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Mehta R, Billings LK, Liebl A, Vilsbøll T. Transitioning from basal-bolus or premix insulin therapy to a combination of basal insulin and glucagon-like peptide-1 receptor agonist in people with type 2 diabetes. Diabet Med 2022; 39:e14901. [PMID: 35708737 PMCID: PMC9542161 DOI: 10.1111/dme.14901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 04/29/2022] [Accepted: 06/14/2022] [Indexed: 11/27/2022]
Abstract
AIMS Two fixed-ratio combinations (FRCs) of basal insulin and glucagon-like peptide-1 receptor agonist (GLP-1RA) are available for once-daily use in adults with type 2 diabetes. We aimed to review the clinical evidence for the efficacy and safety of changing treatment from a basal-bolus insulin (BBI) regimen or a premix insulin to these combination treatments (fixed-ratio or loose) and provide expert opinion on the practicalities of making such a change. METHODS Relevant clinical and trial evidence and general review articles were identified through a literature review of ProQuest (comprising BIOSIS Previews®, Current Contents® Search, Embase® and MEDLINE®) for articles published between 2009 and 2021. RESULTS We identified nine articles reporting the results of FRCs, and seven articles reporting results of loose combinations of basal insulin and GLP-1RAs, in people who transitioned treatment from BBI or premix regimens. In most trials, combination treatment led to improved or equivalent glycaemic control, and a reduction in body weight or BMI, versus the original regimens. Some trials reported a reduction in total insulin dose. A few trials reported reduced or unchanged hypoglycaemia rates, or increased patient satisfaction, with combination therapy where these endpoints were examined. We provide guidance on transitioning of treatment and the patient types most likely to benefit. CONCLUSIONS In people not achieving glycaemic control with BBI or premix insulin regimens, an FRC or loose combination of basal insulin and GLP-1RA may improve control, decrease the risk of body weight gain or hypoglycaemia and reduce the complexity of treatment.
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Affiliation(s)
- Roopa Mehta
- Unidad de Investigación en Enfermedades Metabólicas, Departamento de Endocrinología y MetabolismoInstituto Nacional de Ciencias Médicas y Nutrición Salvador ZubiránMexico CityMexico
| | - Liana K. Billings
- Division of Endocrinology and MetabolismNorthShore University HealthSystemSkokieIllinoisUSA
- Department of MedicineUniversity of Chicago Pritzker School of MedicineSkokieIllinoisUSA
| | - Andreas Liebl
- Center for Diabetes and Metabolism, m&i‐FachklinikBad HeilbrunnGermany
| | - Tina Vilsbøll
- Steno Diabetes Center Copenhagen, Gentofte HospitalGentofteDenmark
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Matsuba I, Kawata T, Ajima M, Umezawa S, Kaneshiro M, Asakura T, Machimura H, Sawa T, Tanaka K, Takeda H, Imaoka T, Kanamori A. Multinational Observational Study to Understand Insulin Treatment Intensification: Japanese Subgroup Analysis of the MOSAIc Study. Diabetes Ther 2022; 13:265-274. [PMID: 34988917 PMCID: PMC8873337 DOI: 10.1007/s13300-021-01195-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 12/15/2021] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION MOSAIc was a multinational, non-interventional, prospective, observational cohort study designed to provide an understanding of the specific challenges associated with intensification of initial insulin therapy in patients with type 2 diabetes mellitus (T2DM). We present a sub-analysis of Japanese patients from MOSAIc, with data analyzed longitudinally over 2 years, to provide insight on how T2DM treatment is intensified. METHODS Japanese patients with T2DM receiving any insulin therapy for at least 3 months were eligible for study inclusion. Baseline and clinical data were collected during an initial baseline visit and during four subsequent prospective visit windows (within ± 3 months) at 6, 12, 18, and 24 months. Treatment intensification was defined as addition of new insulin, increase in insulin dosage (1-unit change or 10% compared with the previous visit), increase in insulin injection frequency, and/or addition of non-insulin antihyperglycemic agents. RESULTS Of 116 Japanese patients who completed the study, 50.0% (n = 58) received treatment intensification. Baseline characteristics of patients with treatment intensification included a longer duration of diabetes, higher incidence of baseline microvascular complications, and higher HbA1c compared to those without intensification. There was no significant difference in HbA1c change from baseline between the two groups at any post-baseline visit. Insulin intensification accounted for 61.2% of treatment changes, with non-insulin-related intensification accounting for 36.2% of treatment changes. An increase in insulin dose was the most frequent treatment change (51.7%), followed by the addition of new insulin (22.4%), and an increase in insulin injection frequency (6.9%). CONCLUSION Real-world data from Japanese patients with T2DM who received treatment intensification showed that an increase in insulin dose and the addition of new insulin were the most frequent treatment intensification methods. HbA1c was maintained through 2 years of treatment. TRIAL REGISTRATION NCT01400971, ClinicalTrials.gov.
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Affiliation(s)
- Ikuro Matsuba
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Kanagawa, Japan
| | - Takehiro Kawata
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Kanagawa, Japan
| | - Miho Ajima
- Department of Diabetology, Kawasaki Saiwai Clinic, Kanagawa, Japan
| | - Shinichi Umezawa
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Kanagawa, Japan
| | - Mizuki Kaneshiro
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Kanagawa, Japan
| | - Taro Asakura
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Kanagawa, Japan
| | - Hideo Machimura
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Kanagawa, Japan
| | - Tasuku Sawa
- Sawa Internal Medicine and Diabetes Clinic, Kanagawa, Japan
| | - Keiji Tanaka
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Kanagawa, Japan
| | - Hiroshi Takeda
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Kanagawa, Japan
| | - Takeshi Imaoka
- Japan Drug Development and Medical Affairs, Eli Lilly Japan K.K., 5-1-28 Isogami-dori, Chuo-ku, Kobe, Hyogo, 651-0086, Japan.
