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Yao J, Guo X, Sun L, Han P, Lv X, Zhang X, Mo Z, Yang W, Zhang L, Wang Z, Zhu L, Li Q, Yang T, Wang W, Xue Y, Shi Y, Lu J, Peng Y, Zhang F, Yan D, Wang D, Yu X. Comparative efficacy and safety of two insulin aspart formulations (Rapilin and NovoRapid) when combined with metformin, for patients with diabetes mellitus: a multicenter, randomized, open-label, controlled clinical trial. Curr Med Res Opin 2022; 38:1797-1806. [PMID: 35833285 DOI: 10.1080/03007995.2022.2100652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE This phase 3 confirmatory diabetes mellitus treatment study compared the safety and efficacy of Rapilin and NovoRapid insulin asparts in combination with metformin. METHODS This 24-week, open-label, randomized, active-controlled, noninferiority phase 3 confirmatory study conducted across centers in China aimed to enroll patients with type 2 diabetes mellitus and blood sugar glucose inadequately controlled by oral antidiabetic drugs. Randomized patients received subcutaneous mealtime Rapilin or NovoRapid (3:1) injections, with metformin. The primary objectives were to demonstrate noninferiority (margin of 0.4%) in HbA1c change from baseline and compare safety profiles of Rapilin versus NovoRapid after 24 weeks. Secondary outcomes included 2-h postprandial plasma glucose (PPG), fasting plasma glucose (FPG), and patients achieving HbA1c <7.0% and ≤6.5%. RESULTS 590 patients with type 2 diabetes mellitus were randomized to Rapilin (n = 441) and NovoRapid (n = 149) groups. After 24 weeks, the mean HbA1c change from baseline was -2.20% (Rapilin) and -2.32% (NovoRapid); the estimated treatment difference based on least-square means was 0.04% (95% CI: -0.17, 0.26), meeting the noninferiority criteria for Rapilin versus NovoRapid. Comparable improvements were reported for mean 2-hour PPG (6.14 and 6.29 mmol/L), FPG (2.02 and 1.70 mmol/L), and patients with HbA1c <7.0% (52.6% and 51.0%) and ≤6.5% (34.2% and 30.9%), in the Rapilin and NovoRapid groups, respectively, with no significant safety or immunogenicity outcome differences. CONCLUSIONS Rapilin demonstrated non-inferior glycemic control, and matching safety and immunogenicity to NovoRapid in patients with type 2 diabetes mellitus also receiving metformin over 24 weeks. TRIAL REGISTRATION ChiCTR20003129041.
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Affiliation(s)
- Jun Yao
- Peking University First Hospital, Xicheng District, Beijing, China
| | - Xiaohui Guo
- Peking University First Hospital, Xicheng District, Beijing, China
| | - Li Sun
- Siping Central Hospital, Siping, China
| | - Ping Han
- Shengjing Hospital Affiliated to China Medical University, Tiexi District, Shenyang, China
| | - Xiaofeng Lv
- Chinese People's Liberation Army General Hospital of Beijing Military Region, No. 5, South Gate Warehouse, Dongcheng District, Beijing, China
| | - Xiuzhen Zhang
- Tongji Hospital Affiliated to Tongji University, Putuo District, Shanghai, China
| | - Zhaohui Mo
- Third Xiangya Hospital of Central South University, Yuelu District, Changsha, China
| | - Wenying Yang
- China-Japan Friendship Hospital, Sakura Garden, Chaoyang District, Beijing, China
| | - Lihui Zhang
- The second hospital of Hebei Medical University, Xinhua District, Shijiazhuang City, China
| | - Zhanjian Wang
- The third hospital of Hebei Medical University, Qiaoxi District, Shijiazhuang City, China
| | - Lvyun Zhu
- Bethune Peace Hospital, Qiaoxi District, Shijiazhuang City, China
| | - Quanmin Li
- The PLA Second Artillery General Hospital, Xicheng District, Beijing, China
| | - Tao Yang
- Jiangsu Province Hospital, Gulou District, Nanjing, China
| | - Wenbo Wang
- Peking University Shougang Hospital, Shijingshan District, Beijing, China
| | - Yaoming Xue
- Southern Medical University Nanfang Hospital, 1838, Baiyun District, Guangzhou City, China
| | - Yongquan Shi
- Shanghai Changzheng Hospital, Huangpu District, Shanghai, China
| | - Juming Lu
- The General Hospital of the People's Liberation Army, Haidian District, Beijing, China
| | - Yongde Peng
