Advancing therapy in type 2 diabetes mellitus with early, comprehensive progression from oral agents to insulin therapy

Modern Challenges in Type 2 Diabetes: Balancing New Medications with Multifactorial Care

Type 2 diabetes mellitus (T2DM) is a prevalent chronic metabolic disorder characterized by insulin resistance and progressive beta cell dysfunction, presenting substantial global health and economic challenges. This review explores recent advancements in diabetes management, emphasizing novel pharmacological therapies and their physiological mechanisms. We highlight the transformative impact of Sodium-Glucose Cotransporter 2 inhibitor (SGLT2i) and Glucagon-Like Peptide 1 Receptor Agonist (GLP-1RA), which target specific physiological pathways to enhance glucose regulation and metabolic health. A key focus of this review is tirzepatide, a dual agonist of the glucose-dependent insulinotropic polypeptide (GIP) and GLP-1 receptors. Tirzepatide illustrates how integrating innovative mechanisms with established physiological pathways can significantly improve glycemic control and support weight management. Additionally, we explore emerging treatments such as glimins and glucokinase activators (GKAs), which offer novel strategies for enhancing insulin secretion and reducing glucose production. We also address future perspectives in diabetes management, including the potential of retatrutide as a triple receptor agonist and evolving guidelines advocating for a comprehensive, multifactorial approach to care. This approach integrates pharmacological advancements with essential lifestyle modifications-such as dietary changes, physical activity, and smoking cessation-to optimize patient outcomes. By focusing on the physiological mechanisms of these new therapies, this review underscores their role in enhancing T2DM management and highlights the importance of personalized care plans to address the complexities of the disease. This holistic perspective aims to improve patient quality of life and long-term health outcomes.

A retrospective comparison between intensive and nonintensive insulin regimens in type 2 diabetes mellitus

BACKGROUND

This study compared the outcomes between intensive and nonintensive insulin regimens and assessed the predictive factors for failing to achieve the glycated hemoglobin (A1C) goals in type-2-diabetes-mellitus (T2DM) patients requiring insulin therapy.

METHODS

A single-center, retrospective assessment of the medical records of 125 T2DM patients undergoing intensive (46 patients) and nonintensive insulin therapy (79 patients) were conducted.

RESULTS

No significant differences were found when the intensive and nonintensive insulin therapy groups were compared in terms of the percentage decreases of glucose and A1C levels. The mean A1C levels of the nonintensive and intensive groups declined from 11.15% and 11.30% to 7.97% and 8.06%, respectively.

CONCLUSIONS

Both intensive and nonintensive insulin therapies improved the baseline glycemic parameters but being overweight or obese and/or being reluctant to dietary recommendations led to treatment failures regardless of the insulin regimen.

Efficacy and safety of a basal insulin + 2-3 oral antihyperglycaemic drugs regimen versus a twice-daily premixed insulin + metformin regimen after short-term intensive insulin therapy in individuals with type 2 diabetes: The multicentre, open-label, randomized controlled BEYOND-V trial

AIM

To compare the efficacy and safety of basal insulin glargine 100 units/ml (Gla) + 2-3 oral antihyperglycaemic drugs (OADs) with twice-daily premixed insulin aspart 70/30 (Asp30) + metformin (MET) after short-term intensive insulin therapy in adults with type 2 diabetes in China.

MATERIALS AND METHODS

This open-label trial enrolled insulin-naïve adults with type 2 diabetes and an HbA1c of 7.5%-11.0% (58-97 mmol/mol) despite treatment with 2-3 OADs. All participants stopped previous OADs except MET, then received short-term intensive insulin therapy during the run-in period, when those with a fasting plasma glucose of less than 7.0 mmol/L and 2-hour postprandial glucose of less than 10.0 mmol/L were randomized to Gla + MET + a dipeptidyl peptidase-4 inhibitor or twice-daily Asp30 + MET. If HbA1c was more than 7.0% (>53 mmol/mol) at week 12, participants in the Gla group were added repaglinide or acarbose, at the physician's discretion, and participants in the Asp30 group continued to titrate insulin dose. The change in HbA1c from baseline to week 24 was assessed in the per protocol (PP) population (primary endpoint).

RESULTS

There were 384 enrollees (192 each to Gla and Asp30); 367 were included in the PP analysis. The threshold for non-inferiority of Gla + OADs versus Asp30 + MET was met, with a least squares mean change from baseline in HbA1c of -1.72% and -1.70% (-42.2 and -42.1 mmol/mol), respectively (estimated difference -0.01%; 95% CI -0.20%, 0.17% [-0.1 mmol/mol; 95% CI -2.2, 1.9]). Achievement of HbA1c less than 7.0% (<53 mmol/mol) was comparable between the groups (60% vs. 57%). The proportion of participants with any (24% vs. 38%; P = .003), symptomatic (19% vs. 31%; P = .007) or confirmed hypoglycaemia (18% vs. 33%; P < .001) was lower in the Gla + OADs group.

CONCLUSIONS

Compared with Asp30 + MET, Gla + 2-3 OADs showed similar efficacy but a lower hypoglycaemia risk in Chinese individuals with type 2 diabetes who had undergone short-term intensive insulin therapy.