| | - Akira Kanamori
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Kanagawa, Japan
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Mehta R, Chen R, Hirose T, John M, Kok A, Lehmann R, Unnikrishnan AG, Yavuz DG, Fulcher G. Practical use of insulin degludec/insulin aspart in a multinational setting: beyond the guidelines. Diabetes Obes Metab 2020; 22:1961-1975. [PMID: 32618405 PMCID: PMC7689716 DOI: 10.1111/dom.14128] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/17/2020] [Accepted: 06/26/2020] [Indexed: 12/17/2022]
Abstract
Insulin degludec/insulin aspart (IDegAsp) is a fixed-ratio co-formulation of insulin degludec, which provides long-lasting basal insulin coverage, and insulin aspart, which targets postprandial glycaemia. This review provides expert opinion on the practical clinical use of IDegAsp, including: dose timings relative to meals, when and how to intensify treatment from once-daily (OD) to twice-daily (BID) dose adjustments, and use in special populations (including hospitalized patients). IDegAsp could be considered as one among the choices for initiating insulin treatment, preferential to starting on basal insulin alone, particularly for people with severe hyperglycaemia and/or when postprandial hyperglycaemia is a major concern. The recommended starting dose of IDegAsp is 10 units with the most carbohydrate-rich meal(s), followed by individualized dose adjustments. Insulin doses should be titrated once weekly in two-unit steps, guided by individualized fasting plasma glucose targets and based on patient goals, preferences and hypoglycaemia risk. Options for intensification from IDegAsp OD are discussed, which should be guided by HbA1c, prandial glucose levels, meal patterns and patient preferences. Recommendations for switching to IDegAsp from basal insulin, premixed insulins OD/BID, and basal-plus/basal-bolus regimens are discussed. IDegAsp can be co-administered with other antihyperglycaemic drugs; however, sulphonylureas frequently need to be discontinued or the dose reduced, and the IDegAsp dose may need to be decreased when sodium-glucose co-transporter-2 inhibitors or glucagon-like peptide-1 receptor agonists are added. Considerations around the initiation or continuation of IDegAsp in hospitalized individuals are discussed, as well as in those undergoing medical procedures.
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Affiliation(s)
- Roopa Mehta
- Unidad de Investigación en Enfermedades Metabólicas, Departamento de Endocrinología y MetabolismoInstituto Nacional de Ciencias Médicas y Nutrición Salvador ZubiránMexico CityMexico
| | - Roger Chen
- Department of EndocrinologySt Vincentʼs HospitalSydneyAustralia
- University of New South Wales, Office of Medical EducationUniversity of SydneySydneyAustralia
| | - Takahisa Hirose
- Division of Diabetes, Metabolism and Endocrinology, Department of MedicineToho University School of MedicineTokyoJapan
| | - Mathew John
- Providence Endocrine and Diabetes Specialty CentreThiruvananthapuramKeralaIndia
| | - Adri Kok
- Netcare Union and Clinton HospitalsAlbertonSouth Africa
- University of WitwatersrandJohannesburgSouth Africa
| | - Roger Lehmann
- Department of EndocrinologyUniversity Hospital ZurichZurichSwitzerland
| | | | - Dilek Gogas Yavuz
- Department of Endocrinology and MetabolismMarmara University School of MedicineIstanbulTurkey
| | - Gregory Fulcher
- Northern Clinical SchoolUniversity of SydneySydneyAustralia
- Department of Diabetes, Endocrinology & MetabolismRoyal North Shore Hospital, University of SydneySydneyAustralia
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Machado-Alba JE, Machado-Duque ME, Gaviria-Mendoza A. Time to modification of antidiabetic therapy in patients over the age of 65 years with newly diagnosed diabetes mellitus. Diabetes Res Clin Pract 2020; 162:108090. [PMID: 32088311 DOI: 10.1016/j.diabres.2020.108090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 02/17/2020] [Accepted: 02/19/2020] [Indexed: 12/19/2022]
Abstract
AIMS To determine the time elapsed from when a patient ≥ 65 years old is diagnosed with type 2 diabetes mellitus (T2DM) and begins antidiabetic treatment until a change in treatment is required as well as the factors associated with the change. METHODS A retrospective study was conducted on patients 65 years or older with a first-time diagnosis of T2DM, and these patients were followed for 60 months until an addition or change was made to their antidiabetic drug regimen. Kaplan-Meier survival analysis was performed to determine the time elapsed until such a modification occurred. RESULTS We identified 13,573 patients with a mean age of 76.8 ± 7.7 years; 59.3% were women. A total of 9144 (67.4%) patients began treatment with a single antidiabetic drug, 4146 (30.5%) began with two, and 282 (2.1%) began with three, especially metformin (n = 10858, 80.0%), sulfonylureas (n = 4525, 33.3%), and insulins (n = 2334, 17.2%). A total of 52.4% (n = 7106) of the patients underwent treatment modification (addition, 39.3% and change, 13.1%). Only 11.2% (n = 600) of the additions corresponded to new antidiabetic drugs (GLP-1 receptor agonists, SGLT2 inhibitors, DPP4 inhibitors). The mean time to modification was 39.1 ± 23.4 months, and the modification occurred earlier in those who started with various antidiabetic agents (33.2 vs. 42.6 months; p < 0.001), men (38.3 vs. 40.4 months; p < 0.001), and those who took glibenclamide vs. metformin (31.9 vs. 44.6 months, p < 0.001). CONCLUSIONS Most elderly adults who were diagnosed with T2DM after 65 years of age were treated with the appropriate medications. Therapy was modified for more than half of the patients, The addition of new antidiabetic drugs was infrequent.
