatment of type 2 diabetes (T2DM) to reduce the risk of diabetes-related complications. Insulin therapy is increasingly combined with oral antidiabetic drugs (OADs) to moderate insulin dosage, reduce weight gain and confer cardiovascular protection. However, traditional insulins are associated with limitations that may act as barriers to initiation, and intensive use of insulin therapy. The advent of newer, longer-acting, basal insulin analogues, such as insulin glargine (glargine) and insulin detemir (detemir), offer improved pharmacokinetic and pharmacodynamic profiles compared with neutral protamine Hagedorn insulin (NPH). This potentially provides concomitant improvements in safety, efficacy and variability of glycaemic control. This paper reviews the properties of these new long-acting, basal insulin analogues and their potential roles in facilitating the initiation and optimisation of insulin therapy. Studies that reported the use of insulin and insulin analogues for the treatment of T2DM were identified using Medline. Key search terms included: 'insulin glargine', 'insulin detemir', 'NPH insulin', 'basal insulin', 'long-acting insulin', 'insulin analogue', 'pharmacokinetics', 'pharmacodynamics', 'dose titration', 'algorithms' and 'type 2 diabetes'. Abstracts presented at the American Diabetes Association and the European Association for the Study of Diabetes annual congresses were also searched. The data show that the long-acting insulin analogues glargine and detemir both offer a low risk of hypoglycaemia and improved glycaemic control. Aggressive dose titration with glargine and detemir facilitates attainment of glycaemic control targets. The goal of achieving good glycaemic control with a low risk of hypoglycaemia may be more feasible with newer insulin therapies as part of a simple basal insulin regimen with continued OADs.
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Affiliation(s)
- Mike A Baxter
- Diabetologist, Ashford and Saint Peter's Hospital NHS Trust, Chertsey, Surrey KT16 0PZ, UK.
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Gamble J, Simpson SH, Brown LC, Johnson JA. Insulin versus an oral antidiabetic agent as add-on therapy in type 2 diabetes after failure of an oral antidiabetic regimen: a meta-analysis. OPEN MEDICINE : A PEER-REVIEWED, INDEPENDENT, OPEN-ACCESS JOURNAL 2008; 2:e26-38. [PMID: 21602937 PMCID: PMC3090175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2007] [Revised: 11/16/2007] [Accepted: 11/16/2007] [Indexed: 11/02/2022]
Abstract
BACKGROUND Although evidence-based guidelines for the treatment of type 2 diabetes mellitus provide clear recommendations for initial therapy, evidence on an optimal treatment strategy after secondary failure is unclear. PURPOSE To compare the efficacy of add-on therapy using basal insulin versus an additional oral antidiabetic agent in patients with type 2 diabetes and secondary failure. DATA SOURCES We searched the following electronic databases from inception until June 2007: MEDLINE; EMBASE; Cochrane Central Register of Controlled Trials; Web of Science; Scopus; CINAHL; International Pharmaceutical Abstracts; Academic OneFile; PASCAL; Global Health Database; LILACS; HealthSTAR; PubMed. Reference lists of potentially relevant articles and clinical trial databases were searched, pharmaceutical manufacturers were contacted, and grey literature sources were sought. STUDY SELECTION Randomized controlled trials (RCTs) involving subjects with type 2 diabetes with secondary failure who were randomly assigned to receive additional basal insulin therapy (insulin glargine, detemir, or NPH [neutral protamine Hagedorn]) versus another oral antidiabetic agent from any class. DATA EXTRACTION Two reviewers independently screened articles, extracted data and assessed methodological quality. Our primary outcome was glycemic control measured by change in glycosylated hemoglobin (Hb(A1C)) and the proportion of subjects achieving a Hb(A1C) value of ≤ 7%. DATA SYNTHESIS To compare overall efficacy between the 2 treatment strategies, change in Hb(A1C) was pooled across studies using a random-effects model and weighted mean difference (WMD). Eleven RCTs, involving 757 participants with a median age of 56 and a median known duration of diabetes of 11 years, were included in our analysis. Insulin treatment demonstrated a small but statistically significant improvement in Hb(A1C) compared with the use of an additional oral agent as add-on therapy (WMD -0.17; 95% CI [confidence interval] -0.33 to -0.02). LIMITATIONS The use of surrogate outcomes and the short duration of the trials makes it impossible to gain information on long-term patient-oriented outcomes. The overall quality of the studies was low, primarily in view of inadequate blinding. CONCLUSIONS Although add-on therapy using injected insulin shows a slight benefit over an additional oral antidiabetic agent, our results indicate that basal insulin therapy and the use of an oral agent as add-on therapy produce comparable results. Non-therapeutic differences must be considered in the choice of treatment strategies. More high-quality studies with adequate safety data using more aggressive insulin titrations are needed.