Perception towards Insulin Therapy and Factors Related to Insulin Refusal among Insulin Naive Type 2 Diabetes Mellitus Patients in Primary Care Clinics PKD Lipis

Introduction: Insulin is one of the suggested treatments to prevent and reduce long-term diabetes complications. However, due to many factors such as socio-demographic factors, many Type 2 diabetes mellitus patients refuse this treatment. This study aimed to determine perception towards insulin among naive Type 2 diabetes mellitus patients, to calculate the prevalence of rejecting insulin therapy, and to find out factors related to the refusal. Materials and methods: This cross-sectional study involved 188 insulin naive Type 2 diabetes mellitus patients attending five primary health clinics in Lipis district, Pahang from October to November 2017. A five-point Likert Scale was used to determine perception towards insulin therapy and the Chi-square test was used to assess the proportion of acceptance of the therapy. Simple and multiple logistic regressions were utilised to study the associated factor(s). Results: Mean score of 60.5 ± 8.2 pointed towards a negative appraisal of insulin therapy. Embarrassment to inject in public (69.1%) and concern of frequent hypoglycaemia (52.7%) were the most common perception. Nearly half of the respondents (46.3%) refused insulin therapy upon suggestion. After adjusting the variables using multiple logistic regressions, only gender (Adjusted OR=0.20, 95% CI=0.10-0.40, p<0.001), educational level (Adjusted OR=0.17, 95% CI=0.06-0.50, p=0.001), age (Adjusted OR=1.04, 95% CI=1.01-1.08, p=0.012) and glycated haemoglobin level (Adjusted OR=1.33, 95% CI=1.07-1.67, p=0.013) remained significant. Conclusion: In conclusion, insulin refusal among insulin naive patients was common in Lipis with an overall negative perception towards therapy. By tailoring strategies according to the patient’s factors such as gender, educational level, age, and glycated haemoglobin level, the insulin refusal rate might decrease in the future.

Efficacy and Safety of Basal Insulin-Based Treatment Versus Twice-Daily Premixed Insulin After Short-Term Intensive Insulin Therapy in Patients with Type 2 Diabetes Mellitus in China: Study Protocol for a Randomized Controlled Trial (BEYOND V)

INTRODUCTION

Many Chinese patients who are uncontrolled by oral antidiabetic drugs (OADs) receive short-term intensive insulin therapy (IIT) in hospital to rapidly relieve glucose-associated toxicity and to preserve/improve β-cell function. However, evidence for optimizing insulin algorithms for maintenance treatment after IIT is lacking. This study will compare the efficacy and safety of basal insulin-based treatment versus twice-daily premixed insulin in type 2 diabetes mellitus (T2DM) patients after short-term in-hospital IIT.

METHODS

This 26-week randomized, multicenter, positive-controlled, open-label, parallel-group study will enroll approximately 400 male and female patients aged 18-70 years with poorly-controlled T2DM (HbA1c > 7.5%) despite treatment with metformin plus at least one other OAD for 8 or more weeks. During a run-in period of 7-10 days, patients will be treated in-hospital with IIT comprising insulin glargine (Lantus^®) once daily and insulin glulisine (Apidra^®) three times daily; both regimens will be titrated daily to achieve the glycemic goal. Eligible patients will then be randomized in a 1:1 ratio to insulin glargine plus OADs or twice-daily premixed insulin (NovoLog^® Mix 70/30) for 24 weeks, with metformin maintained throughout the study in both treatment groups. The primary endpoint is HbA1c change from baseline to week 24. Secondary endpoints include assessment of fasting plasma glucose, total daily insulin dose, hypoglycemia incidence, body weight change, adverse events, and patient satisfaction.

DISCUSSION

Given the current lack of clinical data, this study will provide evidence supporting safe and effective glycemic control using basal insulin glargine-based therapy plus OADs compared with twice-daily premixed insulin in Chinese patients with T2DM after short-term IIT. This will assist physicians by providing a wider choice of treatments.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT03359837 (registered on 2 December 2017).

Metabolic memory phenomenon in diabetes mellitus: Achieving and perspectives

Diabetes mellitus (DM) exhibits raised prevalence worldwide. There is a large body of evidence regarding the incidence of DM closely associates with cardiovascular (CV) complications. In this context, hyperglycaemia, oxidant stress, and inflammation are key factors that contribute in CV events and disease in type1 and type 2 DM, even when metabolic control was optimal and/or intensive glycemic control was implemented. It has been suggested that the effect of poor metabolic control or even transient episodes of hyperglycemia in DM associates in particularly with worsening ability of endogenous vasoreparative systems that are mediated epigenetic changes in several cells (progenitor cells, stem cells, mononuclears, immune cells), and thereby lead to so called "vascular glycemic memory" or "metabolic memory". Both terms are emphasized the fact that prior glucose control has sustained effects that persist even after return to more usual glycemic control. The mechanisms underlying the cellular "metabolic memory" induced by high glucose remain unclear. The review is discussed pathophysiology and clinical relevance of "metabolic" memory phenomenon in DM. The role of oxidative stress, inflammation, and epigenetics in DM and its vascular complications are highlighted. The effects of several therapeutic approaches are discussed.

Hypoglycemia in Diabetes Mellitus as a Coronary Artery Disease Risk Factor in Patients at Elevated Vascular Risk

CONTEXT

Although clinical trials have shown that hypoglycemia is associated with coronary artery disease (CAD), little is known whether hypoglycemia is a CAD risk factor in primary care.

OBJECTIVE

We sought to determine whether previous hypoglycemia was associated with incident CAD, and whether this association differed in patients of different underlying vascular risk.

DESIGN, SETTING AND PARTICIPANTS

This is a longitudinal cohort study of diabetes patients without CAD before January 1, 2006 (n = 9173) followed at an academic network of 13 primary care practices from January 1, 2006 to June 30, 2012. Hypoglycemic events before January 1, 2006 were identified via International Classification of Diseases Ninth Revision codes from emergency department, inpatient and outpatient visits.

