Before oral agents fail: the case for starting insulin early

Treatment Patterns in Patients With Newly Diagnosed Type 2 Diabetes in China: A Retrospective, Longitudinal Database Study

PURPOSE

The objectives of this study were to examine the patterns of antihyperglycemic drug (AHD) therapy among patients with newly diagnosed type 2 diabetes mellitus (T2DM) in the general Chinese population, stratified by initial hemoglobin (Hb) A_1c level, and to assess whether treatment patterns are consistent with the recommendations published in the China Diabetes Society's clinical treatment guideline.

METHODS

A retrospective database analysis was conducted, and data were obtained from the SuValue database. Prescribing patterns for diabetes treatments were determined from data obtained from the Nanhai District-based electronic medical records database, a subset of the SuValue database. Data from patients newly diagnosed with T2DM who also had at least 2 prescriptions for AHD medications after diagnosis and at least 1 HbA_1c test result during the 12 months prior to AHD treatment initiation, between January 1, 2004, and July 22, 2018, were included in the analysis. ANOVA, χ² test, and Kaplan-Meier survival analysis were used to examine differences between 4 initial-HbA_1c groups (<7%, 7%-<8%, 8%-<9%, and ≥9%).

FINDINGS

A total of 4712 patients were included, with women accounting for 47.8%; the mean age (SD) of the study population was 56.44 (12.57) years. Men were more likely to have had a higher HbA_1c level at initial AHD treatment (P < 0.0001). The first-line therapies most frequently prescribed were metformin combination (29.5%), followed by insulin-including treatment (25.9%), and metformin monotherapy (19.2%). Metformin monotherapy (29.5%) was most commonly prescribed in patients with an HbA_1c level of <7%; metformin combination (31.7%), in patients with an HbA_1c level of 7%-<8%; and insulin-containing treatment, in patients with HbA_1c levels of 8%-<9% (28.1%) and ≥9% (38.4%). Insulin-including treatment was more commonly prescribed than was metformin combination in patients with an initial HbA_1c level of ≥8% after initial treatment. In third- and fourth-line treatments, patients with an HbA_1c level of ≥8% more prevalently were prescribed metformin combination and insulin-including treatment, while metformin combination and "other" treatment were more generally prescribed in patients with an HbA_1c level of ≤8%. However, 8.8% of patients with an HbA_1c level of <7% were prescribed insulin-including treatment as first-line therapy. In all lines of treatment, the percentages of patients prescribed insulin were increased with initial HbA_1c levels. A similar pattern was seen with dipeptidyl peptidase 4 inhibitors after first-line treatment. Overall, the median time to treatment switch was shorter than 3 months.

IMPLICATIONS

The findings from the present study depict a comprehensive overview of AHD-treatment patterns in patients stratified by HbA_1c level. The current treatment practices observed were inconsistent the published guideline, in terms of recommendations on metformin monotherapy and insulin use in first-line therapy.

Effects of dietary protein intake on body composition changes after weight loss in older adults: a systematic review and meta-analysis

CONTEXT

The impact of dietary protein on body composition changes after older adults purposefully lose weight requires systematic evaluation

OBJECTIVE

: This systematic review and meta-analysis assessed the effects of protein intake (< 25% vs ≥ 25% of energy intake or 1.0 g/kg/d) on energy restriction-induced changes in body mass, lean mass, and fat mass in adults older than 50 years.

DATA SOURCES

PubMed, Cochrane, Scopus, and Google Scholar were searched using the keywords "dietary proteins," "body composition," "skeletal muscle," and "muscle strength."

STUDY SELECTION

Two researchers independently screened 1542 abstracts.

DATA EXTRACTION

Information was extracted from 24 articles.

DATA SYNTHESIS

Twenty randomized control trials met the inclusion criteria.

CONCLUSION

Older adults retained more lean mass and lost more fat mass during weight loss when consuming higher protein diets.

Adherence to premixed insulin in a prefilled pen compared with a vial/syringe in people with diabetes in Singapore

BACKGROUND

The real-world clinical effectiveness of exogenous insulin is limited by nonadherence. Various insulin delivery systems have been developed to help improve adherence, with prefilled pens gaining popularity among adult Singaporeans with diabetes. However, adherence to insulin in people with diabetes in Singapore and most of Asia has not been studied.

OBJECTIVES

This study aimed to compare adherence to premixed insulin formulated in a prefilled pen versus a vial/syringe and to identify predictors of adherence in 955 patients managed at the outpatient clinics of the largest acute care hospital in Singapore.

METHODS

In this retrospective longitudinal study, electronic medical and pharmacy refill records were used to determine adherence to insulin over 24 months, measured in terms of compliance and persistence. Compliance is expressed as the medication possession ratio (used as continuous and categorical variables), and persistence is reported as a dichotomous variable with a permissible refill gap of 30 days before discontinuation of therapy is considered. Multivariate linear or logistic regression analysis was used to identify predictors of adherence.