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Affiliation(s)
- Jorge Enrique Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Calle 105 No. 14-140, Zip Code: 660003, Pereira, Risaralda, Colombia.
| | - Manuel Enrique Machado-Duque
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Calle 105 No. 14-140, Zip Code: 660003, Pereira, Risaralda, Colombia; Grupo de Investigación Biomedicina, Fundación Universitaria Autónoma de las Américas, Ave Las Américas # 98-56, Pereira, Colombia
| | - Andrés Gaviria-Mendoza
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Calle 105 No. 14-140, Zip Code: 660003, Pereira, Risaralda, Colombia; Grupo de Investigación Biomedicina, Fundación Universitaria Autónoma de las Américas, Ave Las Américas # 98-56, Pereira, Colombia
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Yang W, Ersoy C, Wang G, Ye S, Liu J, Miao H, Asirvatham A, Werther S, Kadu P, Chow F. Efficacy and safety of three-times-daily versus twice-daily biphasic insulin aspart 30 in patients with type 2 diabetes mellitus inadequately controlled with basal insulin combined with oral antidiabetic drugs. Diabetes Res Clin Pract 2019; 150:158-166. [PMID: 30872064 DOI: 10.1016/j.diabres.2019.02.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 12/23/2018] [Accepted: 02/25/2019] [Indexed: 11/25/2022]
Abstract
AIMS To compare the efficacy and safety of biphasic insulin aspart 30 (BIAsp 30) administered three times daily (TID) vs. twice daily (BID), plus metformin, in patients with type 2 diabetes mellitus (T2DM) inadequately controlled on basal insulin ± 1 oral antidiabetic drug (OAD). METHODS Randomised, multinational, open-label, treat-to-target trial. Subjects inadequately controlled (HbA1c 7.5-10.0%) on basal insulin and metformin ± 1 OAD were randomised to BIAsp30 TID (n = 220) or BIAsp30 BID (n = 217). Primary endpoint was change from baseline in HbA1c after 24 weeks of treatment. RESULTS Most (400/437, 91.5%) subjects completed the trial. The majority (276/400 [69.0%]) were from the China region. After 24 weeks, HbA1c decreased comparably in both BIAsp 30 groups (-1.7% vs. -1.6% [-19 vs. -18 mmol/mol], for TID and BID dosing, respectively; estimated treatment difference: -0.09% [-0.23; 0.06]95% CI, -1 mmol/mol [-3; 1], p = 0.26). Safety profiles, including number of subjects experiencing hypoglycaemia, were similar. CONCLUSIONS BIAsp 30 administered either TID or BID with metformin was a safe and effective option when intensifying treatment after failure of basal insulin and OADs in patients with T2DM. Adding a third injection at lunchtime may be preferable if HbA1c remains above target, if the lunchtime meal is the largest meal of the day, or if persistent postprandial hyperglycaemia after lunch is observed. TRIAL REGISTRATION NUMBER ClinicalTrials.gov, NCT02582242.
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Affiliation(s)
- Wenying Yang
- China-Japan Friendship Hospital, East Yinghuayuan Street, Hepingli, Beijing 100029, China.
| | - Canan Ersoy
- Division of Endocrinology and Metabolism, School of Medicine, Uludag University, Bursa, Turkey.
| | - Guixia Wang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, Jilin Province 130021, China.
| | - Shandong Ye
- School of Medicine, Shandong University, Jinan, Shandong, China; Department of Endocrinology, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, China
| | - Jun Liu
- Department of Endocrinology, Shanghai Fifth People's Hospital Affiliated to Fudan University, 801 Heqing Road, Minhang District, Shanghai 200240, China
| | - Heng Miao
- The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China.
| | - Arthur Asirvatham
- Department of Medicine, Government Medical College, Madurai, Tamil Nadu, India
| | | | | | - Francis Chow
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China.
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Candido R, Wyne K, Romoli E. A Review of Basal-Bolus Therapy Using Insulin Glargine and Insulin Lispro in the Management of Diabetes Mellitus. Diabetes Ther 2018; 9:927-949. [PMID: 29654514 PMCID: PMC5984925 DOI: 10.1007/s13300-018-0422-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Indexed: 12/29/2022] Open
Abstract
UNLABELLED Basal-bolus therapy (BBT) refers to the combination of a long-acting basal insulin with a rapid-acting insulin at mealtimes. Basal insulin glargine 100 U/mL and prandial insulin lispro have been available for many years and there is a substantial evidence base to support the efficacy and safety of these agents when they are used in BBT or basal-plus therapy for patients with type 1 or type 2 diabetes mellitus (T1DM, T2DM). With the growing availability of alternative insulins for use in such regimens, it seems timely to review the data regarding BBT with insulin glargine 100 U/mL and insulin lispro. In patients with T1DM, BBT with insulin glargine plus insulin lispro provides similar or better glycemic control and leads to less nocturnal hypoglycemia compared to BBT using human insulin as the basal and/or prandial component, and generally provides similar glycemic control and rates of severe hypoglycemia to those achieved with insulin lispro administered by continuous subcutaneous insulin infusion (CSII). Studies evaluating BBT with insulin glargine plus insulin lispro in patients with T2DM also demonstrate the efficacy and safety of these insulins. Available data suggest that BBT with insulin glargine and insulin lispro provides similar levels of efficacy and safety in pediatric and adult populations with T1DM and in adult patients and those aged more than 65 years with T2DM. These insulin preparations also appear to be safe and effective for controlling T2DM in people of different ethnicities and in patients with T1DM or T2DM and comorbidities. FUNDING Eli Lilly and Company.
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Affiliation(s)
- Riccardo Candido
- Diabetes Centre District 3, Azienda Sanitaria Universitaria Integrata di Trieste, Via Puccini 48/50, 34100, Trieste, Italy.