MAIN OUTCOME MEASURE

Patients were followed until incident CAD or June 30, 2012. Cox regression with time interaction was used to determine the association between hypoglycemia and CAD (significance set at P ≤ .05). We then tested the association among high vascular risk patients (age ≥ 55 y, hemoglobin A1c ≥ 7.5%, ≥2 risk factors [dyslipidemia, hypertension or obesity]), a subset of high vascular risk patients aged 65 years or older, and the remaining patients with lower vascular risk.

RESULTS

Three percent of patients (n = 285) had previous hypoglycemia. Hypoglycemia was associated with a 2-fold CAD risk (hazard ratio [HR] 2.15; 95% confidence interval [95%CI] 1.24-3.74), adjusting for time interaction and vascular risk factors. Among high vascular risk patients, the risk was 3-fold (HR 3.01 [95%CI 1.15-7.91], n = 1823 [20% of cohort]), and over 4-fold (HR 4.62 [95%CI 1.65-12.9], n = 996) in the subset aged more than or equal to 65 years. No association was found in the remaining 80% of the cohort with lower vascular risk.

CONCLUSIONS

Previous hypoglycemia was associated with CAD among high vascular risk patients. Hypoglycemia may not be a CAD risk factor for the majority of primary care patients with lower underlying vascular risk.

Assessment of glycemic control in patients with type 2 diabetes mellitus treated with metformin-sulfonylurea combination: Results of a multicenter, cross-sectional, observational study in Korea

AIMS/INTRODUCTION

To assess the current status of glycemic control in patients with type 2 diabetes treated with a combination of metformin and sulfonylurea for >3 months, as measured by glycosylated hemoglobin (HbA1c).

MATERIALS AND METHODS

Data on patient demographics, diabetic complications, HbA1c, fasting plasma glucose (FPG) and type of treatment were collected in this multicenter, cross-sectional, non-interventional study.

RESULTS

From April 2008 to February 2009, 5,628 patients were recruited from 299 centers in Korea. Patients characteristics (mean ± SD) were as follows: age 58.4 ± 10.8 years, duration of diabetes 6.1 ± 4.7 years, body mass index 24.7 ± 2.9 kg/m(2), HbA1c 7.77 ± 1.22%, FBG 147.4 ± 46.5 mmol/L and FPG 164.0 ± 54.3 mmol/L. The most common diabetic complication was neuropathy (22.5%), followed by retinopathy (18.3%) and microalbuminuria (16.1%). Just 1,524 (27.1%) patients achieved HbA1c ≤7%. A higher number of patients (32.6%) treated by endocrinologists achieved HbA1c ≤7% than those treated by internists (24.4%) and primary care physicians (23.2%). In multivariate analyses, diabetic retinopathy (odds ratio 0.455, 95% confidence interval 0.341-0.606), nephropathy (odds ratio 0.639, 95% confidence interval 0.43-0.949), diabetes for ≥5 years (odds ratio 0.493, 95% confidence interval 0.4-0.606) and older age added by 1 year (odds ratio 1.019, 95% confidence interval 1.01-1.029) was significantly associated with achieving target HbA1c. In addition, treatment by endocrinologists rather than internists significantly increased chances of achieving target HbA1c (odds ratio 1.417, 95% confidence interval 1.146-1.751).

CONCLUSIONS

The majority of patients with type 2 diabetes in Korea had inadequate glycemic control, despite receiving a combination of metformin and sulfonylurea.

Impact of family support improvement behaviors on anti diabetic medication adherence and cognition in type 2 diabetic patients

BACKGROUND

Glycaemic control is the main goal of treatment for type 2 diabetic patients. Hyperglycaemia may result in cognitive decline. More family support may increase medication adherence and decrease glycaemic level. The purpose of this study was to determine the impact of family support improvement behavior on anti diabetic medication adherence and cognition in type 2 diabetic patients.

METHOD

The randomized control trial study was conducted on 91 patients from an outpatient diabetes clinic. They were randomly divided to intervention (n = 45) and control (n = 46) group. Data on the patients' demographic information and their family gathered using a questionnaire, For two groups Morisky Medication Adherence Scale (MMAS), drug administration part of Diabetes Social Support Questionnaire - family version (DSSQ), Number Connection Test (NCT) were applied and hemoglobin A1C was measured two times in the onset of study and three months later for control group and before and after intervention for intervention group. The key family members of the intervention group were taught according to their educational needs in small groups.

RESULT

In intervention group mean of NCT score was significantly decreased after intervention (P = 0.006) however in the control group there was no significant difference after three months. In intervention group a significant correlation was noted between DSSQ scores and MMAS scores after intervention(r =0.67, P < 0.001) but, there was no significant correlation in the control group.

CONCLUSION

Family support instruction based on the educational needs of family members, may improve medication adherence through direct effect and cognitive status with indirect effect.

Duration of diabetes and effectiveness of insulin in the management of insulin-naïve Korean patients uncontrolled on oral antidiabetic drugs: a sub-analysis of the MOdaliTy of Insulin treatment eValuation (MOTIV) registry results

To investigate whether duration of diabetes has an impact on the effectiveness of insulinization in diabetes management. This open-label, noninterventional, observational registry was conducted at >500 centers in Korea. Patients with diabetes, on oral antidiabetic drugs, with HbA1c ≥7 % (53 mmol/mol) in the preceding 3 months, being considered for initiation of basal insulin by their physicians, were included. Data were collected at baseline and at 3 and 6 months. Of 6,616 patients evaluated, 62.5 % had diabetes for <10 years, while only 6.5 % patients had diabetes for ≥20 years. At the end of study, average HbA1c in patients with diabetes for <10 years, for 10 to <20 years, and for ≥20 years was 7.3 ± 1.0 % (56 ± 10.9 mmol/mol), 7.4 ± 1.0 % (57 ± 10.9 mmol/mol), and 7.6 ± 1.1 % (60 ± 12.0 mmol/mol), respectively. Over half the patients (50.7 %) with diabetes <10 years achieved HbA1c <7 % (53 mmol/mol) by the end of study, while only 42.1 and 35.1 % patients with diabetes for 10 to <20 and ≥20 years, respectively, achieved their target. The average insulin dosage required for per unit HbA1c reduction was significantly different among the groups according to duration of type 2 diabetes mellitus (p < 0.05). Among patients who achieved HbA1c <7 %, proportion of patients with hypoglycemia in the ≥20 years group was higher than that in the <10 years, 10 to <20 years groups. Early insulin administration provided a better glycemic control with less insulin dosage and lower frequency of hypoglycemic events. Thus, early insulinization might hold the key to better management of type 2 diabetes mellitus.

