Personalized intensification of insulin therapy in type 2 diabetes - does a basal-bolus regimen suit all patients?

Predictive value of postprandial C-peptide for utilizing multiple daily injection therapy in type 2 diabetes

PURPOSE

Multiple daily injection (MDI) insulin therapy is an effective method of glycemic control and appropriate assignment to MDI therapy could minimize the risks of hypoglycemia and weight gain. The aim of the present study was to identify factors associated with indication for MDI therapy in type 2 diabetes (T2DM).

METHODS

We recruited 360 participants with T2DM that were admitted to the Endocrinology Department of Peking University People's Hospital between August 2017 and July 2018. They first underwent intensive insulin therapy, then were switched to an optimized, simpler insulin treatment that aimed to maintain fasting blood glucose between 4.4 and 7.2 mmol/L, without episodes of hypoglycemia. The baseline characteristics of groups administering either MDI or basal/premix insulin were compared and multivariable logistic regression analysis was used to determine the odds ratios (ORs) for factors associated with MDI therapy. Receiver operating characteristic (ROC) curves were then used to identify independent predictors of MDI insulin regimen efficacy.

RESULTS

The mean age of the participants was 57.6 ± 12.9 years, and diabetes duration was 14.2 ± 8.2 years. Two hundred and sixty-seven participants administered basal/premix insulin and 93 underwent MDI therapy, of whom 61.8% and 46.2% were male, respectively (p = 0.01). The duration of diabetes was significantly longer in the MDI group (13.1 ± 7.7 years vs. 17.3 ± 8.7 years; p < 0.01). Fasting plasma glucose (FPG) was higher in the MDI group than in the basal/premix group (8.3 [6.7, 11.3] mmol/L vs. 7.2 [5.7, 9.3] mmol/L; p < 0.01), while the postprandial C-peptide concentration (PCP) was significantly lower in the MDI group (2.6 [1.8, 3.5] ng/mL) compared to the basal/premix group (3.6 [2.5, 6.2] ng/mL, p < 0.01. Multivariable logistic regression analysis suggested that diabetes duration and FPG were positively associated with MDI therapy: OR (95% confidence interval [CI]) 1.06 (1.02, 1.10) and 1.12 (1.02, 1.24), respectively. In addition, PCP was negatively associated with MDI therapy (0.72 [0.60, 0.86]). ROC analysis suggested that a PCP of < 3.1 ng/mL predicted MDI therapy with 59.6% sensitivity and 72.1% specificity.

CONCLUSION

The results of our study suggest that longer diabetes duration, higher FPG, and lower PCP were associated with necessity for MDI insulin regimen. These findings should assist with the personalization of insulin treatment.

Insulin therapy in type 2 diabetes: Insights into clinical efficacy, patient-reported outcomes, and adherence challenges

Insulin therapy plays a crucial role in the management of type 2 diabetes as the disease progresses. Over the past century, insulin formulations have undergone significant modifications and bioengineering, resulting in a diverse range of available insulin products. These products show distinct pharmacokinetic and pharmacodynamic profiles. Consequently, various insulin regimens have em-erged for the management of type 2 diabetes, including premixed formulations and combinations of basal and bolus insulins. The utilization of different insulin regimens yields disparate clinical outcomes, adverse events, and, notably, patient-reported outcomes (PROs). PROs provide valuable insights from the patient's perspective, serving as a valuable mine of information for enhancing healthcare and informing clinical decisions. Adherence to insulin therapy, a critical patient-reported outcome, significantly affects clinical outcomes and is influenced by multiple factors. This review provides insights into the clinical effectiveness of various insulin preparations, PROs, and factors impacting insulin therapy adherence, with the aim of enhancing healthcare practices and informing clinical decisions for individuals with type 2 diabetes.

Diabetes-related outcomes with basal-bolus vs. premixed insulin among veterans with type 2 diabetes: A single institutional retrospective study

BACKGROUND

The purpose of this study was to compare diabetes (DM)-related outcomes between basal-bolus (BB) and premixed (PM) insulin regimens.

METHODS

Retrospective chart review including veterans with type 2 diabetes (T2DM), ≥18 years old with hemoglobin A1c (HbA1c) ≥8%. Outcomes were assessed after one year of BB or PM insulin therapy. Data were analyzed using Chi-square/Fisher exact tests and logistic regression.

RESULTS

Out of 140 enrolled subjects (70 BB and 70 PM), 94% were males with average age and duration of DM of 65.7 ± 10.1 and 12.9 ± 9 years, respectively. The BB and PM groups were similar in age, gender distribution, HbA1c, body mass index (BMI) and DM duration at baseline. Following 1 year of treatment, there was no significant difference between the groups for change in HbA1c (-1.9 ± 1.8 vs -2.1 ± 1.9%, p = 0.3) or hypoglycemia rate (30% vs 21.4%, p = 0.3), respectively. There was similar increase in average BMI in both groups (0.84 ± 3.1 for BB vs 0.4 ± 2.2 kg/m2 for PM, p = 0.2).

CONCLUSIONS

There were no significant differences for glycemic control, hypoglycemia rate or BMI between the BB or PM insulin groups. These results suggest PM insulin is equally effective and safe as BB insulin.

A Real-World, Observational Study of the Initiation, Use, and Effectiveness of Basal-Bolus or Premixed Insulin in Japanese People with Type 2 Diabetes

INTRODUCTION

Basal-bolus (BB) and premixed insulin regimens may lower fasting plasma glucose (FPG) and postprandial plasma glucose (PPG), but are complex to use and associated with weight gain and hypoglycaemia. Although randomized controlled trials and prospective observational studies in insulin-naïve Japanese patients with type 2 diabetes (T2D) inadequately controlled with oral antidiabetic drugs (OADs) initiating these regimens have been conducted, real-world data are lacking. This study describes the characteristics of patients initiating these regimens in routine clinical practice and identifies the course and outcomes of therapy in the year following initiation.