| | - Kathleen Wyne
- The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA
| | - Ester Romoli
- Eli Lilly Italia SPA, via A. Gramsci 731/733, 50019, Sesto Fiorentino, Italy
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Girbés Borrás J, Escalada San Martín J, Mata Cases M, Gomez-Peralta F, Artola Menéndez S, Fernández García D, Ortega Millán C, Alvarez Guisasola F, Ferrer García JC, Ezkurra Loiola P, Escobar Jiménez F, Fornos Pérez JA, Galindo Rubio M, Rica Echevarría I, Menéndez Torre E. Consenso sobre tratamiento con insulina en la diabetes tipo 2. ENDOCRINOL DIAB NUTR 2018. [DOI: 10.1016/j.endinu.2018.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Linjawi S, Lee BW, Tabak Ö, Lövdahl S, Werther S, Abusnana S. A 32-Week Randomized Comparison of Stepwise Insulin Intensification of Biphasic Insulin Aspart (BIAsp 30) Versus Basal-Bolus Therapy in Insulin-Naïve Patients with Type 2 Diabetes. Diabetes Ther 2018; 9:1-11. [PMID: 29129018 PMCID: PMC5801220 DOI: 10.1007/s13300-017-0334-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION This 32-week, open-label, randomized, parallel-group, multinational trial aimed to compare the efficacy and safety of stepwise insulin intensification of biphasic insulin aspart 30 (BIAsp 30) relative to stepwise intensification of a basal-bolus regimen in insulin-naïve adults with type 2 diabetes (T2D) who continued pretrial treatment with metformin and sulfonylurea. METHODS Adults with T2D were randomized into one of two treatment arms for 32 weeks: (1) BIAsp 30 once daily (OD), with the possibility of stepwise treatment intensification up to BIAsp 30 three times daily (TID); (2) insulin glargine OD, with the possibility of stepwise treatment intensification with insulin aspart up to TID. The primary endpoint was change from baseline in HbA1c after 32 weeks. RESULTS After 32 weeks, the estimated mean change in HbA1c from baseline was statistically significantly lower in the BIAsp 30 arm (- 1.18%) versus basal-bolus (- 1.36%) [estimated treatment difference 0.18%; 95% confidence interval (95% CI) 0.01; 0.36; p < 0.05]. The proportion of patients with HbA1c below 7.0% was statistically significantly lower with BIAsp 30 (42.9%) compared with basal-bolus (56.9%) (odds ratio 0.58; 95% CI 0.37; 0.89; p = 0.01). The overall rate of severe or blood glucose (BG)-confirmed hypoglycemic events was numerically lower for BIAsp 30 compared with basal-bolus, and a statistically significantly lower rate in nocturnal severe or BG-confirmed hypoglycemia in the BIAsp 30 arm relative to basal-bolus was observed: estimated rate ratio 0.32 (95% CI 0.13; 0.79), p = 0.0131. The proportion of patients with adverse events was similar in both treatment arms. CONCLUSION Insulin intensification with BIAsp 30 and basal-bolus showed an improvement in glycemic control; the change in HbA1c was statistically significantly lower for BIAsp 30 compared to basal-bolus. Basal-bolus treatment was accompanied by a numerically, and statistically significantly, higher rate of overall and nocturnal severe or BG-confirmed hypoglycemia, respectively, compared with BIAsp 30. FUNDING Novo Nordisk A/S. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT02453685.
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Affiliation(s)
- Sultan Linjawi
- Coffs Endocrine and Diabetes Service, Coffs Harbour, NSW, Australia.
| | - Byung-Wan Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Ömür Tabak
- Internal Medicine Clinic, Ministry of Health Istanbul Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
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9
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Ghosh S, Unnikrishnan AG, Saboo B, Kesavadev J, Aravind SR, Bajaj S, Rajput R, Seshadri K, Verma N, Gupta A, Makkar BM, Saikia M, Kale S, Damodaran S, Dengra A, Eashwar TKM, Maheshwari A, Pendsey S, Phatak SR, Sharma SK, Singh SK, Ramachandran A, Zargar AH, Joshi SR, Sadikot SM. Evidence-based recommendations for insulin intensification strategies after basal insulin in type 2 diabetes. Diabetes Metab Syndr 2017; 11 Suppl 1:S507-S521. [PMID: 28433618 DOI: 10.1016/j.dsx.2017.03.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Indexed: 01/27/2023]
Abstract
Over the time due to progressive nature of diabetes, proactive intensification of the existing insulin therapy becomes imminent as it minimizes patients' exposure to chronic hypo/hyperglycaemia and reduces weight gain while achieving individualized glycaemic targets. This review focuses on the strength of evidence behind various options for intensification, primarily the insulins as also the GLP-1 analogues. The recommendations presented here are meant to serve as a guide for the physician managing type 2 diabetes patients requiring insulin intensification upon failing of basal insulin therapy.
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Affiliation(s)
- Sujoy Ghosh
- Department of Endocrinology and Metabolism, Institute of Post-Graduate Medical Education and Research, Kolkata, India.
| | | | | | | | | | - Sarita Bajaj
- Department of Medicine, Motilal Nehru Medical College, Allahabad, India
| | - Rajesh Rajput
- Department of Endocrinology, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, India
| | - Krishna Seshadri
- Department of Endocrinology and Metabolism, Shri Rama Chandra University, Chennai, India
| | | | | | | | | | | | | | - Ashish Dengra
- Mahi Diabetes & Thyroid Care and Research Center, Jabalpur, India
| | | | - Anuj Maheshwari
- Department of Medicine, Babu Banarasi Das University, Lucknow, India
| | | | | | | | - Surya Kumar Singh
- Department of Endocrinology and Metabolism, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | | | - Abdul H Zargar
- Advanced Center for Diabetes and Endocrine Care, Srinagar, India
| | - Shashank R Joshi
- Lilavati and Bhatia Hospital and Grant Medical College, Mumbai, India
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Giugliano D, Sieradzki J, Stefanski A, Gentilella R. Personalized intensification of insulin therapy in type 2 diabetes - does a basal-bolus regimen suit all patients? Curr Med Res Opin 2016; 32:1425-34. [PMID: 27126277 DOI: 10.1080/03007995.2016.1181051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Many patients with type 2 diabetes mellitus (T2DM) require insulin therapy. If basal insulin fails to achieve glycemic control, insulin intensification is one possible treatment intensification strategy. We summarized clinical data from randomized clinical trials designed to compare the efficacy and safety of basal-bolus and premixed insulin intensification regimens. We defined a between-group difference of ≥0.3% in end-of-study glycated hemoglobin (HbA1c) as clinically meaningful. A PubMed database search supplemented by author-identified papers yielded 15 trials which met selection criteria: randomized design, patients with T2DM receiving basal-bolus (bolus injection ≤3 times/day) vs. premixed (≤3 injections/day) insulin regimens, primary/major endpoint(s) HbA1c- and/or hypoglycemia-related, and trial duration ≥12 weeks. Glycemic control improved with both basal-bolus and premixed insulin regimens with - in most cases - acceptable levels of weight gain and hypoglycemia. A clinically meaningful difference between regimens in glycemic control was recorded in only four comparisons, all of which favored basal-bolus therapy. The incidence of hypoglycemia was significantly different between regimens in only three comparisons, one of which favored premixed insulin and two basal-bolus therapy. Of the four trials that reported a significant difference between regimens in bodyweight change, two favored basal-bolus therapy and two favored premixed insulin. Thus, on a population level, neither basal-bolus therapy nor premixed insulin showed a consistent advantage in terms of glycemic control, hypoglycemic risk, or bodyweight gain. It is therefore recommended that clinicians should adopt an individualized approach to insulin intensification - taking into account the benefits and risks of each treatment approach and the attitude and preferences of each patient - in the knowledge that both basal-bolus and premixed regimens may be successful.