North American Ginseng (Panax quinquefolius) prevents hyperglycemia and associated pancreatic abnormalities in diabetes

North American ginseng (NAG) has received increasing attention as an alternative medicine for the treatment of diabetes. Extract of the NAG root has been reported to possess antidiabetic properties, but the underlying mechanisms for such effects have not been identified. Here we investigated the effects of NAG root extract on type 1 and 2 diabetes and the underlying mechanisms involved for such effects. Type 1 [C57BL/6 mice with streptozotocin (STZ)-induction] and type 2 (db/db) diabetic models were examined. Groups of diabetic mice (both type 1 and 2) were treated with alcoholic extract of the NAG root (200 mg/kg BW/day, oral gavage) for 1 or 2 months following onset of diabetes. Ginseng treatment significantly increased the body weight in type 1 diabetic animals in contrast to the type 2 model, where it caused diminution of body weight. Blood glucose and glycated hemoglobin levels diminished in the diabetic groups of both models with NAG treatment. Interestingly, plasma insulin and C-peptide levels were significantly increased in the STZ-diabetic mice, whereas they were reduced in the db/db mice following NAG treatment. Histological and morphometric analyses (islet/pancreas ratio) of the pancreas revealed an increase in the islet area following the treatment compared to both the untreated diabetic groups. These data indicate that NAG possibly causes regeneration of β-cells resulting in enhanced insulin secretion. On the other hand, in type 2 diabetes, the additional effects of NAG on body weight might have also resulted in improved glucose control.

Development and validation of the Chinese Attitudes to Starting Insulin Questionnaire (Ch-ASIQ) for primary care patients with type 2 diabetes

OBJECTIVES

To develop and evaluate the psychometric properties of a Chinese questionnaire which assesses the barriers and enablers to commencing insulin in primary care patients with poorly controlled Type 2 diabetes.

RESEARCH DESIGN AND METHOD

Questionnaire items were identified using literature review. Content validation was performed and items were further refined using an expert panel. Following translation, back translation and cognitive debriefing, the translated Chinese questionnaire was piloted on target patients. Exploratory factor analysis and item-scale correlations were performed to test the construct validity of the subscales and items. Internal reliability was tested by Cronbach's alpha.

RESULTS

Twenty-seven identified items underwent content validation, translation and cognitive debriefing. The translated questionnaire was piloted on 303 insulin naïve (never taken insulin) Type 2 diabetes patients recruited from 10 government-funded primary care clinics across Hong Kong. Sufficient variability in the dataset for factor analysis was confirmed by Bartlett's Test of Sphericity (P<0.001). Using exploratory factor analysis with varimax rotation, 10 factors were generated onto which 26 items loaded with loading scores > 0.4 and Eigenvalues >1. Total variance for the 10 factors was 66.22%. Kaiser-Meyer-Olkin measure was 0.725. Cronbach's alpha coefficients for the first four factors were ≥0.6 identifying four sub-scales to which 13 items correlated. Remaining sub-scales and items with poor internal reliability were deleted. The final 13-item instrument had a four scale structure addressing: 'Self-image and stigmatization'; 'Factors promoting self-efficacy; 'Fear of pain or needles'; and 'Time and family support'.

CONCLUSION

The Chinese Attitudes to Starting Insulin Questionnaire (Ch-ASIQ) appears to be a reliable and valid measure for assessing barriers to starting insulin. This short instrument is easy to administer and may be used by healthcare providers and researchers as an assessment tool for Chinese diabetic primary care patients, including the elderly, who are unwilling to start insulin.

Factors influencing insulin acceptance among type 2 diabetes mellitus patients in a primary care clinic: a qualitative exploration

BACKGROUND

Many Type 2 Diabetes Mellitus (T2DM) patients refuse insulin therapy even when they require this modality of treatment. However, some eventually accept insulin. This study aimed to explore the T2DM patients' reasons for accepting insulin therapy and their initial barriers to use insulin.

METHODS

This qualitative study interviewed twenty-one T2DM patients at a primary care clinic who had been on insulin for more than a year through three in-depth interviews and three focus group discussions. A semi structured interview protocol was used and the sessions were audio-recorded. Subsequently, thematic analysis was conducted to identify major themes.

RESULTS

The participants' acceptance of insulin was influenced by their concerns and beliefs about diabetes and insulin. Concerns about complications of poorly controlled diabetes and side effects of other treatment regime had resulted in insulin acceptance among the participants. They also had a strong belief in insulin benefits and effectiveness. These concerns and beliefs were the results of having good knowledge about the diabetes and insulin, experiential learning, as well as doctors' practical and emotional support that helped them to accept insulin therapy and become efficient in self-care management. These factors also allayed their negative concerns and beliefs towards diabetes and insulin, which were their barriers for insulin acceptance as it caused fear to use insulin. These negative concerns were related to injection (self-injection, needle phobia, injection pain), and insulin use (inconvenience, embarrassment, lifestyle restriction, negative social stigma, and poor self-efficacy), whereas the negative beliefs were 'insulin could cause organ damage', 'their diabetes was not serious enough', 'insulin is for life-long', and 'insulin is for more severe disease only'.