RESULTS

Compared with prefilled pen users, vial/syringe users were older (mean [SD] age, 64.1 [10.6] vs 62.4 [11.9] years; P = 0.032), and more were undergoing polypharmacy (69.6% vs 54.1%; P < 0.001). The mean (SD) medication possession ratio was comparable in vial/syringe versus prefilled pen users (83.8% [26.9%] vs 86.0% [23.2%]; P = 0.266). Prefilled pen users were more persistent with therapy compared with vial/syringe users (odds ratio = 1.36; 95% CI, 1.01-1.86) after adjusting for sociodemographic and clinical covariates. Median time to discontinuation of therapy was comparable (vial/syringe vs prefilled pen: 409 vs 532 days; P = 0.076). Being managed by an endocrinologist and not receiving government subsidies were significant predictors of persistence.

CONCLUSIONS

Compared with other studies that found strong associations between adherence and insulin devices, the findings of this study suggest that persistence but not compliance varies by insulin device. The willingness to pay for health care, in addition to affordability, may affect insulin therapy adherence. Patients with uncontrolled diabetes due to suspected nonadherence may benefit from referral to a multidisciplinary care team comprising endocrinologists, diabetes nurse educators, dietitians, and allied health professionals. These findings are applicable to outpatients with similar demographic features managed at other acute care hospitals in Singapore. The impact of insulin devices on glycemic control needs to be investigated in future larger studies.

Call-to-action: timely and appropriate treatment for people with type 2 diabetes in Latin America

Latin America faces a unique set of challenges in the treatment of type 2 diabetes mellitus (T2DM). This report identifies these challenges and provides a framework for implementation of the strategies, policies and education programs which are needed to optimize the management of this condition. In order to improve future diabetes care, it will be necessary to address existing problems such as limitation of resources, inadequate management of hyperglycemia, and inappropriate education of healthcare team members and people with diabetes. Achieving these goals will require collaborative efforts by many individuals, groups and organizations. These include policymakers, international organizations, healthcare providers, those responsible for setting medical school curricula, patients and society as a whole. It is anticipated that improved/continuing education of healthcare professionals, diabetes self-management education and development of a team approach for T2DM care will lead to optimization of patient-centered care. Implementation of multicentric demonstration studies and rational use of antidiabetic treatments will be necessary to demonstrate the long-term favorable impact of these strategies upon quality of care, prevention of chronic complications, mortality, healthcare costs and patient quality of life.

Glycemic control and the first use of oral antidiabetic agents among patients with type 2 diabetes mellitus

OBJECTIVE

Examine how patients diagnosed with type 2 diabetes mellitus (T2DM) are treated with oral antidiabetic (OAD) agents and the relationship between treatment patterns and glycemic control.

RESEARCH DESIGN AND METHODS

Data were obtained from the i3 Invision Data Mart database (OptumInsight, Eden Prairie, MN, USA). The analyses examined 4627 individuals who received a first prescription for an OAD (with first date identified as index date) and received at least one HbA1c test in both the 1 year prior and 2 years post index date. Patients were categorized based upon their level of glycemic control pre index date and logistic multivariate analyses were used to examine the probability of a patient's first treatment pattern change being a switch, augmentation, or discontinuation compared to continuation on the intent-to-treat (ITT) OAD.

RESULTS

Men tended to have worse glycemic control at OAD initiation. During the post-period, younger patients were more likely to switch, augment or discontinue therapy, while patients initially treated with metformin were more likely to switch or augment therapy. Results indicated that patients with moderate or poor glycemic control, compared to those with good glycemic control, were significantly more likely to switch or augment therapy. Practice patterns revealed minimal use of insulin although, on average, many patients were above target HbA1c levels at initiation. Interpretation of results are limited by the fact that only a small subset of patients had valid HbA1c data and that the analyses was not able to account for other factors, such as race and weight, that may also impact the analyses.

CONCLUSIONS

Patient initial level of glycemic control was associated with changes in treatment patterns in the 2 years post initiation on an OAD, with patients with moderate or poor control more likely to switch or augment their ITT therapy, compared to individuals with good control.

The association between use of mealtime insulin pens versus vials and healthcare charges and resource utilization in patients with type 2 diabetes: a retrospective cohort study

OBJECTIVE

To compare all-cause and diabetes-related resource utilization and healthcare charges among adults with type 2 diabetes mellitus who initiated therapy with mealtime insulin disposable pens or vials.

METHODS

Data were obtained from the Innovus inVision database from January 1, 2006 through June 30, 2010. Generalized linear models with a gamma distribution and log link estimated the association between medical charges and use of mealtime insulin pens vs vials in the 1 year post-index date, while generalized linear models with a negative binomial distribution estimated resource utilization.

