Consequences of Delaying Progression to Optimal Therapy in Patients with Type 2 Diabetes Not Achieving Glycemic Goals:

Real-World Effects of Second-Generation Versus Earlier Intermediate/Basal Insulin Analogues on Rates of Hypoglycemia in Adults with Type 1 and 2 Diabetes (iNPHORM, US)

INTRODUCTION

Second-generation basal insulin analogues have been shown to reduce hypoglycemia in several trials and observational studies of select populations; however, it remains unclear whether these results persist in real-world settings. Using self-reported hypoglycemia events, we assessed whether second-generation basal insulin analogues reduce rates of hypoglycemia events (non-severe/severe; overall/daytime/nocturnal) compared to earlier intermediate/basal insulin analogues among people with insulin-treated type 1 or 2 diabetes.

METHODS

We used prospectively collected data from the Investigating Novel Predictions of Hypoglycemia Occurrence Using Real-World Models (iNPHORM) panel survey. This US-wide, 1-year internet-based survey assessed hypoglycemia experiences and related sociodemographic and clinical characteristics of people with diabetes (February 2020-March 2021). We estimated population-average rate ratios for hypoglycemia comparing second-generation to earlier intermediate/basal insulin analogues using negative binomial regression, adjusting for confounders. Within-person variability of repeated observations was addressed with generalized estimating equations.

RESULTS

Among iNPHORM participants with complete data, N = 413 used an intermediate/basal insulin analogue for ≥ 1 month during follow-up. After adjusting for baseline and time-updated confounders, average second-generation basal insulin analogue users experienced a 19% (95% CI 3-32%, p = 0.02) lower rate of overall non-severe hypoglycemia and 43% (95% CI 26-56%, p < 0.001) a lower rate of nocturnal non-severe hypoglycemia compared to earlier intermediate/basal insulin users. Overall severe hypoglycemia rates were similar among second-generation and earlier intermediate/basal insulin users (p = 0.35); however, the rate of severe nocturnal hypoglycemia was reduced by 44% (95% CI 10-65%, p = 0.02) among second-generation insulin users compared to earlier intermediate/basal insulin users.

CONCLUSION

Our real-world results suggest second-generation basal insulin analogues reduce rates of hypoglycemia, especially nocturnal non-severe and severe events. Whenever possible and feasible, clinicians should prioritize prescribing these agents over first-generation basal or intermediate insulin in people with type 1 and 2 diabetes.

Effect of Glucose Levels on Cardiovascular Risk

Cardiovascular diseases remain the leading cause of death and disability. The development of cardiovascular diseases is traditionally associated with various risk factors, most of which are somehow related to an unhealthy lifestyle (smoking, obesity, lack of physical activity, etc.). There are also risk factors associated with genetic predisposition, as well as the presence of concomitant diseases, especially chronic ones. One of the most striking examples is, of course, type 2 diabetes. This metabolic disorder is associated with impaired carbohydrate metabolism. The main clinical manifestation of type 2 diabetes is elevated blood glucose levels. The link between diabetes and CVD is well known, so it is logical to assume that elevated glucose levels may be important, to some extent, in the context of heart and vascular disease. In this review, we tried to summarize data on the possible role of blood glucose as a risk factor for the development of CVD.

Emerging technologies for the management of type 2 diabetes mellitus

Diabetes mellitus is a global health problem affecting 422 million people worldwide, of which 34.2 million live in the United States alone. Complications due to diabetes can lead to considerable morbidity and mortality related to both microvascular and macrovascular disease. While glycosylated hemoglobin testing is the standard test utilized to evaluate glycemic control, emerging targets like "time in range" and "glycemic variability" often provide more accurate assessments of glycemic fluctuations and have implications for diabetes complications and quality of life. Patients with diabetes face considerable burdens of self-care including frequent glucose monitoring, multiple insulin injections, dietary management, and the need to track daily activities, all of which lead to reduced adherence and psychological burnout. From the provider perspective, limited patient data and access to self-management tools lead to treatment inertia and a reduced ability to help patients achieve and maintain their glycemic goals. In the past few decades, there have been considerable advances in treatment-based technology and technological applications designed to help reduce patient burden and provide tools for better self-management. These advances make real-time clinical data available for clinicians to make necessary changes in treatment regimens. In this review, we discuss the latest emerging technologies available for the management of people with type 2 diabetes mellitus.

Nudging physicians and patients with autopend clinical decision support to improve diabetes management

OBJECTIVES

To determine the impact on routine glycated hemoglobin (A1C) laboratory test completion of incorporating an autopend laboratory order functionality into clinical decision support, which (1) routed provider alerts to a separate electronic folder, (2) automatically populated preauthorization forms, and (3) linked the timing and content of electronic patient health maintenance topic (HMT) reminders to the provider authorization.

STUDY DESIGN

Observational pre-post study from November 2011 (1 year before autopend) through June 2014 (1.5 years after).