CONCLUSIONS

Exploring patients' concerns and beliefs about diabetes and insulin is crucial to assist physicians in delivering patient-centered care. By understanding this, physicians could address their concerns with aim to modify their patients' misconceptions towards insulin therapy. In addition, continuous educations as well as practical and emotional support from others were found to be valuable for insulin acceptance.

TRIAL REGISTRATION

Universiti Kebangsaan Malaysia FF-214-2009.

Evidence for central regulation of glucose metabolism

Evidence for central regulation of glucose homeostasis is accumulating from both animal and human studies. Central nutrient and hormone sensing in the hypothalamus appears to coordinate regulation of whole body metabolism. Central signals activate ATP-sensitive potassium (KATP) channels, thereby down-regulating glucose production, likely through vagal efferent signals. Recent human studies are consistent with this hypothesis. The contributions of direct and central inputs to metabolic regulation are likely of comparable magnitude, with somewhat delayed central effects and more rapid peripheral effects. Understanding central regulation of glucose metabolism could promote the development of novel therapeutic approaches for such metabolic conditions as diabetes mellitus.

Predictors of achieving HbA(1c) <7% and no hypoglycaemia 6 months after initiation of biphasic insulin aspart 30 in patients with type 2 diabetes in the IMPROVE study

BACKGROUND

Early initiation of insulin therapy has widely been associated with numerous benefits, including improved glycaemic control and reduced long-term risk of developing microvascular diseases. Biphasic insulins offer a convenient option for insulin initiation, addressing both basal and postprandial insulin requirements with one injection, making them relatively simple for patients to dose. Development of biphasic insulin aspart (BIAsp) has further offered improved postprandial glycaemic control and lower rates of nocturnal and major hypoglycaemia than biphasic human insulin.

METHODS

The safety and efficacy of the 30/70 rapid-acting/intermediate-acting formulation of BIAsp (BIAsp 30) in patients with type 2 diabetes was examined in the IMPROVE study, a 26-week, international, observational trial. In this subanalysis, baseline clinical factors that predicted treatment success, defined as HbA1c <7% (<53 mmol/mol) without experiencing hypoglycaemia after 26 weeks on BIAsp 30 therapy, were assessed.

RESULTS

The composite endpoint was defined for 44,010 (77%) patients from the total cohort of 57,478, and 28,696 of these were included in the statistical examination. The results of the analysis suggest that those with lower baseline HbA1c of ≤8% (≤64 mmol/mol), shorter duration of diabetes at baseline (<5 years) and no incidence of major hypoglycaemia at 13 weeks, or minor hypoglycaemia at 4 weeks, before the beginning of the trial were more likely to achieve treatment success.

CONCLUSION

Lower baseline HbA1c, shorter duration of diabetes and no incidence of hypoglycaemia up to 13 weeks prior to initiation are predictors of achieving HbA1c <7% without hypoglycaemia with a BIAsp 30 regimen. These results suggest that it is easier to reach target without hypoglycaemia with BIAsp 30 when prescribed earlier. As this was an observational study, lack of control groups or randomisation, as well as varying clinical practices in study countries, potentially introduced bias.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00659282.

Effects of glucocorticoids and exercise on pancreatic β-cell function and diabetes development

Peripheral insulin resistance and pancreatic β-cell dysfunction are hallmark characteristics of type 2 diabetes mellitus (T2DM). Several contributing factors have been proposed to promote these two defects in individuals with T2DM, including physical inactivity and chronic exposure to various psychosocial factors that increase the body's exposure to glucocorticoids, the main stress hormones in humans. Initially, β-cells have been shown to adapt to these stimuli, a phenomenon known as β-cell 'compensation'. However, long-term exposure to these physiologic and psychological stressors induces islet failure. Interestingly, glucocorticoids stimulate β-cell mass growth in parallel with promoting severe insulin resistance, the former being an important adaptive response to the latter. The direct relationship between glucocorticoids and β-cell dysfunction remains a controversial area of research. Elevations in circulating and/or tissue specific glucocorticoids have been associated with the development of obesity and T2DM in human and rodent models; however, the progression from insulin resistance to overt T2DM is highly disputed with respect to the in vivo and in vitro effects of glucocorticoids. Paradoxically, both intermittent physical stress and regular exercise alleviate insulin resistance and help to preserve β-cell mass, potentially by lowering glucocorticoid levels. Recent studies have begun to examine the mechanisms of intermittent and chronic glucocorticoid exposure and regular exercise in altering β-cell function. This review highlights recent discoveries on the physiological regulation of β-cells and diabetes development in conditions of elevated glucocorticoids, regular exercise and intermittent stress.

The economic and clinical benefits of adequate insulin initiation and intensification in people with type 2 diabetes mellitus

AIM

To study the clinical and economic benefits associated with adequate and early initiation and intensification of insulin in people with type 2 diabetes mellitus (T2DM).

METHODS

A systematic review was performed using published articles from January 2000 to August 2010 that linked intervention, disease, study design and outcomes. Studies were further classified as initiation and intensification based on predefined criteria. Individual studies in systematic reviews and meta-analysis were searched and included if relevant.