RESULTS

Controlling for patient characteristics, general health, and patient copayments, insulin therapy initiation with disposable pens, compared to vials, was associated with significantly fewer all-cause hospitalizations (1.45 vs. 1.66; p < 0.0001) as well as a significantly shorter hospital length of stay (2.16 days vs. 3.53 days; p < 0.0001). Pen use, compared to vials, was also associated with significantly fewer diabetes-related hospitalizations (1.36 vs. 1.47; p < 0.0001), and shorter hospital length of stay (1.12 days vs. 1.72 days; p < 0.0001). Despite higher diabetes-related drug charges ($3593 vs. $2755; p < 0.0001) associated with the use of pens, results showed significantly lower all-cause total healthcare charges ($42,150 vs. $53,340; p < 0.0001) and significantly lower diabetes-related total healthcare charges ($12,722 vs. $14,540; p < 0.0001) for patients who initiated therapy on mealtime insulin with pens compared to vials.

LIMITATIONS

Data were drawn from administrative claims and included only patients with medical and outpatient prescription drug benefit coverage. Hence, the results may not be generalizable. The retrospective analyses relied on diagnostic codes to identify patients, assess patient general health, and determine other values, rather than formal, clinical assessments. The analyses did not include indirect healthcare costs.

CONCLUSIONS

The administration of mealtime insulin via disposable pens, compared to vials, was associated with a significant reduction in all-cause and diabetes-related resource utilization and total healthcare charges.

Self-titration of insulin in the management of people with type 2 diabetes: a practical solution to improve management in primary care

Good glycaemic control in type 2 diabetes (T2DM) is associated with a reduced risk of diabetes complications; however, achieving and maintaining glycaemic control represents a major challenge to physicians, and despite the availability of a range of antidiabetic therapies, many patients with T2DM will eventually require insulin supplementation to reach target glycaemic levels. Insulin initiation, adjustment of the insulin dose and the need for frequent assessment of blood glucose levels are often complicated by patient and physician misconceptions and concerns regarding its use. For most patients requiring insulin therapy, dose titration is carried out by physicians; however, evidence suggests that this process may not provide optimal glycaemic management for patients. Self-monitoring of blood glucose and self-adjustment of insulin dose (insulin self-titration) is well established in type 1 diabetes, suggesting that similar therapeutic self-management may be beneficial when applied to patients with T2DM. This article reviews the rationale and clinical evidence for insulin self-titration in patients with T2DM with the aim of highlighting the importance of educating patients about insulin therapy and empowering them to manage their diabetes through self-titration of insulin.

Insulin initiation in type 2 diabetes: what are the treatment regimen options and how can we best help patients feel empowered?

PURPOSE

This article summarizes treatment regimens and issues involved in initiating insulin therapy in type 2 diabetes (T2D). Progressive deterioration of beta-cell mass and function characterizes the course of T2D. Following diet and exercise, oral antidiabetic drugs (OADs), and incretin therapies, many patients require insulin, but initiation is often delayed until complications develop.

DATA SOURCES

Published guidelines for the management of T2D, primary and review articles, and Food and Drug Administration (FDA) prescribing information.

CONCLUSIONS

The diabetes nurse practitioner should encourage patients to initiate insulin when appropriate; patients need to know that this represents a natural step in treatment, not a personal failing. Initiation often occurs when OADs no longer confer adequate glycemic control. Treatment regimens available include once-daily basal insulin, sometimes with addition of prandial insulin, or premix/biphasic insulin. Insulin analogs confer less risk of hypoglycemia and weight gain, and greater dosing flexibility compared with conventional insulins. Insulin efficacy may be enhanced by continuing metformin and/or incretin therapies, while discontinuing other drugs as appropriate.

IMPLICATIONS FOR PRACTICE

The well-versed diabetes nurse practitioner assists the patient in selecting the most appropriate option for his/her specific needs. It is essential to help patients overcome barriers, including fears of injection pain, public embarrassment, and hypoglycemia risk.

What options are available when considering starting insulin: premix or basal?

Several large studies in diabetes have shown that early initiation of intensive therapy is better for the prevention of long-term complications and suggest that patients with more advanced disease may be at increased risk of adverse cardiovascular events. Despite these findings, insulin initiation is often delayed in patients with type 2 diabetes, typically until A1C exceeds 8.5%. Barriers to the use of insulin are many, arising from both a patient and a physician perspective, and the decision to initiate insulin treatment can be influenced by cost, risk of hypoglycemia, convenience, and the potential for weight gain. Choosing when to initiate insulin and which insulin/treatment regimen to adopt in patients with type 2 diabetes is key, and the importance of tailoring treatment to the patient is widely acknowledged. However, there is currently no universal consensus on the optimal course of action. Once-daily basal insulin and twice-daily premix insulin are commonly used for insulin initiation. Relatively few studies have directly compared these starter treatment regimens, although general findings suggest that, although glycemic control appears to be similar with once-daily basal insulin and twice-daily premix, the lower hypoglycemia rates, lower weight gain, simplicity, and convenience associated with basal insulin support its first-line use as a starter insulin regimen in patients failing on oral antidiabetes agents. Variables such as age, body mass index, and bedtime or post-breakfast plasma glucose levels may alter the efficacy of the chosen treatment regimen, further supporting the need to tailor treatment to meet individual patient's requirements.