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Affiliation(s)
- D Giugliano
- a Department of Medical, Surgical, Neurological, Metabolic Sciences and Aging , Second University of Naples , Naples , Italy
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11
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Roth Flach RJ, Danai LV, DiStefano MT, Kelly M, Menendez LG, Jurczyk A, Sharma RB, Jung DY, Kim JH, Kim JK, Bortell R, Alonso LC, Czech MP. Protein Kinase Mitogen-activated Protein Kinase Kinase Kinase Kinase 4 (MAP4K4) Promotes Obesity-induced Hyperinsulinemia. J Biol Chem 2016; 291:16221-30. [PMID: 27226575 PMCID: PMC4965570 DOI: 10.1074/jbc.m116.718932] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 05/17/2016] [Indexed: 01/01/2023] Open
Abstract
Previous studies revealed a paradox whereby mitogen-activated protein kinase kinase kinase kinase 4 (Map4k4) acted as a negative regulator of insulin sensitivity in chronically obese mice, yet systemic deletion of Map4k4 did not improve glucose tolerance. Here, we report markedly reduced glucose-responsive plasma insulin and C-peptide levels in whole body Map4k4-depleted mice (M4K4 iKO) as well as an impaired first phase of insulin secretion from islets derived from M4K4 iKO mice ex vivo After long-term high fat diet (HFD), M4K4 iKO mice pancreata also displayed reduced β cell mass, fewer proliferating β cells and reduced islet-specific gene mRNA expression compared with controls, although insulin content was normal. Interestingly, the reduced plasma insulin in M4K4 iKO mice exposed to chronic (16 weeks) HFD was not observed in response to acute HFD challenge or short term treatment with the insulin receptor antagonist S961. Furthermore, the improved insulin sensitivity in obese M4K4 iKO mice was abrogated by high exogenous insulin over the course of a euglycemic clamp study, indicating that hypoinsulinemia promotes insulin sensitivity in chronically obese M4K4 iKO mice. These results demonstrate that protein kinase Map4k4 drives obesity-induced hyperinsulinemia and insulin resistance in part by promoting insulin secretion from β cells in mice.
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Affiliation(s)
| | | | | | - Mark Kelly
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts 01605
| | | | | | - Rohit B Sharma
- Department of Medicine, Division of Endocrinology, Metabolism and Diabetes, and
| | | | | | - Jason K Kim
- From the Program in Molecular Medicine, Department of Medicine, Division of Endocrinology, Metabolism and Diabetes, and
| | | | - Laura C Alonso
- Department of Medicine, Division of Endocrinology, Metabolism and Diabetes, and
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12
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Bonafede M, Chandran A, DiMario S, Saltiel-Berzin R, Saliu D. Medication usage, treatment intensification, and medical cost in patients with type 2 diabetes: a retrospective database study. BMJ Open Diabetes Res Care 2016; 4:e000189. [PMID: 27547410 PMCID: PMC4964196 DOI: 10.1136/bmjdrc-2015-000189] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 06/06/2016] [Accepted: 06/27/2016] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE The goal of this study was to describe medication usage patterns in patients with type 2 diabetes mellitus (T2DM) initiating treatment with non-insulin antidiabetic drugs (NIADs), basal insulin, or prandial/mixed insulin using real-world data. RESEARCH DESIGN AND METHODS A retrospective analysis using the Truven Health MarketScan Research Databases was conducted to identify adults (≥18 years) with T2DM from 2006 to 2012. Patients were categorized into four cohorts based on diabetes treatment. Cohort 1 (n=597 664) consisted of newly diagnosed patients who did not receive any treatment, cohort 2 (n=342 511) included NIAD initiators, cohort 3 (n=99 578) included basal insulin initiators, and cohort 4 (n=62 876) included prandial/mixed insulin initiators. Patients transitioned out of a cohort once they met the criteria for the next one. RESULTS Patients in cohort 2 were younger (56.2 years, SD±12.1) than patients in cohorts 1, 3, and 4 (58 years, SD±0.75). Metformin was the most commonly prescribed drug in cohort 2 patients. Basal insulin usage decreased from 71% in year 1 to 47% in year 4, in cohort 3 patients. Approximately one-third of these patients switched to prandial/mixed insulin each year. In cohort 4, the usage of prandial/mixed insulin decreased to 61% by year 4. Use of basal insulin and NIAD remained common in this group. Mean glycosylated hemoglobin (HbA1c) values decreased by ∼1% for each of the treatment cohorts following treatment initiation and remained stable during follow-up. All-cause and diabetes-related medical costs were highest for patients in cohorts 3 and 4. CONCLUSIONS Overall, our findings demonstrate that treatment intensification was low in all study cohorts despite elevated HbA1c levels during preindex and follow-up period.