RESULTS

A total of 2690 articles were screened with 76 (40 initiation and 36 intensification) studies included. Most initiation studies had mean baseline HbA1c values of >8.5%. The endpoint HbA1c values were reduced with insulin treatment in these studies, with endpoint values ranging from 6.6 to 9.8%. Similar results were seen with the intensification studies (endpoint HbA1c: 6.4-9.6%). Addition of insulin to oral antidiabetics (OADs) resulted in better glycaemic control in most studies. Blood glucose levels reduced substantially with OADs + insulin compared with OADs alone. Quality of life outcomes and treatment satisfaction were reported in six studies and not significantly different for insulin vs. OADs. Hypoglycaemic events were manageable with insulin initiation. However, all insulin types were associated with weight gain although the comparison with OADs elicited varying results.

CONCLUSIONS

Proactive management with early insulin initiation and intensification should be considered in people with T2DM in inadequate glycaemic control. The economic benefits with early initiation and intensification have to be fully explored.

Optimizing insulin glargine plus one injection of insulin glulisine in type 2 diabetes in the ELEONOR study: similar effects of telecare and conventional self-monitoring of blood glucose on patient functional health status and treatment satisfaction

OBJECTIVE

To determine the functional health status and treatment satisfaction in patients with type 2 diabetes from the Evaluation of Lantus Effect ON Optimization of use of single dose Rapid insulin (ELEONOR) study that investigated whether a telecare program helps optimization of basal insulin glargine with one bolus injection of insulin glulisine.

RESEARCH DESIGN AND METHODS

Functional health status and treatment satisfaction were investigated using the 36-Item Short-Form (SF-36) Health Survey, the World Health Organization Well-Being Questionnaire (WBQ), and the Diabetes Treatment Satisfaction Questionnaire.

RESULTS

Of 291 randomized patients, 238 completed the study (telecare: 114; self-monitoring blood glucose: 124). Significant improvements were detected in most SF-36 domains, in WBQ depression and anxiety scores, and in treatment satisfaction, without differences between study groups.

CONCLUSIONS

An insulin regimen that substantially improves metabolic control, while minimizing the risk of hypoglycemia, can positively affect physical and psychologic well-being and treatment satisfaction irrespective of the educational support system used.

Weight and glycaemic control in type 2 diabetes: what is the outcome of insulin initiation?

AIMS

Little information is available on the association between obesity at time of insulin initiation and attainment of glycaemic targets in type 2 diabetic (T2DM) patients. This study describes changes in HbA1c, weight and body mass index (BMI) over 24 months postinsulin initiation.

METHODS

First-time insulin users with T2DM were selected from the UK General Practice Research Database for the period 1st January 2002 to 31st March 2008. The cohort was stratified into BMI categories (kg/m(2) ) at the time of insulin initiation. Data were reviewed at 6-monthly intervals. A multivariate repeated-measures linear model was fitted assessing weight change over 12 months.

RESULTS

3783 patients were included (normal weight, n = 672; overweight, n = 1259; obese, n = 1070; clinically obese, n = 480; morbidly obese, n = 302). The largest reductions in HbA1c were observed 6 months postinsulin initiation and were greatest in lower BMI categories: median observed HbA1c at initiation and 6 months was 9.7 and 7.9% in normal weight patients and 9.6 and 8.2% in the clinically obese, respectively. A minority of patients achieved HbA1c ≤ 7.5% and by 24 months the proportion achieving this was: normal weight 41%; overweight 34%; obese 30%; clinically obese 26%; morbidly obese 31%; trend p < 0.001. The greatest weight gain occured by 6 months and multivariate adjusted models showed that normal weight patients had the highest gains 5.07 kg (95% CI: 3.35, 6.79), as did those with HbA1c ≥ 12.1%-5.55 kg (95% CI: 3.81, 7.28).

CONCLUSION

Obesity is associated with a poorer response to insulin illustrated by higher HbA1c values and lower achievement of targets.

Evidence-based risk assessment and recommendations for physical activity clearance: diabetes mellitus and related comorbidities1This paper is one of a selection of papers published in this Special Issue, entitled Evidence-based risk assessment and recommendations for physical activity clearance, and has undergone the Journal’s usual peer review process

Physical activity (PA) is one of the most powerful treatment options for persons with prediabetes or diabetes. However, some elevation in risk occurs with increased PA, at least initially, and certain precautions need to be made to lower these risks, particularly if these persons are unaccustomed to exercise. We conducted a standardized search of all adverse events associated with increased PA in persons with prediabetes or diabetes (type 1 or type 2) and provided evidence-based guidelines on PA screening in these apparently high-risk individuals. A systematic literature review was performed of all studies reporting on adverse events in persons with prediabetes or diabetes. Studies included were from all designs (retrospective and prospective including randomized controlled trials) and were assessed according to evaluation criteria adapted by a consensus panel. A total of 47 studies, involving >8000 individuals, were deemed eligible. A number of these studies identified a range of mild to severe acute risks with exercise (musculoskeletal injury, hypoglycemia, foot ulceration, proliferative retinopathy, hypotension, sudden death) but the overall prevalence was low. Based on several randomized controlled trials and prospective studies in which prescribed exercise was performed at a wide range of intensities, it appears that increased PA is a relatively safe procedure with no evidence of a loss of life. Based on our assessment of the available literature, we provide a new PA risk algorithm for persons with prediabetes and diabetes and comment on the role of the patient, the qualified exercise professional, and the patient’s physician in the risk screening process.

Successes and challenges of insulin therapy for type 2 diabetes in a managed-care setting

OBJECTIVE

Although insulin is the most effective diabetes medication for lowering blood glucose, how insulin is used in clinical practice and how well patients respond to insulin therapy over the course of several years has not been documented. Our objective was to describe glycemic control, side-effects and dose titration over 7 years among persons starting insulin in a health plan that has long used a treatment algorithm similar to the current American Diabetes Association/European Association for the Study of Diabetes (ADA-EASD) algorithm for the management of hyperglycemia.