- Shanghai General Hospital, Hongkou District, Shanghai, China
| | - Fan Zhang
- Peking University Shenzhen Hospital, Futian District, Shenzhen City, China
| | - Dewen Yan
- The Second People's Hospital of Shenzhen, Futian District, Shenzhen City, China
| | - Damei Wang
- Gan & Lee Pharmaceuticals Co Ltd, Huoxian, Tongzhou District, Beijing, China
| | - Xuefeng Yu
- Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Qiao Estuary Hankou, Wuhan, China
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Chawla R, Mukherjee JJ, Chawla M, Kanungo A, Shunmugavelu MS, Das AK. Expert Group Recommendations on the Effective Use of Bolus Insulin in the Management of Type 2 Diabetes Mellitus. Med Sci (Basel) 2021; 9:38. [PMID: 34071359 PMCID: PMC8162981 DOI: 10.3390/medsci9020038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/22/2021] [Accepted: 05/25/2021] [Indexed: 11/16/2022] Open
Abstract
Evidence suggests a major contribution of postprandial glucose (PPG) excursions to the increased risk of micro- and macro-vascular complications in individuals with type 2 diabetes mellitus (T2DM). Administration of bolus insulin remains a very effective therapeutic option for PPG control. The aim of this expert group recommendation document was to provide practical and easy-to-execute guidelines for physicians on the appropriate use of bolus insulin in the management of T2DM. A panel of key opinion leaders from India reviewed and discussed the available clinical evidence and guideline recommendations on the following topics: (1) optimum control of PPG; (2) choice of bolus insulin; and (3) special situations and practical considerations. The expert panel critically analyzed the current literature and clinical practice guidelines and factored their rich clinical experience to develop a set of nine expert group recommendations for the effective use of bolus insulin. These recommendations will not only result in a more evidence-based application of bolus insulin in the clinical setting but also trigger further research and provide a valuable base for the development of future guidelines on the use of bolus insulin in the management of individuals with T2DM.
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Affiliation(s)
- Rajeev Chawla
- Department of Diabetology, North Delhi Diabetes Centre, 180, Jai Apartments, Sec 9, Rohini 110085, India;
| | - Jagat Jyoti Mukherjee
- Division of Endocrinology, Department of Medicine, Apollo Gleneagles Hospitals, 58, Canal Circular Road, Kolkata 700054, India
| | - Manoj Chawla
- Lina Diabetes Care and Mumbai Diabetes Research Centre, 704, Cosmos Plaza, Opp. Indian Oil Nagar, J.P. Road, Andheri (W), Mumbai 400053, India;
| | - Alok Kanungo
- Department of Diabetology, Kanungo Institute of Diabetes Specialities Pvt. Ltd., 1120, Dumduma, Bhubaneswar 751019, India;
| | - Meenakshi Sundaram Shunmugavelu
- Department of Diabetology, Trichy Diabetes Speciality Centre (P) Ltd. B-37, Sasthri Road, VII Cross East, Thillai Nagar, Trichy 620018, India;
| | - Ashok Kumar Das
- Department of Internal Medicine, Pondicherry Institute of Medical Sciences, Kalathumettupathai, Ganapathichettikulam Village, No 20, Kalapet, Puducherry 6050146, India;
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Pfohl M, Seufert J, Borck A, Bramlage P, Siegmund T. Effectiveness and Safety of Insulin Glulisine When Initiating Supplementary Prandial Insulin Treatment (SIT) in Insulin-Naïve Patients with Type 2 Diabetes: The Observational IGLU-SIT Study. Diabetes Ther 2021; 12:733-747. [PMID: 33544355 PMCID: PMC7947113 DOI: 10.1007/s13300-021-00998-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 01/06/2021] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION The IGLU-SIT study documented the effectiveness of initiating supplementary prandial insulin treatment (SIT) with insulin glulisine after failure of oral antidiabetic drugs alone in patients with type 2 diabetes (T2DM) in a real-world setting in Germany. METHODS The IGLU-SIT study was an open-label, prospective, multicentre, non-interventional study with an observation period of 12 ± 1 months. The primary objective was to determine the proportion of