Impact of therapeutic advances on hypoglycaemia in type 2 diabetes

Patients with type 2 diabetes experience hypoglycaemia less frequently than those with type 1 diabetes. Some protection against hypoglycaemia is afforded by the relatively intact glucose counter-regulatory pathways that characterize the pathophysiology of early type 2 diabetes. To some extent, this protection explains why hypoglycaemic episodes in intensively treated individuals with type 2 diabetes, when they occur, are rarely severe. As diabetes progresses and therapy intensifies to achieve recommended glycaemic goals, hypoglycaemia frequency and severity increase. Thus, when it comes to instituting intensive therapy, fear of hypoglycaemia may contribute to health-care providers' 'clinical inertia'. Because maintaining glycaemic control is so important to both public and individual health, many new therapies and technologies have been developed. This manuscript reviews and considers whether these advancements in therapy make glycaemic goals easier to achieve by minimizing hypoglycaemia. Putting the hypoglycaemia experienced by type 2 diabetes patients into appropriate clinical perspective, the impact of recent progress made in pharmacotherapy, drug delivery systems, and BG monitoring on hypoglycaemia incidence is largely positive. The extent to which this progress can effect improvement over traditional therapies will, however, depend upon patient (and provider) education, motivation and behaviour change.

A randomised, 52-week, treat-to-target trial comparing insulin detemir with insulin glargine when administered as add-on to glucose-lowering drugs in insulin-naive people with type 2 diabetes

AIMS/HYPOTHESIS

This 52-week multinational, randomised, open-label, parallel-group, non-inferiority trial compared clinical outcomes following supplementation of oral glucose-lowering drugs with basal insulin analogues detemir and glargine in type 2 diabetic patients.

METHODS

Insulin-naive adults (n=582, HbA(1c) 7.5-10.0%, BMI <or= 40.0 kg/m(2)) were randomised 1:1 to receive insulin detemir or glargine once daily (evening) actively titrated to target fasting plasma glucose (FPG) <or= 6.0 mmol/l. An additional morning insulin detemir dose was permitted if pre-dinner plasma glucose (PG) was >7.0 mmol/l after achieving FPG <7.0 mmol/l. Due to labelling restrictions, no second glargine dose was allowed.

RESULTS

Baseline HbA(1c) decreased from 8.6 to 7.2 and 7.1% (NS) with detemir and glargine, respectively. FPG improved from 10.8 to 7.1 and 7.0 mmol/l (NS), respectively. With detemir, 45% of participants completed the study on once daily dosing and 55% on twice daily dosing, with no difference in HbA(1c). Overall, 52% of participants achieved HbA(1c) <or= 7.0%: 33% (detemir) and 35% (glargine) without hypoglycaemia. Within-participant variability for self-monitored FPG and pre-dinner PG did not differ by insulin treatment, nor did the relative risk of overall or nocturnal hypoglycaemia. Modest reductions in weight gain were seen with detemir vs glargine in completers (3.0 vs 3.9 kg, p=0.01) and in the intention-to-treat population (2.7 vs 3.5 kg, p=0.03), primarily related to completers on once-daily detemir. Mean daily detemir dose was higher (0.78 U/kg [0.52 with once daily dosing, 1.00 U/kg with twice daily dosing]) than glargine (0.44 IU/kg). Injection site reactions were more frequent with detemir (4.5 vs 1.4%).

CONCLUSIONS/INTERPRETATION

Supplementation of oral agents with detemir or glargine achieves clinically important improvements in glycaemic control with low risk of hypoglycaemia. Non-inferiority was demonstrated for detemir using higher insulin doses (mainly patients on twice daily dosing); weight gain was somewhat reduced with once daily insulin detemir.