RESEARCH DESIGN AND METHODS

Patients (n = 2417) who initiated insulin therapy between 1 January 1999 and 31 December 2004 were followed for a mean of 49.5 months until 30 June 2007, death, or health plan termination. Mean hemoglobin A1C, number of units of insulin purchased and body weight were assessed on a quarterly basis. The proportion experiencing edema or hypoglycemia was assessed annually.

RESULTS

Mean population A1C declined from 9.3 to 7.8% following insulin initiation and remained at that level for 7 years. However, A1C remained above 8% for 40% of patients, half of whom remained above 9.0%. The mean individual coefficient of variation in A1C was 0.12 (inter-quartile range 0.072-0.143). Mean daily insulin dosage started at 55 units and increased to approximately 100 units. Patients gained a mean of 6 lb (2.7 kg) during the first year then gained weight more gradually thereafter. Physicians diagnosed edema in 8-9% of patients annually. Hypoglycemia occurred in fewer than 2% of patients in any given year, with no cases requiring hospitalization.

CONCLUSIONS

Insulin lowered mean A1C by about 1.5 percentage points to stable levels, but this required ongoing dosage increases. Nevertheless, many patients remained in poor control. Insulin is effective when used per ADA-EASD guidelines but health plans wishing to optimize diabetes care may need to intensify insulin therapy or consider the use of adjunct therapies in the years after initiation. This study was limited by its observational descriptive design, and its reliance on insulin purchases rather than actual consumption.

Nerve growth factor and expression of its receptors in patients with diabetic neuropathy

AIMS

Low serum nerve growth factor (NGF) levels have been reported in patients with diabetic peripheral neuropathy (DPN), but the role of NGF in the development of neuropathy is unclear. Thus, we investigated the associations of serum NGF level and NGF receptor activity with the presence and severity of DPN.

METHODS

One hundred and thirty-six patients with Type 2 diabetes were included in this cross-sectional study. Serum NGF levels were measured by ELISA. Expressions of NGF receptors (TrkA and p75(NTR)) were measured by immunohistochemical staining. The presence and severity of DPN were assessed by neuropathy disability score (NDS) and by corneal nerve fibre length (cNFL) and nerve branch density (cNBD) using in vivo confocal microscopy.

RESULTS

Patients with DPN had higher serum NGF levels (56-451 pg/ml) than patients without DPN (4-54 pg/ml). However, in DPN patients, serum NGF was negatively associated with neuropathy severity (mild 222 +/- 64 pg/ml; moderate 114 +/- 17 pg/ml; severe 89 +/- 20 pg/ml). This negative association was consistent in all severity indices (NDS, P < 0.001; cNFL, P < 0.001; cNBD P = 0.010) even after adjustment for age, sex, diabetes duration, insulin use, fasting glucose and glycated haemoglobin. Although NGF receptor activities had significantly (P < 0.05) negative associations with the presence and severity of neuropathy, these associations were not significant when adjusted for other factors.

CONCLUSIONS

Serum NGF level was positively associated with the presence of DPN but negatively associated with neuropathy severity in DPN patients. The change in serum NGF might be a consequence of, rather than a contributor to, the early development of DPN.

A comparison of insulin use, glycemic control, and health care costs with insulin detemir and insulin glargine in insulin-naive patients with type 2 diabetes

OBJECTIVES

The goal of this study was to compare daily insulin use, glycemic control, and health care costs in insulin-naive patients with type 2 diabetes who initiated treatment with either insulin detemir or insulin glargine.

METHODS

This was a retrospective cohort analysis of health care claims data and laboratory results for adult, insulin-naive patients with type 2 diabetes who were enrolled in a large US managed care organization and initiated basal therapy with insulin detemir or insulin glargine between May 1, 2006, and December 31, 2006. The daily average consumption (DACON) of insulin was calculated as the total number of units dispensed (excluding the last fill) divided by the number of days between the index date and the date of the last fill of the index insulin. Glycemic control was evaluated by comparing mean glycosylated hemoglobin (HbA(1c)) values in the preindex period (the 180 days before the index date) and the follow-up period (the 180 days after the index date). Mean all-cause and diabetes-related health care costs in the preindex and follow-up periods were calculated and compared.

RESULTS

The analysis included 48 patients initiating therapy with insulin detemir and 258 initiating therapy with insulin glargine. The mean age of the 2 cohorts was approximately 54 years, and most patients in each cohort were male (52.1% and 59.7%, respectively). Few patients in either cohort had a baseline HbA(1c) value <7% (13% and 10%), suggesting poor glycemic control at the time of insulin initiation. After adjustment for confounders (eg, preindex diabetes medication), the DACON of insulin was comparable between cohorts (29.3 and 29.6 U/d; P = NS), as were follow-up HbA(1c) values (8.2% and 7.9%). Insulin detemir and insulin glargine also were associated with comparable mean adjusted all-cause pharmacy costs ($3074 and $2899), medical costs ($2319 and $3704), and total health care costs ($6014 and $7023). However, insulin glargine was associated with significantly higher mean adjusted diabetes-related medical costs compared with insulin detemir ($1510 vs $707, respectively; P = 0.03), as well as significantly higher mean adjusted total diabetes-related health care costs ($3408 vs $2261; P = 0.03).

CONCLUSIONS

In this managed care population of insulin-naive patients who initiated therapy with insulin detemir or insulin glargine, the daily insulin dose and glycemic control did not differ significantly between the 2 insulins. However, patients receiving insulin detemir incurred lower diabetes-related medical and total health care costs.

Obesity, diabetes, and smoking are important determinants of resource utilization in liver resection: a multicenter analysis of 1029 patients

OBJECTIVE

To investigate independent contributions of obesity, diabetes, and smoking to resource utilization in patients following liver resection.