patients reaching their pre-defined glycosylated haemoglobin (HbA1c) goal at 3, 6, 9 and 12 months. Selected secondary objectives were absolute change in HbA1c, a 7-point blood glucose profile, and rate of hypoglycaemia. Data were evaluated overall and by age group (< 65, 65-74 and ≥ 75 years). RESULTS Overall, 215 patients with T2DM were observed in 64 centres. Baseline HbA1c was 8.3%, and mean HbA1c target was 6.8% (baseline 8.1% and target 6.9% in patients ≥ 75 years). Individual HbA1c target attainment in patients peaked at 38.9% (95% confidence interval [CI] 32.1-46.1%) after 12 months; this was 45.9% in patients aged ≥ 75 years. The mean HbA1c reduction was 1.12 ± 1.05% (p < 0.0001) with only minor differences by age group. A 7-point blood glucose profile revealed significant reductions (p < 0.0001) at all time-points. The rate of confirmed symptomatic hypoglycaemia was 2.2% (95% CI 0.7-5.1) during the 12-month follow-up; rates were increased in patients aged ≥ 75 years (7.0%; 95% CI 1.5-19.1) as were the rates of adverse events (17.8 vs. 6.1%). CONCLUSION Initiating SIT with insulin glulisine is an appropriate treatment option in patients whose T2DM is insufficiently controlled. Particular attention should be paid to elderly patients in whom higher attainment rates of treatment target were associated with adverse events. TRIAL REGISTRATION https://awbdb.bfarm.de ; Identifier: 6819; Date of registration: 23.06.2016.
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Affiliation(s)
- Martin Pfohl
- Department of Internal Medicine I, Bethesda-Hospital Duisburg, Evangelisches Krankenhaus Bethesda, Duisburg, Germany.
| | - Jochen Seufert
- Division of Endocrinology and Diabetology, Department of Medicine II, Faculty of Medicine, Medical Centre, University of Freiburg, Freiburg, Germany
| | - Anja Borck
- Sanofi-Aventis Deutschland GmbH, Berlin, Germany
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Thorsten Siegmund
- Division for Endocrinology, Diabetology and Metabolism, Isar Clinic, Munich, Germany
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Hermansen K, Bohl M, Schioldan AG. Insulin Aspart in the Management of Diabetes Mellitus: 15 Years of Clinical Experience. Drugs 2016; 76:41-74. [PMID: 26607485 PMCID: PMC4700065 DOI: 10.1007/s40265-015-0500-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Limiting excessive postprandial glucose excursions is an important component of good overall glycemic control in diabetes mellitus. Pharmacokinetic studies have shown that insulin aspart, which is structurally identical to regular human insulin except for the replacement of a single proline amino acid with an aspartic acid residue, has a more physiologic time-action profile (i.e., reaches a higher peak and reaches that peak sooner) than regular human insulin. As expected with this improved pharmacokinetic profile, insulin aspart demonstrates a greater glucose-lowering effect compared with regular human insulin. Numerous randomized controlled trials and a meta-analysis have also demonstrated improved postprandial control with insulin aspart compared with regular human insulin in patients with type 1 or type 2 diabetes, as well as efficacy and safety in children, pregnant patients, hospitalized patients, and patients using continuous subcutaneous insulin infusion. Studies have demonstrated that step-wise addition of insulin aspart is a viable intensification option for patients with type 2 diabetes failing on basal insulin. Insulin aspart has shown a good safety profile, with no evidence of increased receptor binding, mitogenicity, stimulation of anti-insulin antibodies, or hypoglycemia compared with regular human insulin. In one meta-analysis, there was evidence of a lower rate of nocturnal hypoglycemia compared with regular human insulin and, in a trial that specifically included patients with a history of recurrent hypoglycemia, a significantly lower rate of severe hypoglycemic episodes. The next generation of insulin aspart (faster-acting insulin aspart) is being developed with a view to further improving on these pharmacokinetic/pharmacodynamic properties.