METHODS

The study included HMT reminders concerning an A1C test for patients with type 1 or type 2 diabetes (N = 15,630 HMT reminders; 8792 patients) in a large multispecialty ambulatory healthcare system. A Cox proportional hazard model, adjusted for patient and provider demographics, estimated the likelihood of laboratory test completion based on 3 HMT reminder characteristics: preautopend versus postautopend period, read versus unread, and the patient's time to reading.

RESULTS

In the postautopend period, the median time for patients to read reminders decreased (1 vs 3 days; P <.001) and the median time to complete laboratory tests decreased (40 vs 48 days; P <.001). Comparing preautopend HMT reminders with a similar time to reading, the likelihood of A1C laboratory test completion increased after autopend by between 21.1% (hazard ratio [HR], 1.211; P = .050), when time to reading was 57 days, and 33.9% (HR, 1.339; P = .003), when time to reading was 0 days. This result included 68% of the reminders. There was no statistical difference in A1C laboratory test completion for unread reminders in the preautopend versus postautopend period.

CONCLUSIONS

Automated patient-centered decision support can improve guideline-concordant monitoring of A1C among patients with diabetes, particularly among patients who read reminders in a timely fashion.

Glycaemic impact of treatment intensification in patients with type 2 diabetes uncontrolled with oral antidiabetes drugs or basal insulin

AIMS

To investigate the impact of treatment intensification (TI) on glycaemic outcomes in patients with type 2 diabetes with glycated haemoglobin A1c (A1C) ≥7% after ≥6 months of treatment with 2 oral antidiabetes drugs (OADs) or basal insulin (BI).

MATERIALS AND METHODS

Data were extracted from the Optum administrative claims database from 1 January 2009 to 31 August 2015. Patients with TI ≤6 months after the first A1C ≥7% (index date) were compared with patients with no TI (NTI). TI included addition of OAD, GLP-1 receptor agonist or premixed insulin in OAD and BI cohorts, addition of BI and/or bolus insulin in the OAD cohort and addition of bolus insulin or increasing BI dose in the BI cohort. Change from the index A1C value and hypoglycaemia events was compared at 12 months after TI after adjusting for confounders.

RESULTS

A total of 3990/28 123 (14.2%) and 10 425/16 140 (65%) of eligible adults in the OAD and BI cohorts, respectively, underwent TI. These patients showed greater adjusted A1C change vs NTI patients (OAD cohort: -0.59% vs -0.25%; BI cohort: -0.30% vs -0.16%; P < .001 for both comparisons), but with higher hypoglycaemia rates (OAD cohort: odds ratio [OR] 1.68; P < .001; BI cohort: OR: 1.23; P = .004) at follow-up.

CONCLUSIONS

Clinical inertia appears to be a significant issue in this population. Although associated with more frequent hypoglycaemia, these results demonstrate that timely TI improves A1C levels, highlighting the need for new and improved agents to effectively manage glycaemia while reducing hypoglycaemia risk.

Dapagliflozin as add-on therapy in Asian patients with type 2 diabetes inadequately controlled on insulin with or without oral antihyperglycemic drugs: A randomized controlled trial

BACKGROUND

This 24-week Phase 3 double-blind placebo-controlled study assessed the safety and efficacy of dapagliflozin as add-on to insulin, with or without oral antihyperglycemic drugs (OADs), in Asian patients with inadequately controlled type 2 diabetes mellitus.

METHODS

Adult patients with HbA1c between ≥7.5% and ≤10.5%, body mass index ≤45 kg/m² , and on insulin doses ≥20 IU daily were randomized to dapagliflozin 10 mg (n = 139) or placebo (n = 133) to assess 24-week changes in HbA1c (primary outcome), fasting plasma glucose (FPG), body weight, total daily dose of insulin (TDDI), and seated systolic blood pressure (SeSBP; exploratory outcome).

RESULTS

Baseline characteristics were similar in both groups. At Week 24, compared with placebo, dapagliflozin significantly improved HbA1c (mean [95% confidence interval] 0.03% [-0.11, 0.17] for placebo vs -0.87% [-1.00, -0.74] for dapagliflozin; between-group difference - 0.90% [-1.09, -0.71], P < 0.0001]), FPG, body weight, TDDI, and SeSBP. The incidence of adverse events (AEs) in the dapagliflozin and placebo groups was 80.5% and 71.2%, respectively, with few patients discontinuing due to AEs (dapagliflozin, 2.2%; placebo, 4.2%). The occurrence of hypoglycemia was similar in the dapagliflozin and placebo groups (23.7% and 22.6%, respectively; no major events). The frequency of urinary tract and genital infections was low; no deaths were reported.

CONCLUSIONS

Dapagliflozin as add-on to insulin, with or without OADs, significantly improved glycemic control and reduced body weight and blood pressure in Asian patients. Dapagliflozin was well tolerated, with a similar frequency of hypoglycemia in both groups. These results support the use of dapagliflozin as add-on to insulin, with or without OADs, in this population.