Defining the role of insulin detemir in Basal insulin therapy

Insulin detemir is a novel long-acting insulin analogue with a unique mechanism underlying its prolonged duration of action. Unlike neutral protamine Hagedorn (NPH) insulin (insulin suspension isophane) and insulin glargine, which precipitate after administration, insulin detemir remains soluble after it is injected. The prolonged duration of action of insulin detemir is a result of the ability to self-associate into hexamers and dihexamers, and to bind reversibly to albumin. This mechanism of protraction provides a more prolonged, consistent and predictable glycaemic effect in patients with type 1 or type 2 diabetes mellitus compared with NPH insulin. Clinical studies have demonstrated that insulin detemir administered once or twice daily is at least as effective as NPH insulin and insulin glargine in achieving glycaemic control. Most trials have also shown that insulin detemir exhibits less intrapatient variability in glycaemic control compared with NPH insulin and insulin glargine. One of the benefits of insulin detemir is its favourable effect on bodyweight. Insulin detemir has shown weight neutrality in patients with type 1 diabetes and is associated with less weight gain than NPH insulin in clinical studies. Patients with type 2 diabetes using insulin detemir gain less weight than patients using NPH insulin and insulin glargine. In addition, a reduced risk of hypoglycaemia, particularly nocturnal hypoglycaemia, has been reported with insulin detemir compared with NPH insulin in patients with type 1 and type 2 diabetes. A reduced risk of major and nocturnal hypoglycaemia compared with insulin glargine in patients with type 1 diabetes has also been observed. Together, these data indicate that insulin detemir is a valuable new option for basal insulin therapy in patients with type 1 or type 2 diabetes.

Self-reported predictors of depressive symptomatology in an elderly population with type 2 diabetes mellitus: a prospective cohort study

Background

The prevalence of depression increases among the elderly with chronic medical conditions like diabetes. Hence, the purpose of this study was to determine predictors of depressive symptomatology in Medicare enrolled elderly population with type 2 diabetes mellitus.

Methods

A prospective cohort study was conducted by administrating health risk assessment questionnaire to elderly (≥65 years) with type 2 diabetes. Responses were linked with administrative claim's data. Data were obtained from elderly with type 2 diabetes who were enrolled in Medicare Health Maintenance Organization (HMO) in southeastern United States. The instrument collected information related to demographics, health status, medication use, and healthcare service utilization prior to enrollment. Responses were combined with the administrative claims data of HMO to obtain information on actual utilization of healthcare resources. The Short Form Center for Epidemiologic Studies Depression scale was used to assess depressive symptoms. Multivariable logistic regression analyses were conducted to determine predictor variables.

Results

Of 792 respondents, about 17% had depressive symptoms. Almost 96% of patients were using 1 or more antidiabetic medications. Overall, increased risk of depression was associated with lower health related quality of life (HRQoL) (OR: 0.97; 95% CI: 0.96–0.98) and higher impairments in instrumental activities of daily living (IADLs) (OR: 1.31; 95% CI: 1.14–0.52) in elderly patients. Poor health related quality of life (OR: 0.97, 95%CI: 0.95–0.99) was associated with higher risk of depression in patients on insulin therapy.

Conclusion

Impairments in daily activities and lower HRQoL were predictors of depressive symptomatology in elderly with diabetes. Determinants of depression varied according to pharmacotherapeutic class of antidiabetic medications.

Health Outcomes and Economic Impact of Therapy Conversion to a Biphasic Insulin Analog Pen Among Privately Insured Patients with Type 2 Diabetes Mellitus

STUDY OBJECTIVE

To evaluate claims-related treatment adherence, health care resource utilization, and associated costs of therapy conversion from an insulin vial and syringe to a premixed biphasic insulin analog pen device among privately insured patients with type 2 diabetes mellitus.

DESIGN

Retrospective, longitudinal, intrapatient (before and after) analysis.

DATA SOURCE

PharMetrics database of medical and pharmaceutical claims from 57 commercial health plans across the United States.

PATIENTS

Four hundred eighty-six adult patients with a confirmed diagnosis of type 2 diabetes who converted from an insulin analog vial and syringe (233 patients) or a human insulin vial and syringe (253 patients) to a biphasic insulin analog pen device between July 1, 2001 and December 31, 2002.

MEASUREMENTS AND MAIN RESULTS

All patients had no previous use of the pen device. Primary end points were medication possession ratio (MPR), a measure of adherence; hypoglycemic events; associations between treatment adherence and hypoglycemic events, and adherence and all-cause health care costs; and all-cause-attributable, hypoglycemia-attributable, and other diabetes-attributable costs. After conversion, MPR increased significantly from 59% to 68% (p<0.01). A significant decrease in the likelihood of experiencing a hypoglycemic event was also observed after conversion (odds ratio [OR] 0.40, 95% confidence interval [CI] 0.27-0.61, p<0.05), with hypoglycemic occurrences reduced nearly two thirds among subjects with optimal adherence indicated by an MPR of 80% or greater (incidence rate ratio 0.36, 95% CI 0.11-0.76, p<0.05). Significant decreases in hypoglycemia-attributable emergency department visits (OR 0.36, 95% CI 0.16-0.84, p<0.05) and physician visits (OR 0.39, 95% CI 0.20-0.77, p<0.05) were observed. Total mean all-cause annual treatment costs were reduced by $1748/patient (p<0.01), hypoglycemia-attributable costs were reduced by $908/patient (p<0.01), and other diabetes-attributable costs were reduced by $643/patient (p<0.01). Patients with an MPR of 80% or greater were associated with significant reductions in all-cause health care costs (OR 0.55, 95% CI 0.31-0.80, p<0.05).