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Affiliation(s)
| | - Arthi Chandran
- Health Economics and Outcomes Research, Becton Dickinson, Franklin Lakes, New Jersey, USA
| | - Stefan DiMario
- Health Economics and Outcomes Research, Becton Dickinson, Franklin Lakes, New Jersey, USA
| | | | - Drilon Saliu
- Medical Affairs, Becton Dickinson, Franklin Lakes, New Jersey, USA
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13
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Affiliation(s)
- P. Gaye Knutsen
- Washington University Diabetes Center at Barnes Jewish Hospital, St. Louis, MO
| | - Cheryl Q. Voelker
- Washington University Diabetes Center at Barnes Jewish Hospital, St. Louis, MO
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14
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Anvari E, Wikström P, Walum E, Welsh N. The novel NADPH oxidase 4 inhibitor GLX351322 counteracts glucose intolerance in high-fat diet-treated C57BL/6 mice. Free Radic Res 2015; 49:1308-18. [DOI: 10.3109/10715762.2015.1067697] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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15
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Danai LV, Roth Flach RJ, Virbasius JV, Garcia Menendez L, Jung DY, Kim JH, Kim JK, Czech MP. Inducible Deletion of Protein Kinase Map4k4 in Obese Mice Improves Insulin Sensitivity in Liver and Adipose Tissues. Mol Cell Biol 2015; 35:2356-65. [PMID: 25918248 PMCID: PMC4456439 DOI: 10.1128/mcb.00150-15] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Revised: 02/24/2015] [Accepted: 04/21/2015] [Indexed: 01/01/2023] Open
Abstract
Studies in vitro suggest that mitogen-activated protein kinase kinase kinase kinase 4 (Map4k4) attenuates insulin signaling, but confirmation in vivo is lacking since Map4k4 knockout is lethal during embryogenesis. We thus generated mice with floxed Map4k4 alleles and a tamoxifen-inducible Cre/ERT2 recombinase under the control of the ubiquitin C promoter to induce whole-body Map4k4 deletion after these animals reached maturity. Tamoxifen administration to these mice induced Map4k4 deletion in all tissues examined, causing decreased fasting blood glucose concentrations and enhanced insulin signaling to AKT in adipose tissue and liver but not in skeletal muscle. Surprisingly, however, mice generated with a conditional Map4k4 deletion in adiponectin-positive adipocytes or in albumin-positive hepatocytes displayed no detectable metabolic phenotypes. Instead, mice with Map4k4 deleted in Myf5-positive tissues, including all skeletal muscles tested, were protected from obesity-induced glucose intolerance and insulin resistance. Remarkably, these mice also showed increased insulin sensitivity in adipose tissue but not skeletal muscle, similar to the metabolic phenotypes observed in inducible whole-body knockout mice. Taken together, these results indicate that (i) Map4k4 controls a pathway in Myf5-positive cells that suppresses whole-body insulin sensitivity and (ii) Map4k4 is a potential therapeutic target for improving glucose tolerance and insulin sensitivity in type 2 diabetes.
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Affiliation(s)
- Laura V. Danai
- Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Rachel J. Roth Flach
- Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Joseph V. Virbasius
- Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Lorena Garcia Menendez
- Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Dae Young Jung
- Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Jong Hun Kim
- Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Jason K. Kim
- Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
- Department of Medicine, Division of Endocrinology, Metabolism and Diabetes, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Michael P. Czech
- Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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16
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Morales J, Merker L. Minimizing Hypoglycemia and Weight Gain with Intensive Glucose Control: Potential Benefits of a New Combination Therapy (IDegLira). Adv Ther 2015; 32:391-403. [PMID: 25962992 PMCID: PMC4449377 DOI: 10.1007/s12325-015-0208-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Indexed: 12/24/2022]
Abstract
Due to the progressive nature of type 2 diabetes (T2D), the majority of patients require increasing levels of therapy to achieve and maintain good glycemic control. At present, once patients become uncontrolled on oral antidiabetic therapies, the two primary treatment options are glucagon-like peptide-1 receptor agonists (GLP-1RAs) or basal insulin, although earlier use of GLP-1RAs has also been advocated. While both of these drug classes have proven efficacy in treating T2D, there can be limitations to their use in some patients, and resistance to further treatment intensification among both patients and physicians. More recently, treatment incorporating both a GLP-1RA and a basal insulin has been used successfully in the clinic and the first such combination product, IDegLira (insulin degludec + liraglutide), has recently been approved for use in Europe. IDegLira combines insulin degludec and the GLP-1RA liraglutide in a single injection. In both insulin-naïve and basal insulin-treated individuals with T2D, IDegLira has demonstrated greater reductions in glycated hemoglobin (HbA1c) than either of the individual components, with a low rate of hypoglycemia and weight loss. IDegLira may provide a new option for patients requiring treatment intensification but for whom increased weight or a higher risk of hypoglycemia are barriers. This article discusses the rationale behind combining these two drug classes and reviews the available clinical evidence for the efficacy and safety of IDegLira.
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Affiliation(s)
- Javier Morales
- Advanced Internal Medicine Group, Great Neck, New York, USA,
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Machado-Alba JE, Machado-Duque ME, Moreno-Gutierrez PA. Time to and factors associated with insulin initiation in patients with type 2 diabetes mellitus. Diabetes Res Clin Pract 2015; 107:332-7. [PMID: 25648389 DOI: 10.1016/j.diabres.2015.01.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 12/03/2014] [Accepted: 01/14/2015] [Indexed: 10/24/2022]
Abstract
AIMS Determine the time between the start of oral antidiabetic therapy (OAD) and the initiation of insulin therapy and to establish factors associated with insulin prescription among patients with type 2 diabetes mellitus (T2DM) in Colombia. METHODS Cohort, retrospective, population-based study. We identify patients with T2DM who started OAD therapy between 1 January 2007 and 31 December 2008, and a 5-year follow-up was performed. Kaplan-Meier survival analysis for time to start insulin therapy was generated and factors associated with insulin initiation were determined using logistic regression. RESULTS A total of 1042 patients (52.4% women), mean age 63.4 years at the start of pharmacological treatment. After 5 years, 272 patients (26.1%) initiated insulin therapy. Using combination therapy of metformin and glibenclamide was associated with greater risk of insulin initiation (OR: 1.64, 95% CI: 1.12-2.40, p=0.010), while being a male over 45 years of age (OR: 0.59, 95% CI: 0.37-0.96, p=0.034) and initiating OAD therapy with metformin (OR: 0.30, 95% CI: 0.20-0.46, p<0.001) reduced the risk of insulin use. CONCLUSIONS After 5 years of OAD treatment, 26.1% of people with T2DM started insulin therapy. Age, sex and type of initial OAD affected the probability of switching to insulin in these patients in Colombia.
