Glycemic control with insulin glargine as part of an ethnically diverse, community-based diabetes management program

Insulin detemir for the treatment of obese patients with type 2 diabetes

The risk for developing type 2 diabetes (T2DM) is greater among obese individuals. Following onset of the disease, patients with T2DM become more likely to be afflicted with diabetic micro- and macrovascular complications. Decreasing body weight has been shown to lower glycosylated hemoglobin and improve other metabolic parameters in patients with T2DM. Medications used to lower blood glucose may increase body weight in patients with T2DM and this has been repeatedly shown to be the case for conventional, human insulin formulations. Insulin detemir is a neutral, soluble, long-acting insulin analog in which threonine-30 of the insulin B-chain is deleted, and the C-terminal lysine is acetylated with myristic acid, a C14 fatty acid chain. Insulin detemir binds to albumin, a property that enhances its pharmacokinetic/pharmacodynamic profile. Results from clinical trials have demonstrated that treatment with insulin detemir is associated with less weight gain than either insulin glargine or neutral protamine Hagedorn insulin. There are many potential reasons for the lower weight gain observed among patients treated with insulin detemir, including lower risk for hypoglycemia and therefore decreased defensive eating due to concern about this adverse event, along with other effects that may be related to the albumin binding of this insulin that may account for lower within-patient variability and consistent action. These might include faster transport across the blood-brain barrier, induction of satiety signaling in the brain, and preferential inhibition of hepatic glucose production versus peripheral glucose uptake. Experiments in diabetic rats have also indicated that insulin detemir increases adiponectin levels, which is associated with both weight loss and decreased eating.

Addressing cultural barriers to the successful use of insulin in Hispanics with type 2 diabetes

Hispanics experience a higher rate of diabetes than non-Hispanic whites and tend to have worse glycemic control and a greater risk of diabetes-related complications. Once oral antidiabetic agents become insufficient, insulin plays an important role in achieving glycemic goals. However, many Hispanic patients are resistant to initiating insulin therapy or hesitant to increase doses, as necessary, to control their glucose levels. Barriers to insulin therapy include socioeconomic issues (eg, cost, insurance status), language difficulties, poor health literacy, and cultural beliefs that impact the patient-provider relationship and negatively affect patients' perceptions of diabetes and insulin. Healthcare providers can help overcome these issues and improve patient-provider communication by practicing culturally competent care. Implementation of a simple titration regimen using once-daily basal insulin may enable Hispanic patients to maintain glycemic control and improve outcomes.