CONCLUSION

Privately insured patients with type 2 diabetes may exhibit considerable improvements in clinical and economic outcomes after insulin therapy conversion from vial and syringe to a premixed biphasic insulin analog pen device.

Why and how to use insulin therapy earlier in the management of type 2 diabetes

Most patients with type 2 diabetes are inadequately controlled on their current therapy. Suboptimal glycemic control can have devastating consequences, such as retinopathy, nephropathy, neuropathy, and cardiovascular disease that may ultimately lead to mortality. Most patients eventually need insulin therapy, and initiating insulin earlier in the course of type 2 diabetes may lead to optimal glycemic control and prevent or delay diabetes-related complications. Although insulin therapy is the most effective method of managing hyperglycemia, it is often delayed owing to concerns about the complexity and inconvenience of treatment regimens; fear of injections, hypoglycemia or weight gain; and the time required to learn how to effectively manage insulin therapy. The development of insulin analogs, biphasic insulin analogs, and more convenient insulin delivery systems may make insulin therapy more manageable and help more patients achieve their treatment goals.

Medication adherence and the associated health-economic impact among patients with type 2 diabetes mellitus converting to insulin pen therapy: An analysis of third-party managed care claims data

OBJECTIVE

This study evaluated the impact on adherence, hypoglycemic events, resource utilization, and the associated health care costs of converting from administration of insulin therapy by a vial/syringe to an insulin analogue pen device in patients with type 2 diabetes mellitus.

METHODS

This pre-post analysis used an integrated medical and pharmacy claims database containing information for >40 million covered lives from 57 managed care health plans in the United States. Adults with a diagnosis of type 2 diabetes whose treatment was converted from conventional human or analogue insulin injection (vial/syringe) to a prefilled insulin analogue pen from July 2001 through December 2002, with no use of an insulin analogue pen device in the preceding 6 months, were identified and analyzed retrospectively. The primary end points were adherence (as measured by a medication possession ratio [MPR] > or =80%); the odds ratio (OR) for hypoglycemic events requiring health care resource utilization and resulting in a claim; the association between adherence and hypoglycemic events; and all-cause, hypoglycemia-attributable (HA), and diabetes-attributable (DA) health care costs.

RESULTS

A total of 1156 subjects were identified and analyzed (mean [SD] age, 45.4 [13.7] years; 53.8% male; previous insulin vial use: 595 [51.5%] human, 561 [48.5%] analogue). Medication adherence was significantly improved after conversion to the insulin pen device (from 62% to 69%; P < 0.01). The proportion of subjects considered adherent was significantly higher in the period after the conversion compared with before the conversion (54.6% vs 36.1%, respectively; P < 0.01). The likelihood of experiencing a hypoglycemic event was significantly reduced after conversion (OR = 0.50; 95% CI, 0.37-0.68; P < 0.05), and the incidence of hypoglycemia in subjects with an MPR > or =80% decreased by nearly two thirds (incident rate ratio = 0.35; 95% CI, 0.11-0.81; P < 0.05). There were significant decreases in HA emergency department visits (OR = 0.44; 95% CI, 0.21-0.92; P < 0.05) and physician visits (OR = 0.39; 95% CI, 0.24-0.64; P < 0.05), whereas HA-related hospitalizations and outpatient visits remained similar after conversion. Total mean all-cause annual treatment costs were reduced by $1590 per patient (from $16,359 to $14,769; P < 0.01). Annual HA costs were reduced by $788 per patient (from $1415 to $627; P < 0.01), predominantly as a result of decreased hospitalization costs (from $857 to $288; P < 0.01). Annual DA costs were reduced by $600 per patient (from $8827 to $8227; P < 0.01).

CONCLUSIONS

Among these patients with type 2 diabetes treated in a managed care setting, a switch from administration of insulin therapy by vial/syringe to a prefilled insulin analogue pen device was associated with improved medication adherence, fewer claims for hypoglycemic events, reduced emergency department and physician visits, and lower annual treatment costs.

Prevalence of inadequate glycemic control among patients with type 2 diabetes in the United Kingdom general practice research database: A series of retrospective analyses of data from 1998 through 2002

BACKGROUND

Since the mid-1990s, the development of new oral antidiabetic agents (OAs) and treatment guidelines have created an opportunity to improve glycemic control in patients with type 2 diabetes.

OBJECTIVES

This study aimed to assess the prevalence of good and inadequate glycemic control across a 5-year period among patients with diabetes in the United Kingdom. It also investigated the factors associated with achieving glycemic targets.