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Affiliation(s)
- Jorge Enrique Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira, Audifarma S.A, Paraje la Julita, AA: 97, 660003 Pereira, Risaralda, Colombia.
| | - Manuel Enrique Machado-Duque
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira, Pereira, Colombia
| | - Paula Andrea Moreno-Gutierrez
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia. Universidad Tecnológica de Pereira, Audifarma S.A., Pereira, Colombia
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18
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Similar glucose control with basal-bolus regimen of insulin detemir plus insulin aspart and thrice-daily biphasic insulin aspart 30 in insulin-naive patients with type 2 diabetes: Results of a 50-week randomized clinical trial of stepwise insulin intensification. DIABETES & METABOLISM 2014; 41:223-30. [PMID: 25483023 DOI: 10.1016/j.diabet.2014.11.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 10/31/2014] [Accepted: 11/07/2014] [Indexed: 11/20/2022]
Abstract
OBJECTIVE This study aimed to demonstrate the non-inferiority of 50-week treatment with stepwise insulin intensification of basal-bolus insulin analogues [insulin detemir (IDet) and aspart (IAsp)] versus biphasic insulin aspart 30 (BIAsp30) in insulin-naive type 2 diabetes mellitus (T2DM) patients not controlled by oral glucose-lowering drugs (OGLDs). RESEARCH DESIGN AND METHODS In this open-label multicentre, multinational, randomized, parallel-arm treat-to-target trial, 403 insulin-naive patients with T2DM in four African countries were randomized to either an IDet+IAsp (n = 200) or BIAsp1-2-3 (n = 203) treatment group. Stepwise insulin intensification was performed at the end of 14, 26 and 38 weeks, depending on HbA1c values. The primary endpoint was change in HbA1c after 50 weeks of treatment. Safety variables were hypoglycaemia incidence, occurrence of adverse events and weight gain. RESULTS Non-inferiority of the IDet+IAsp versus BIAsp1-2-3 treatment regimen was demonstrated by their similar HbA1c levels at the end of trial (IDet+IAsp: baseline 8.6%, 50 weeks 7.4%; BIAsp1-2-3: baseline 8.7%, 50 weeks 7.3%; full analysis set difference: 0.1% [95% CI: -0.1, 0.3]; per protocol: 0.2% [95% CI: -0.1, 0.4]). At week 50, 40.3 and 44.9% of patients achieved HbA1c <7.0% with IDet+IAsp and BIAsp1-2-3, respectively. The rate of overall hypoglycaemia during the trial was also similar in both groups (IDet+IAsp: 9.4 events/patient-year; BIAsp1-2-3: 9.8 events/patient-year). CONCLUSION Insulin initiation and intensification using IDet+IAsp was not inferior to BIAsp1-2-3 in insulin-naive patients with T2DM not controlled by OGLDs. Both regimens led to similar reductions in HbA1c values after 50 weeks of treatment.
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19
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Johns BR, Jones TC, Sink JH, Cooke CE. Real-world assessment of glycemic control after V-Go® initiation in an endocrine practice in the southeastern United States. J Diabetes Sci Technol 2014; 8:1060-1. [PMID: 24876455 PMCID: PMC4455367 DOI: 10.1177/1932296814537041] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Barry R Johns
- The Jones Center for Diabetes & Endocrine Wellness, Macon, GA, USA Department of Internal Medicine, Mercer University School of Medicine, Macon, GA, USA
| | - Thomas C Jones
- The Jones Center for Diabetes & Endocrine Wellness, Macon, GA, USA Department of Internal Medicine, Mercer University School of Medicine, Macon, GA, USA
| | - John H Sink
- The Jones Center for Diabetes & Endocrine Wellness, Macon, GA, USA
| | - Catherine E Cooke
- PosiHealth, Inc, Ellicott City, MD, USA University of Maryland School of Pharmacy, Baltimore, MD, USA
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20
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Gunawardana SC. Benefits of healthy adipose tissue in the treatment of diabetes. World J Diabetes 2014; 5:420-430. [PMID: 25126390 PMCID: PMC4127579 DOI: 10.4239/wjd.v5.i4.420] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 03/24/2014] [Accepted: 06/03/2014] [Indexed: 02/05/2023] Open
Abstract
The major malfunction in diabetes mellitus is severe perturbation of glucose homeostasis caused by deficiency of insulin. Insulin deficiency is either absolute due to destruction or failure of pancreatic β cells, or relative due to decreased sensitivity of peripheral tissues to insulin. The primary lesion being related to insulin, treatments for diabetes focus on insulin replacement and/or increasing sensitivity to insulin. These therapies have their own limitations and complications, some of which can be life-threatening. For example, exogenous insulin administration can lead to fatal hypoglycemic episodes; islet/pancreas transplantation requires life-long immunosuppressive therapy; and anti-diabetic drugs have dangerous side effects including edema, heart failure and lactic acidosis. Thus the need remains for better safer long term treatments for diabetes. The ultimate goal in treating diabetes is to re-establish glucose homeostasis, preferably through endogenously generated hormones. Recent studies increasingly show that extra-pancreatic hormones, particularly those arising from adipose tissue, can compensate for insulin, or entirely replace the function of insulin under appropriate circumstances. Adipose tissue is a versatile endocrine organ that secretes a variety of hormones with far-reaching effects on overall metabolism. While unhealthy adipose tissue can exacerbate diabetes through limiting circulation and secreting of pro-inflammatory cytokines, healthy uninflamed adipose tissue secretes beneficial adipokines with hypoglycemic and anti-inflammatory properties, which can complement and/or compensate for the function of insulin. Administration of specific adipokines is known to alleviate both type 1 and 2 diabetes, and leptin mono-therapy is reported to reverse type 1 diabetes independent of insulin. Although specific adipokines may correct diabetes, administration of individual adipokines still carries risks similar to those of insulin monotherapy. Thus a better approach is to achieve glucose homeostasis with endogenously-generated adipokines through transplantation or regeneration of healthy adipose tissue. Our recent studies on mouse models show that type 1 diabetes can be reversed without insulin through subcutaneous transplantation of embryonic brown adipose tissue, which leads to replenishment of recipients’ white adipose tissue; increase of a number of beneficial adipokines; and fast and long-lasting euglycemia. Insulin-independent glucose homeostasis is established through a combination of endogenously generated hormones arising from the transplant and/or newly-replenished white adipose tissue. Transplantation of healthy white adipose tissue is reported to alleviate type 2 diabetes in rodent models on several occasions, and increasing the content of endogenous brown adipose tissue is known to combat obesity and type 2 diabetes in both humans and animal models. While the underlying mechanisms are not fully documented, the beneficial effects of healthy adipose tissue in improving metabolism are increasingly reported, and are worthy of attention as a powerful tool in combating metabolic disease.
