Correlates of analog vs human basal insulin use among individuals with type 2 diabetes: A cross-sectional study

Racial/ethnic and socioeconomic disparities in achievement of treatment goals within a clinical trial: a secondary analysis of the ACCORD trial

AIMS/HYPOTHESIS

Clinical trial participation should theoretically reduce barriers to care by ensuring medication and healthcare access. We aimed to evaluate disparities in achieving diabetes treatment targets by race/ethnicity and educational attainment within the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial (ClinicalTrials.gov NCT00000620).

METHODS

The ACCORD trial included three interventions of varying participant burden: glycaemic (high burden), blood pressure (medium burden) and triglyceride-lowering (low burden). We examined adjusted odds ratios (aORs) for achievement of glycaemic targets, blood pressure targets and a ≥25% reduction in triglyceride levels (a proxy for adherence to fenofibrate therapy) in the first year, and for hypoglycaemia requiring medical assistance at any time, by treatment arm, race/ethnicity and educational attainment using multivariable models adjusted for demographics and clinical characteristics. We explored whether disparities in glycaemic goal achievement were mediated by hypoglycaemia, medication use, change in BMI or number of study visits attended.

RESULTS

Compared with White participants, participants who identified as Black, Hispanic and Other race/ethnicity were less likely to achieve glycaemic targets (aOR [95% CI]) 0.63 [0.55,0.71], 0.73 [0.61, 0.88], 0.82 [0.71, 0.96], respectively); Black participants but not Hispanic and Other race/ethnicity participants were less likely to achieve blood pressure targets (aOR [95% CI] 0.77 [0.65, 0.90], 1.01 [0.78, 1.32], 1.01 [0.81, 1.26], respectively); and Black, Hispanic and Other race/ethnicity participants were equally or more likely to achieve triglyceride reduction (aOR [95% CI] 1.77 [1.38, 2.28], 1.34 [0.98, 1.84], 1.43 [1.10, 1.85], respectively). Differences in goal achievement by educational attainment were generally not significant after adjusting for baseline characteristics. Rates of hypoglycaemia requiring medical assistance were highest among Black individuals and those with lower educational attainment. Associations between race/ethnicity and glycaemic control were partially mediated by differences in insulin dosing and oral medication use.

CONCLUSIONS/INTERPRETATION

Racially/ethnically minoritised participants in the ACCORD trial were less likely to achieve high-burden (glycaemic) treatment goals but were generally similarly likely to achieve goals of less intensive interventions. Differences in glycaemic treatment goal achievement were partially mediated by differences in medication use but not mediated by hypoglycaemia, change in BMI or study visit attendance.

Deficits and Disparities in Early Uptake of Glucagon-Like Peptide 1 Receptor Agonists and SGLT2i Among Medicare-Insured Adults Following a New Diagnosis of Cardiovascular Disease or Heart Failure

OBJECTIVE

To examine the association of race/ethnicity and socioeconomic deprivation with initiation of guideline-recommended diabetes medications with cardiovascular benefit (glucagon-like peptide 1 receptor agonists [GLP1-RA] and sodium-glucose cotransporter 2 inhibitors [SGLT2i]) among older adults with type 2 diabetes (T2D) and either incident atherosclerotic cardiovascular disease (ASCVD) or congestive heart failure (CHF).

RESEARCH DESIGN AND METHODS

Using Medicare data (2016-2019), we identified 4,057,725 individuals age >65 years with T2D and either incident ASCVD or CHF. We estimated incidence rates and hazard ratios (HR) of GLP1-RA or SGLT2i initiation within 180 days by race/ethnicity and zip code-level Social Deprivation Index (SDI) using adjusted Cox proportional hazards models.

RESULTS

Incidence rates of GLP1-RA or SGLT2i initiation increased over time but remained low (<0.6 initiations per 100 person-months) in all years studied. Medication initiation was less common among those of Black or other race/ethnicity (HR 0.81 [95% CI 0.79-0.84] and HR 0.84 [95% CI 0.75-0.95], respectively) and decreased with increasing SDI (HR 0.96 [95% CI 0.96-0.97]). Initiation was higher in ASCVD than CHF (0.35 vs. 0.135 initiations per 100 person-months). Moderate (e.g., nephropathy, nonalcoholic fatty liver disease) but not severe (e.g., advanced chronic kidney disease, cirrhosis) comorbidities were associated with higher probability of medication initiation.