METHODS

This was a retrospective, cross-sectional analysis of data from the General Practice Research Database. Three limits were used to assess glycosylated hemoglobin (HbA1c): 6.5%, 7.0%, or 7.5%. Values above the cutoffs indicated inadequate control of HbA1c; those at or below the cutoffs indicated good control. The study evaluated clinical and pharmacy data from the years 1998 to 2002 for patients with type 2 diabetes, > or =2 years of follow-up, and > or =2 HbA1c measurements during the first year. Five independent cross-sectional analyses were conducted, grouping data by year. Statistical significance was determined by Student t and chi2 tests.

RESULTS

Data were analyzed for 10,663 patients aged 17 to 98 years. The number of total eligible type 2 diabetes patients increased over the course of the study period: 5674 patients in 1998, 6553 in 1999, 7314 in 2000, 7323 in 2001, and 6192 in 2002. Overall, the study population had a mean (SD) age of 66 (11.0) years, was 53% male (3033/5674), and had a body mass index of 29 kg/m(2). Seventy-six percent of patients had HbA1c >7.0% and 37% were taking > or =2 oral agents. In 1998 and 2002, 79% (4482/5674) and 76% (4732/6192) of patients, respectively, had inadequate glycemic control, defined as HbA1c >7.0%. When defined as HbA1c >7.5%, 69% (3923/5674) and 62% (3814/6192) of patients, respectively, had inadequate control. Finally, when defined as HbA1c >6.5%, 88% (5011/5674) of patients in both 1998 and 2002 had inadequate control. Compared with patients with good disease control (HbA1c < or =7.0%), patients with inadequate control were approximately 2 years younger (P < 0.001) and had been prescribed more OAs: 41% received > or =2 OAs in 1998 and 52% in 2002, compared with 23% and 34% (both, P = 0.001), respectively, of patients with good glycemic control (P < 0.02). Sex, number of diabetes complications, and number of comorbidities did not differ between groups (P = NS).

CONCLUSIONS

Despite the introduction of new OAs and treatment guidelines, the prevalence of inadequate glycemic control remains high (>60%) in patients with type 2 diabetes in the United Kingdom. Regardless of the HbA1c cutoff, patients with inadequate control were younger and received prescriptions for more OAs than patients with good control.

Attainment of glycaemic goals in type 2 diabetes with once-, twice-, or thrice-daily dosing with biphasic insulin aspart 70/30 (The 1-2-3 study)

AIM

This observational study in patients with type 2 diabetes failing oral agent therapy with or without basal insulin was conducted to assess whether addition and self-titration of biphasic insulin aspart 70/30 (BIAsp 30) could achieve American Association of Clinical Endocrinologists (AACE)/International Diabetes Federation (IDF) and American Diabetes Association (ADA) glycemic targets (HbA(1c)< or =6.5 and <7%).

METHODS

Enrolled patients (n = 100, HbA(1c)> or =7.5 and < or =10%) were > or =18 years of age, had diabetes > or =12 months and had received a stable antidiabetic regimen for at least 3 months [minimum of two oral antidiabetic drugs (OADs) or at least one OAD plus once-daily basal insulin < or =60 U]. Patients discontinued prior basal insulin and added one injection of BIAsp 30 (12 U or 70-100% of prior basal insulin dose within 15 min of dinner initiation). Patients self-titrated their BIAsp 30 dose with investigator guidance every 3 or 4 days to achieve pre-breakfast fasting blood glucose (FBG) of 80-110 mg/dl. At 16 weeks, a pre-breakfast injection of 6 U of BIAsp 30 was added if week 15 HbA(1c) exceeded 6.5%; the added dose was titrated to achieve pre-dinner BG of 80-110 mg/dl. After an additional 16 weeks, 3 U of pre-lunch BIAsp 30 was added if HbA(1c) exceeded 6.5%. This added dose was adjusted based on 2-h post-lunch BG to achieve postprandial glucose of 100-140 mg/dl. Subjects achieving an HbA(1c)< or =6.5% at 15 and 31 weeks completed the study at weeks 16 and 32 respectively.

RESULTS

Addition of once-daily BIAsp 30 before dinner enabled 21% of the patients to achieve AACE and IDF targets (HbA(1c)< or =6.5%) and 41% to achieve ADA targets (HbA(1c) <7%). With two daily injections of BIAsp 30, these glycaemic goals were achieved by 52 and 70% of subjects. With three daily BIAsp 30 injections, 60% of patients achieved HbA(1c)< or =6.5%, and 77% achieved HbA(1c) <7.0%.