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Affiliation(s)
- Kjeld Hermansen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Tage-Hansens Gade 2, 8000, Aarhus C, Denmark.
| | - Mette Bohl
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Tage-Hansens Gade 2, 8000, Aarhus C, Denmark
| | - Anne Grethe Schioldan
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Tage-Hansens Gade 2, 8000, Aarhus C, Denmark
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Home PD. The pharmacokinetics and pharmacodynamics of rapid-acting insulin analogues and their clinical consequences. Diabetes Obes Metab 2012; 14:780-8. [PMID: 22321739 DOI: 10.1111/j.1463-1326.2012.01580.x] [Citation(s) in RCA: 132] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Postprandial glucose excursions can inhibit achievement of good glycaemic control, and possibly have a specific effect on the risk of vascular comorbidities. Rapid-acting analogues control these excursions better than human insulin because their pharmacokinetic/pharmacodynamic (PK/PD) profile is closer to that of meal-time endogenous insulin secretion. Review of the findings of PK/PD studies and clinical trials suggests that the three marketed rapid-acting analogues--insulin lispro, insulin aspart and insulin glulisine--are equally efficacious and safe. In comparison with human insulin when using the same basal insulin, they provide comparable glycaemic control with a reduced risk of hypoglycaemia, although the combination of rapid-acting and basal analogues reduces glycated haemoglobin (HbA(1c)) more than human meal-time insulin combined with neutral protamine Hagedorn (NPH) insulin. Some studies have suggested that insulin glulisine has a slightly faster onset of action compared with insulin lispro or insulin aspart, but this has not been translated into demonstrable clinical benefit. Treatment satisfaction in patients with diabetes has been higher when therapy with a rapid-acting analogue is used instead of human insulin, perhaps due to differences in advised timing of injection. The largest benefits in efficacy, hypoglycaemia incidence, treatment satisfaction and quality of life have occurred when patients receive an all-analogue meal-time plus basal regimen as compared with an all-human insulin regimen. No new safety issues have been identified with the marketed rapid-acting analogues, and their insulin-like growth factor 1 receptor affinity and mitogenic activity are comparable to human insulin.
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Affiliation(s)
- P D Home
- Newcastle Diabetes Centre and Newcastle University, Newcastle upon Tyne, UK.
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Abstract
This article presents strategies on how to meet the challenges presented by the use of insulin in the hospital setting and describes trends seen in current hospital practice. Insulin provides the greatest flexibility in the hospital setting to achieve optimal blood glycemic control in patients with known type 2 diabetes, thereby reducing complications and death. Important challenges include implementing protocols for use of subcutaneous insulin injection (including optimal use of insulin pens), conversion from continuous subcutaneous insulin infusion or intravenous infusion to subcutaneous administration by multiple injections, and dosing of insulin in patients receiving corticosteroids. One important trend is a move away from the use of sliding-scale insulin to the use of correction-dose insulin as an adjunct to basal/bolus insulin. In this approach, insulin treatment is closely tailored to changing levels of glycemia, and a protocol is put in place for administration of a correction dose of rapid-acting insulin in response to a glycemic excursion. Insulin analogs can more closely mimic physiological insulin profiles than regular insulin, and rapid-acting analogs are invaluable agents as correction insulin administered by pump or in transition to multiple daily injections and as part of basal/bolus therapy. Good glycemic control can improve outcomes of hospital patients in several ways, including facilitating more rapid recovery from infections, shortening intensive care stays, and minimizing costs. Strategies employed to meet the challenges of insulin use in the hospital setting include the increasing use of continuous glucose monitoring systems and the development of insulin dosing algorithms.