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Home PD, Bailey CJ, Donaldson J, Chen H, Stewart MW. A double-blind randomized study comparing the effects of continuing or not continuing rosiglitazone + metformin therapy when starting insulin therapy in people with Type 2 diabetes. Diabet Med 2007; 24:618-25. [PMID: 17403121 PMCID: PMC1974817 DOI: 10.1111/j.1464-5491.2007.02141.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2006] [Indexed: 11/28/2022]
Abstract
AIMS To compare the efficacy and safety of either continuing or discontinuing rosiglitazone + metformin fixed-dose combination when starting insulin therapy in people with Type 2 diabetes inadequately controlled on oral therapy. METHODS In this 24-week double-blind study, 324 individuals with Type 2 diabetes inadequately controlled on maximum dose rosiglitazone + metformin therapy were randomly assigned to twice-daily premix insulin therapy (target pre-breakfast and pre-evening meal glucose < or = 6.5 mmol/l) in addition to either rosiglitazone + metformin (8/2000 mg) or placebo. RESULTS Insulin dose at week 24 was significantly lower with rosiglitazone + metformin (33.5 +/- 1.5 U/day, mean +/- se) compared with placebo [59.0 +/- 3.0 U/day; model-adjusted difference -26.6 (95% CI -37.7, -15,5) U/day, P < 0.001]. Despite this, there was greater improvement in glycaemic control [HbA(1c) rosiglitazone + metformin vs. placebo 6.8 +/- 0.1 vs. 7.5 +/- 0.1%; difference -0.7 (-0.8, -0.5)%, P < 0.001] and more individuals achieved glycaemic targets (HbA(1c) < 7.0% 70 vs. 34%, P < 0.001). The proportion of individuals reporting at least one hypoglycaemic event during the last 12 weeks of treatment was similar in the two groups (rosiglitazone + metformin vs. placebo 25 vs. 27%). People receiving rosiglitazone + metformin in addition to insulin reported greater treatment satisfaction than those receiving insulin alone. Both treatment regimens were well tolerated but more participants had oedema [12 (7%) vs. 4 (3%)] and there was more weight gain [3.7 vs. 2.6 kg; difference 1.1 (0.2, 2.1) kg, P = 0.02] with rosiglitazone + metformin. CONCLUSIONS Addition of insulin to rosiglitazone + metformin enabled more people to reach glycaemic targets with less insulin, and was generally well tolerated.
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Affiliation(s)
- P D Home
- School of Medical Sciences--Diabetes, The Medical School, Newcastle University, Newcastle upon Tyne, UK.
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Zammitt NN, Frier BM. Hypoglycemia in type 2 diabetes: pathophysiology, frequency, and effects of different treatment modalities. Diabetes Care 2005; 28:2948-61. [PMID: 16306561 DOI: 10.2337/diacare.28.12.2948] [Citation(s) in RCA: 284] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Nicola N Zammitt
- Department of Diabetes, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, Scotland, U.K
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