SUMMARY BACKGROUND DATA

Despite being highly resource-intensive, liver resections are performed with increasing frequency. This study evaluates how potentially modifiable factors affect measures of resource utilization after hepatectomy.

METHODS

The American College of Surgeons' National Surgical Quality Improvement Program (ACS NSQIP) public-use database was queried for patients undergoing liver resection. Resource variables were operative time (OT), intraoperative transfusion, length of stay (LOS), ventilator support at 48 hours, and reoperation. Bivariable and multivariable linear and logistic regressions were performed.

RESULTS

There were 1029 patients identified. Most resections involved less than a hemiliver (599 patients, 58.2%). Mean BMI was 28.0 +/- 6.0. Mean OT was 253 +/- 122 minutes (range, 27 to 794) but varied by procedure (P < 0.001). Mean LOS was 8.7 +/- 10.7 days (range, 0 to 202). Morbid obesity added 48 minutes to OT (P = 0.018), 1.1 units to transfusions (P = 0.049), 2.2 days to LOS (P < 0.001), and accounted for delayed ventilator weaning (odds ratio, 4.5; P = 0.022). Underweight patients had shorter OT, but stayed 3.3 days longer than normal weight patients (P < 0.001). Insulin-treated patients with diabetes had longer OT (P < 0.001), increased transfusions (P < 0.001), and delayed ventilator weaning (odds ratio, 6.7; P < 0.001), while orally-treated patients with diabetes showed opposite trends. Smokers stayed 1.9 days longer (P < 0.001), with increased risk of prolonged ventilation (odds ratio, 3.3; P = 0.002) and reoperation (odds ratio, 2.3; P = 0.015).

CONCLUSION

Obesity, diabetes, and smoking are each associated with important components of healthcare expenditure. Education and prevention programs are needed to limit their impact on overall resource utilization.

Insulin glargine provides greater improvements in glycaemic control vs. intensifying lifestyle management for people with type 2 diabetes treated with OADs and 7-8% A1c levels. The TULIP study

AIM

To determine whether earlier administration of insulin glargine (glargine) vs. the intensification of lifestyle management (LM) improves glycaemic control in type 2 diabetes patients with A1c 7-8% treated with oral therapy.

METHODS

TULIP [Testing the Usefulness of gLargine when Initiated Promptly in type 2 diabetes mellitus (T2DM)] was a 9-month, 12-visit, open-label, multinational, multicentre, randomized study to evaluate starting glargine or intensifying LM in T2DM patients aged 40-75 years, body mass index (BMI) 24-35 kg/m2 and A1c 7-8%, treated with maximum doses of metformin and sulphonylurea for > or = 2 years. Glargine was injected once daily (evening) and titrated to fasting blood glucose 0.7-1.0 g/l. In the LM arm, dietary and physical activity counselling recommended stable weight for people with BMI < 27 kg/m2 or weight loss of 3 kg for patients with BMI > or = 27 kg/m2. A total of 215 patients were randomized to glargine (n = 106) or LM (n = 109). The primary objective was patients achieving A1c < 7% at endpoint. Secondary endpoints included changes in A1c, in fasting plasma glucose (FPG), body weight and hypoglycaemia incidence.

RESULTS

Two hundred and eleven (52.6% male) patients were randomized and treated; mean (+/- s.d.) age 60.7 +/- 7.9 years, weight 84.5 +/- 13.1 kg, BMI 29.9 +/- 3.5 kg/m2 and A1c 7.6 +/- 0.4%. More patients reached A1c < 7% (66 vs. 38%; p < 0.0001) or < 6.5% (34 vs. 11%; p = 0.0001) with glargine vs. LM. The change in FPG from baseline to study endpoint was significantly greater in the glargine vs. the LM arm (-0.50 +/- 0.47 vs. -0.05 +/- 0.39 g/l respectively; p < 0.0001). Compared with the glargine group, the LM group showed a decrease in weight (+0.9 +/- 2.9 vs. -2.5 +/- 3.2 kg; p < 0.0001), as well as the expected lower symptomatic hypoglycaemia (55.3 vs. 25.0%; p < 0.0001) and nocturnal hypoglycaemia (20.4 vs. 5.6%; p = 0.0016). No significant changes were observed from baseline to study endpoint in any of the lipid parameters tested.

CONCLUSIONS

In patients with T2DM with A1c 7-8%, who were previously treated by conventional LM and OAD therapy, adding glargine resulted in greater improvements in glycaemic control vs. intensifying LM.

Psychological insulin resistance: patient beliefs and implications for diabetes management

PURPOSE

To define and understand patient psychological insulin resistance (PIR) and its impact on diabetes management.

METHODS

Systematic literature review of peer-refereed journals using the MEDLINE database, including all articles in English from 1985 to 2007. The population included patients with type 1 and type 2 diabetes, insulin naïve, and those currently using insulin. A total of 116 articles were reviewed.

RESULTS

PIR is impacted by patients' beliefs and knowledge about diabetes and insulin, negative self-perceptions and attitudinal barriers, the fear of side effects and complications from insulin use, as well as lifestyle adaptations, restrictions required by insulin use, and social stigma. These etiological influences, both independently and in combination, constitute a patient's PIR and may result in the reluctance of patients to both initiate and intensify treatment, leading to delayed treatment initiation and compromised glucose control.

CONCLUSIONS

PIR is complex and multifaceted. It plays an important, although often ignored, role in diabetes management. Assisting health care professionals in better understanding PIR from the patient's perspective should result in improved treatment outcomes. By tailoring treatments to patients' PIR, clinicians may be better able to help their patients begin insulin treatment sooner and improve compliance, thus facilitating target glycemic control.