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Affiliation(s)
- R. Keith Campbell
- College of Pharmacy, Washington State University, P.O. Box 6510, Pullman, WA 99164-6510
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Abstract
Type 2 diabetes mellitus affects 5.9% of the world adult population, with older people and some ethnic groups disproportionately affected. Treatment of older people with diabetes differs in many ways from that in younger adults since the majority have type 2 disease and are at particular risk of macrovascular rather than disabling microvascular disease. Insulin therapy, the most effective of diabetes medications, can reduce any level of elevated HBA1c if used in adequate doses. However, some clinicians are often reluctant to initiate insulin therapy in older people with diabetes mainly out of their concerns about adverse reactions to insulin, particularly hypoglycemia. There is evidence suggesting that insulin aspart appears to act similarly to regular human insulin in older people with type 2 diabetes mellitus. Insulin aspart can be used in the treatment of older people with diabetes, but this should be individualized. There is evidence that it improves postprandial glucose control, improves long-term metabolic control, reduces risk of major nocturnal hypoglycemia and increases patient satisfaction compared with soluble insulin.
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Affiliation(s)
- Eltayeb Marouf
- Institute of Diabetes for Older People – IDOP, Bedfordshire and Hertfordshire Postgraduate Medical School, University of Bedfordshire, UK
| | - Alan J Sinclair
- Institute of Diabetes for Older People – IDOP, Bedfordshire and Hertfordshire Postgraduate Medical School, University of Bedfordshire, UK
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Abstract
AIM To systematically review the literature regarding insulin use in patients with type 2 diabetes mellitus METHODS A Medline and Embase search was performed to identify randomized controlled trials (RCT) published in English between 1 January 2000 and 1 April 2008, involving insulin therapy in adults with type 2 diabetes mellitus. The RCTs must comprise at least glycaemic control (glycosylated haemoglobin (HbA1c), postprandial plasma glucose and /or fasting blood glucose (FBG)) and hypoglycaemic events as outcome measurements. RESULTS The Pubmed search resulted in 943 hits; the Embase search gave 692 hits. A total of 116 RCTs were selected by title or abstract. Eventually 78 trials met the inclusion criteria. The studies were very diverse and of different quality. They comprised all possible insulin regimens with and without combination with oral medication. Continuing metformin and/or sulphonylurea after start of therapy with basal long-acting insulin results in better glycaemic control with less insulin requirements, less weight gain and less hypoglycaemic events. Long-acting insulin analogues in combination with oral medication are associated with similar glycaemic control but fewer hypoglycaemic episodes compared with NPH insulin. Most of the trials demonstrated better glycaemic control with premix insulin therapy than with a long-acting insulin once daily, but premix insulin causes more hypoglycaemic episodes. Analogue premix provides similar HbA1c, but lower postprandial glucose levels compared with human premix, without increase in hypoglycaemic events or weight gain. Drawing conclusions from the limited number of studies concerning basal-bolus regimen seems not possible. Some studies showed that rapid-acting insulin analogues frequently result in a better HbA1c or postprandial glucose without increase of hypoglycaemia than regular human insulin. CONCLUSION A once-daily basal insulin regimen added to oral medication is an ideal starting point. All next steps, from one to two or even more injections per day should be taken very carefully and in thorough deliberation with the patient, who has to comply with such a regimen for many years.