METHODS

Adults with T2D initiating BB or premixed regimens following OAD therapies held in a Japanese electronic medical record database were identified (2010-2019). Subcohorts were determined by treatment changes during ≤ 12 months of follow-up (no change, intensified, switched, discontinued). Outcomes included change in glycated haemoglobin levels (HbA1c), probability of first reaching HbA1c < 7% (stratified by baseline OAD number, HbA1c and age), and hypoglycaemia incidence.

RESULTS

The main cohorts comprised 1315 BB and 1195 premixed therapy initiators. Most individuals (67.9%) initiated BB as inpatients; 50.8% switched at a mean of 47.6 days. Mean HbA1c lowering was  - 2.5% for BB and  - 1.4% for premixed regimens (no change cohorts). Overall, a greater proportion achieved HbA1c < 7% if they were (at baseline) taking fewer OADs, in a lower HbA1c category, and aged ≥ 65 years. Hypoglycaemia incidence (< 70 mg/dl) was higher with BB than premixed regimens and lower in patients aged < 65 years.

CONCLUSION

Greater HbA1c reductions, but a higher incidence of hypoglycaemia, were reported with BB versus premixed regimens, while both cohorts demonstrated clinically meaningful reductions in HbA1c during follow-up. After initiation, most premixed regimens remained unchanged, whereas switches from BB to less intensive regimens were numerous, in accordance with the use of BB for a limited duration to improve FPG and PPG control.

Type 2 diabetes: Prescription patterns and treatment outcomes of IDMPS survey in Argentina

AIM

To assess prescription patterns for treatment of type 2 diabetes (T2D) and their outcomes in the IDMPS survey in Argentina.

METHODS

Data from 2551 people with T2D recruited from 210 physicians participating in IDMPS surveys in Argentina (2006 to 2012 waves) were recorded, including medical history, medications, glycemic control, blood pressure, and lipid status.

RESULTS

Most people were treated with oral glucose-lowering drugs (OGLDs) (65%), followed by combinations of these drugs plus insulin (22%) and only insulin (13%). These percentages varied according to T2D duration, the frequency of OGLDs decreasing while contrastingly and only insulin increasing (under 5 years versus over 10 years of disease duration, respectively). Average systolic blood pressure (SBP), HbA1c and LDL-c were significantly higher in patients treated with insulin either alone or associated with OGLDs. The percentage of people at target values for these parameters was also lower in these two groups. The percentage of people that reached simultaneous goal treatment values for BP, HbA1c and LDL-c levels was markedly low.

CONCLUSION

Prescription patterns for treatment of T2D follows a chronological trend and the percentage of people at goal values (HbA1c, BP and LDL-c values) was significantly lower in people receiving insulin. These data must be carefully considered by health and academic authorities in order to implement effective strategies to modify this situation.

Dipeptidyl peptidase-4 inhibitors as add-on therapy to insulin in patients with type 2 diabetes mellitus: a meta-analysis of randomized controlled trials

PURPOSE

Addition of the dipeptidyl peptidase-4 (DPP4) inhibitors to insulin in patients with type 2 diabetes mellitus (T2DM) may achieve better glycemic control. However, results of pilot randomized controlled trials (RCTs) are inconsistent. We aimed to perform a meta-analysis of RCTs to evaluate efficacy and safety of DPP4 inhibitors compared with placebo/no treatment as add-on therapy to insulin in T2DM patients.

MATERIALS AND METHODS

Relevant studies were identified via a search of PubMed, Cochrane Library, and Embase databases. A fixed or random effect model was applied according to the heterogeneity.

RESULTS

Overall, 22 RCTs with 6,957 T2DM patients were included. Addition of DPP4 inhibitors to insulin was associated with significantly reduced HbA1c as compared with controls (weighed mean difference [WMD]: -0.54%, p<0.001). The benefits of DPP4 inhibitors as add-on therapy on HbA1c were independent of study design, follow-up duration, categories of DPP4 inhibitors used, and using of fixed/adjustable insulin doses as indicated by predefined subgroup analyses. Moreover, addition of DPP4 inhibitors to insulin was associated with significantly reduced fasting blood glucose (WMD: -0.47mmol/L, p<0.001), postprandial glucose at 2 hrs (WMD: -2.03 mmol/L, p<0.001), and daily dose of insulin (WMD: -2.73U/d, p<0.001), while body weight (WMD: 0.02 g, p=0.81) or risk of symptomatic hypoglycemia (risk ratio: 0.92, p=0.37) were not affected.

CONCLUSIONS

Addition of DPP4 inhibitors to insulin significantly improved the glycemic control in T2DM patients without further increasing the risk of weight gain and hypoglycemia.

The Discovery of Insulin: An Important Milestone in the History of Medicine

The discovery of insulin represents an authentic breakthrough, characterized, at the same time, by contrasts, controversies and disputes among scholars, as well as by great disappointments, failures and hopes. It is the story of famous, almost famous and little known people, of serendipities, discoveries and re-discoveries. The discovery of insulin has been a milestone and has truly revolutionized both the therapy and the prognosis of the diabetes, one of the diseases most studied in the history of medicine, whose first mentions trace back to a collection of ancient Egyptian, Indian and Chinese textbooks. As stated by Colwell, the introduction of insulin has heralded the end of the so-called "pre-insulin era" or "frustration era", paving the way for a new era and clinical advancements. The current review offers a broad, comprehensive overview of main steps culminating into insulin discovery, including recent advancements such as personalized and individualized insulin therapy.