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Helena WR, Karolicki B. Management of Type 2 Diabetes - Methods for Addition of Prandial to Basal Insulin. EUROPEAN ENDOCRINOLOGY 2014; 10:124-130. [PMID: 29872476 DOI: 10.17925/ee.2014.10.02.124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 08/08/2014] [Indexed: 11/24/2022]
Abstract
As glycaemic control deteriorates with the progression of type 2 diabetes, treatment guidelines advocate starting basal insulin therapy, and then progressing to a basal-bolus regimen as needed. Nevertheless, although timely intensification of therapy is important to minimise the risk of diabetic complications, considerable clinical inertia exists, not only in the initiation of insulin but also in the progression to multiple-dose insulin regimens. One barrier has been the lack of guidance about how to make the transition from basal-only to basal-bolus insulin therapy. In this review, we discuss how data from the recent FullSTEP study, along with other randomised studies, will help to bridge this gap. Prandial boluses can be added to basal insulin in a stepwise manner, using a straightforward, patient-led dose titration approach and simple estimation of which meal to add the initial prandial bolus to. Reducing the complexity of progression to multiple-dose insulin regimens and empowering patients will lessen the burden on clinicians, improve treatment satisfaction and facilitate timely implementation of treatment guidelines.
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Affiliation(s)
- W Rodbard Helena
- Medical Director, Endocrine and Metabolic Consultants, Rockville, Maryland, US
| | - Boris Karolicki
- Medical Director, Novo Nordisk Inc., Princeton, New Jersey, US
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Stoops WW, Rush CR. Combination pharmacotherapies for stimulant use disorder: a review of clinical findings and recommendations for future research. Expert Rev Clin Pharmacol 2014; 7:363-74. [PMID: 24716825 DOI: 10.1586/17512433.2014.909283] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Despite concerted efforts to identify a pharmacotherapy for managing stimulant use disorders, no widely effective medications have been approved. Innovative strategies are necessary to develop successful pharmacotherapies for stimulant use disorders. This manuscript reviews human laboratory studies and clinical trials to determine whether one such strategy, use of combination pharmacotherapies, holds promise. The extant literature shows that combination pharmacotherapy produced results that were better than placebo treatment, especially with medications shown to have efficacy as monotherapies. However, many studies did not compare individual constituents to the combination treatment, making it impossible to determine whether combination treatment is more effective than monotherapy. Future research should systematically compare combined treatments with individual agents using medications showing some efficacy when tested alone.
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Affiliation(s)
- William W Stoops
- Department of Behavioral Science, University of Kentucky, College of Medicine, Medical Behavioral Science Building, Lexington, KY 40536, USA
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Bailey T. Options for combination therapy in type 2 diabetes: comparison of the ADA/EASD position statement and AACE/ACE algorithm. Am J Med 2013; 126:S10-20. [PMID: 23953074 DOI: 10.1016/j.amjmed.2013.06.009] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Treating patients with diabetes is one of the most challenging and important activities a physician (primary care physician or specialist) can undertake. A key to successful therapy for type 2 diabetes is the insight that this condition is progressive and that the need for additional agents over time is normative. The ability to individualize therapy by patient and medication characteristics comes from experience and knowledge of pertinent clinical studies. However, guidelines from expert bodies such as the American Diabetes Association/European Association for the Study of Diabetes and American Association of Clinical Endocrinologists/American College of Endocrinology can help clinicians of all levels of expertise to approach therapy choices more rationally. There is unity across these guidelines about the role and benefits of metformin as first-line pharmacological treatment, probability of good efficacy, low risk of hypoglycemia, modest weight loss, and overall long-term data. Unfortunately, this unity does not extend to recommendations for subsequent pharmacological agents and their use in combination to intensify treatment when insulin is not (yet) appropriate. Across both statements, some drug classes seem more prominent, and looking at their benefit-risk profile, it is clear why this is the case. The most profound recent change in diabetes therapy has been the introduction of incretin therapies. Incretin therapies minimize 2 important adverse effects seen with many other therapies: hypoglycemia and weight gain. These agents have increased the range of options available for early intensification of treatment of type 2 diabetes. In combination with more established therapies, there are more opportunities than ever to accommodate patient preferences while improving glycemic control and harnessing extraglycemic benefits of a second (or third) agent.
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Abstract
Primary care practitioners are increasingly responsible for the management of the escalating numbers of patients with type 2 diabetes. The majority of these patients will require insulin replacement therapy as their disease progresses, because glycemic control is often unsustainable using oral antidiabetic drugs. This review explains the practicalities of initiating and optimizing basal insulin in clinical practice, emphasizing the need for regular glycated hemoglobin (A1c) monitoring to allow timely initiation of insulin when the A1c target is not met. The importance of patient education in overcoming barriers to insulin is discussed, as well as the choice of available basal insulins and the necessity to optimize basal insulin dosage by self-titration. The traditional view of insulin therapy as a last resort is challenged with the modern basal insulin analogues (insulin detemir and insulin glargine), which offer simple and effective glycemic control with a reduced risk of hypoglycemia compared with older insulin formulations such as neutral protamine Hagedorn.
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