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Affiliation(s)
- Mariëlle J P van Avendonk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
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Lippaiova N, Pallayova M, Kuzmina G, Peterson K, Fajkosova L, Luza J. Safety of new algorithms for premeal insulin boluses in high glycaemic index meals in persons with type 1 diabetes mellitus using insulin pumps. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2008; 152:73-7. [PMID: 18795078 DOI: 10.5507/bp.2008.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
AIMS Consumption of glucose or foodstuffs with high glycaemic index (GI) in persons with type 1 diabetes mellitus (PWD1) is a hot topic in present diabetology. The aim of our pilot prospective study was to assess the efficiency of empirically suggested simple algorithms for premeal boluses in PWD1 using insulin pumps and continuous glucose monitoring (CGM). METHODS Six PWD1 (aged 46.2+/-15.09 y, diabetes duration 14.5+/-9.65 y, HbA1c/IFCC 6.3+/-1.59%, BMI 23.6+/-1.67 kg/m(2), mean+/-SD) on insulin pumps Paradigm 522/722 with RT-CGMS sensors (Medtronic MiniMed, Northridge, CA) underwent a 12-week CGM. In one week, subjects consumed 50 g of carbohydrates in eleven alternative meals (rice squares, dark chocolate, white bread, honey, glucose, ravioli with meat and Eidam cheese, mashed potatoes with fish fingers, apricot dumplings with butter, spa waffles, spalta squares, and tomato soup with pasta) eaten for breakfasts, lunches, snacks and dinners in order to calculate their GI. The insulin boluses were adjusted according to empirically defined algorithms. Average glucose levels and daily insulin doses over three one-week periods (before testing, testing and after testing) were compared. RESULTS During the observational period, the weekly averages of glucose levels (9.1+/-2.33 mmol/l vs. 9.2+/-2.30 mmol/l vs. 9.0+/-2.43 mmol/l, respectively) and daily insulin doses (39.1+/- 8.14 IU/d vs. 39.7+/-10.7 IU/d vs. 38.6+/-9.97 IU/d, respectively) were similar. One-week consumption of high GI foodstuffs had only a negligeable effect on average glucose levels. CONCLUSION The suggested algorithms for premeal insulin boluses appear to limit the risk of potential hyperglycaemia resulting from intake of high GI foodstuffs.
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Affiliation(s)
- Natalia Lippaiova
- Department of Physiology, 2nd Department of Medicine, Faculty of Medicine and Dentistry, Palacký University, Olomouc, Czech Republic.
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Abstract
OBJECTIVE Type 2 diabetes is a progressive disease requiring constant monitoring of patients to ensure maintenance of glycemic goals and advancement of therapy when necessary. The challenges of treatment in rural areas may be different from those in urban areas. This review article will evaluate the barriers to treatment of type 2 diabetes and the role of insulin analogs in overcoming such barriers and in treating the disease, particularly with respect to rural communities. RESEARCH DESIGN AND METHODS A literature review of English language articles in the Medline Database was conducted to identify published articles through April 2008. Search terms included rural, diabetes, insulin, treatment, and treatment challenges/barriers and were used either alone or in various combinations with one another. Articles were included if they pertained to rural communities in the United States. Barriers related to treatment of type 2 diabetes and the role of insulin analogs in treatment and in overcoming such barriers, were examined. RESULTS Health-care providers and patients in rural areas face barriers both common to the general population and unique to the rural setting. Challenges include limited access to health care, lack of health-care resources, and lack of multidisciplinary staff. CONCLUSIONS A number of strategies exist, including simple, stepwise treatment algorithms for insulin therapy, to manage type 2 diabetes in rural populations effectively. Because this article focused on rural communities in the United States, barriers in other rural communities may not have been identified. Additionally, although Medline is one of the largest and most comprehensive databases of published medical literature, publications not in the Medline database have not been included in this analysis.
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Affiliation(s)
- Scott Nelson
- Cleveland Family Medicine, Cleveland, MS 38732, USA.
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