CONCLUSIONS

This clinical trial demonstrates that initiation of once-daily BIAsp 30 to type 2 diabetes patients poorly controlled on various OAD regimens was an effective treatment approach for achieving glycaemic goals. Additional patients safely achieved these goals by increasing the number of BIAsp 30 injections from one to two, and then, if uncontrolled, from two to three doses per day. Eventually, most patients previously uncontrolled on OADs with or without basal insulin were controlled by the addition and vigorous titration of BIAsp 30 to oral agent therapy.

Initiating insulin therapy in type 2 Diabetes: a comparison of biphasic and basal insulin analogs

OBJECTIVE

Safety and efficacy of biphasic insulin aspart 70/30 (BIAsp 70/30, prebreakfast and presupper) were compared with once-daily insulin glargine in type 2 diabetic subjects inadequately controlled on oral antidiabetic drugs (OADs).

RESEARCH DESIGN AND METHODS

This 28-week parallel-group study randomized 233 insulin-naive patients with HbA(1c) values >/=8.0% on >1,000 mg/day metformin alone or in combination with other OADs. Metformin was adjusted up to 2,550 mg/day before insulin therapy was initiated with 5-6 units BIAsp 70/30 twice daily or 10-12 units glargine at bedtime and titrated to target blood glucose (80-110 mg/dl) by algorithm-directed titration.

RESULTS

A total of 209 subjects completed the study. At study end, the mean HbA(1c) value was lower in the BIAsp 70/30 group than in the glargine group (6.91 +/- 1.17 vs. 7.41 +/- 1.24%, P < 0.01). The HbA(1c) reduction was greater in the BIAsp 70/30 group than in the glargine group (-2.79 +/- 0.11 vs. -2.36 +/- 0.11%, respectively; P < 0.01), especially for subjects with baseline HbA(1c) >8.5% (-3.13 +/- 1.63 vs. -2.60 +/- 1.50%, respectively; P < 0.05). More BIAsp 70/30-treated subjects reached target HbA(1c) values than glargine-treated subjects (HbA(1c) </=6.5%: 42 vs. 28%, P < 0.05; HbA(1c) <7.0%: 66 vs. 40%, P < 0.001). Minor hypoglycemia (episodes/year) was greater in the BIAsp 70/30 group than in the glargine group (3.4 +/- 6.6 and 0.7 +/- 2.0, respectively; P < 0.05). Weight gain and daily insulin dose at study end were greater for BIAsp 70/30-treated subjects than for glargine-treated subjects (weight gain: 5.4 +/- 4.8 vs. 3.5 +/- 4.5 kg, P < 0.01; insulin dose: 78.5 +/- 39.5 and 51.3 +/- 26.7 units/day, respectively).

CONCLUSIONS

In subjects with type 2 diabetes poorly controlled on OADs, initiating insulin therapy with twice-daily BIAsp 70/30 was more effective in achieving HbA(1c) targets than once-daily glargine, especially in subjects with HbA(1c) >8.5%.

Achieving Glycemic Control in Type 2 Diabetes: A Practical Guide for Clinicians on Oral Hypoglycemics

Type 2 diabetes mellitus has reached epidemic proportions in the United States. Cardiovascular morbidity and mortality are particularly high in this patient population. Improved glucose control, especially early in the course of diabetes, can slow or prevent complications, preserve beta-cell function, and improve long-term outcomes. Within the last decade, new treatments and glycemic goals have created an opportunity to better manage this prevalent, chronic disease. Defects of insulin resistance and deficiency leading to type 2 diabetes can now be directly targeted with available therapies. In addition to diet and exercise, oral treatment options have been broadened, with both insulin secretagogues and insulin sensitizers. These advances in treatment options make glycemic control an obtainable target, and therefore should improve overall morbidity and mortality for patients. This paper will review currently available oral therapies, with a focus on the unique attributes of the insulin sensitizers for patients with type 2 diabetes.

Self-management support for insulin therapy in type 2 diabetes

PURPOSE

The purpose of this article is to describe the self-management support that can be provided by diabetes educators for type 2 diabetes patients who are transitioning from therapy with oral hypoglycemic agents to insulin.

METHODS

The role of the diabetes educator in patient education and self-management support during all aspects of insulin therapy is discussed. Phases during which support may be especially important include the decision-making process, initiation, and maintenance.

RESULTS

Although some patients make the decision fairly easily, the introduction of insulin therapy is likely to raise many issues and questions for many type 2 diabetes patients. The more reluctant patients may experience psychological insulin resistance, a syndrome where insulin therapy is viewed as a threat or failure, which can affect health professionals as well. The diabetes educator can provide support and approaches to help diminish this resistance and make the transition to insulin therapy easier and more effective for patients with type 2 diabetes.

CONCLUSIONS

Education and ongoing self-management support are needed for informed decision making and the initiation and maintenance of insulin therapy. Therefore, diabetes educators have a critical role to play during both the decision-making process and the safe transition to insulin therapy.