CONCLUSIONS

Among older adults with T2D and either ASCVD or CHF, initiation of GLP1-RA or SGLT2i was low, suggesting a substantial deficit in delivery of guideline-recommended care or treatment barriers. Individuals of Black and other race/ethnicity and those with higher area-level socioeconomic deprivation were less likely to initiate these medications.

Trends in Insulin Types and Devices Used by Adults With Type 2 Diabetes in the United States, 2016 to 2020

IMPORTANCE

Despite rising costs and public scrutiny devoted to insulin, less is known regarding recent trends in its ambulatory use in the United States.

OBJECTIVE

To characterize trends in ambulatory insulin use, overall and based on insulin characteristics, among adults with type 2 diabetes in the United States from January 1, 2016, through December 31, 2020.

DESIGN, SETTING, AND PARTICIPANTS

This serial cross-sectional study included patients whose data were collected in IQVIA's National Disease and Therapeutic Index (NDTI), a 2-stage, all-payer, nationally representative audit of outpatient care. Approximately 4800 physicians each calendar quarter completed a form for 2 consecutive days regarding visits for each of their patients, including diagnoses, treatments, and demographic information. Data were collected from January 2016 through December 2020.

EXPOSURES

Ambulatory use of insulin.

MAIN OUTCOMES AND MEASURES

Nationally representative projections for ambulatory use of insulin (ie, treatment visits), overall and aggregated by insulin molecule (insulins regular, neutral protamine Hagedorn [NPH], lispro, glulisine, glargine, detemir, degludec, and aspart), delivery devices (vials/syringes or pens), therapeutic class (short-acting, rapid-acting, long-acting, intermediate-acting, and premixed insulin), insulin type (human, analog, and biosimilar), and date of approval (newer: before 2010; and older: after 2010).

RESULTS

There were 27 860 691 insulin treatment visits between 2016 and 2020. Among all patient encounters that indicated use of insulin in 2020, 1 989 154 (43.9%) were among those aged 60 to 74 years; 2 372 629 (52.4%) among men; 2 646 247 (58.4%) among White patients; 811 639 (17.9%) among Black patients; and 701 912 (15.5%) among Hispanic patients. Insulin glargine was the most frequently used insulin from 2016 to 2020, accounting for approximately half of treatment visits (eg, 2020: 2.6 of 4.9 million visits; 95% CI, 2.1-3.1 million). Among insulin classes, long-acting insulin accounted for approximately two-thirds of treatment visits during this period (eg, 2020: 3.7 million visits; 95% CI, 3.0-4.4 million). Treatment visits for insulin pens increased from 36.1% in 2016 (2.2 of 6.0 million visits; 95% CI, 1.7-2.7 million) to 58.7% in 2020 (2.9 million visits; 95% CI, 2.3-3.5 million), while use of insulin vials/syringes declined in parallel. Analog insulin use predominated and accounted for more than 80% of total treatment visits across all years (eg, 2020: 4.3 million visits; 95% CI, 3.4-5.1 million). Newer insulins were increasingly used, from 18.1% of total treatment visits in 2016 (1.1 million visits; 95% CI, 0.8-1.4 million) to 40.9% in 2020 (2.0 million visits; 95% CI, 1.5-2.5 million). The use of biosimilar insulin, which was first approved in 2015, increased from 2.6% in 2017 (0.1 of 5.3 million visits; 95% CI, 0.04-0.2 million) to 8.2% in 2020 (0.4 million visits; 95% CI, 0.2-0.6 million) of total insulin treatment visits. The total number of insulin treatment visits declined from a peak of 6.0 million visits in 2016 to a nadir of 4.9 million visits in 2020 (approximately 18% decline).

CONCLUSIONS AND RELEVANCE

In this study, ambulatory insulin use in the United States during the past 5 years remained dominated by the use of insulin analogs and insulin pen delivery devices, with increasing uptake of newer products as they have been brought to market.