Emerging Technologies for Diabetes Care

New therapies, monitoring, and revolutionary enabling technologies applied to healthcare represent an historic opportunity to improve the lives of people with diabetes. These advances enable more meaningful monitoring of blood glucose values with the facilitation of more optimal insulin dosing and delivery. Newer insulins and delivery systems are in development that seek to mitigate both hyperglycemia and hypoglycemia and increase time in range. Information systems now exist that may be leveraged to merge data from previously discrete systems into new models of connected care. This review highlights important developments that serve to increase effectiveness while reducing the burden of diabetes care in the near future.

Clinical inertia and its impact on treatment intensification in people with type 2 diabetes mellitus

Many people with type 2 diabetes mellitus (T2DM) fail to achieve glycaemic control promptly after diagnosis and do not receive timely treatment intensification. This may be in part due to 'clinical inertia', defined as the failure of healthcare providers to initiate or intensify therapy when indicated. Physician-, patient- and healthcare-system-related factors all contribute to clinical inertia. However, decisions that appear to be clinical inertia may, in fact, be only 'apparent' clinical inertia and may reflect good clinical practice on behalf of the physician for a specific patient. Delay in treatment intensification can happen at all stages of treatment for people with T2DM, including prescription of lifestyle changes after diagnosis, introduction of pharmacological therapy, use of combination therapy where needed and initiation of insulin. Clinical inertia may contribute to people with T2DM living with suboptimal glycaemic control for many years, with dramatic consequences for the patient in terms of quality of life, morbidity and mortality, and for public health because of the huge costs associated with uncontrolled T2DM. Because multiple factors can lead to clinical inertia, potential solutions most likely require a combination of approaches involving fundamental changes in medical care. These could include the adoption of a person-centred model of care to account for the complex considerations influencing treatment decisions by patients and physicians. Better patient education about the progressive nature of T2DM and the risks inherent in long-term poor glycaemic control may also reinforce the need for regular treatment reviews, with intensification when required.

Association of more negative attitude towards commencing insulin with lower glycosylated hemoglobin (HbA1c) level: a survey on insulin-naïve type 2 diabetes mellitus Chinese patients

Background

Delay in commencing insulin among type 2 Diabetes Mellitus (DM) patients is common.  One of the reasons is patients' psychological insulin resistance, which is particularly prevalent in Chinese patients. This study examined the correlation between socio-demographic and clinical characteristics; and attitudes towards commencing insulin in Chinese primary care patients.

Method

A cross-sectional survey was conducted on 303 insulin-naïve Type 2 DM patients recruited from 15 primary care clinics across Hong Kong using the Chinese Attitudes to Starting Insulin Questionnaire (Ch-ASIQ). Subject selection criteria were patients on maximal oral anti-diabetes treatment who needed to commence insulin therapy. Linear regression was used to identify correlations between age, sex, educational level, occupation, body mass index, diabetes disease duration, laboratory test indicating disease control and biochemical markers including glycosylated hemoglobin (HbA1c) level, low density lipoprotein level and estimated glomeruli filtration rate, and presence of diabetic complications with the four sub-scales (self-image and stigmatization; factors promoting self-efficacy; fear of pain or needles; time and family support ) and the overall Ch-ASIQ score.

Results

The most prevalent negative attitude was ‘fear of needle injections’ (70.1 %). The most common positive attitude was ‘I can manage the skill of injecting insulin’ (67.5 %). The mean Ch-ASIQ score of 2.50 (S.D. = 0.38) was equal to the mid-score, which signified an overall ambivalent attitude among the study population. Women scored significantly higher in the fear of pain or needles subscale (p = 0.011) and had an overall more negative attitude towards commencing insulin (p = 0.016). Subjects with lower HbA1c levels also had a significantly lower Ch-ASIQ sum score (p = 0.048) indicating a more negative attitude towards commencing insulin.

Conclusion

In Chinese primary care patients with Type 2 DM, the need to commence insulin was associated with a number of negative emotions, which lead to a lower motivation to accept treatment. Perception of need as indicated by HbA1c level may be an important influencing factor determining a patient’s overall attitude towards starting insulin. Fortunately, in our setting, the injection technique does not appear to be a major barrier. However, needle fears are common, especially amongst women. Target interventions to acknowledge and help them to overcome their fears are essential before insulin treatment is commenced.

Clinical course after five years of insulin therapy in patients with type 2 diabetes in Spain: results of the EDIN study

OBJECTIVES

The primary study objective was to assess the proportion of patients with type 2 diabetes and an HbA1c value ≤ 6.5% from the start of insulin therapy to five years later in the outpatient setting in Spain.

MATERIAL AND METHODS

This was an observational, multicenter, naturalistic study with retrospective collection of clinical data. Investigators were endocrinologists or internal medicine specialists from all over Spain. During standard clinical care, patients started insulin therapy, which was continued for at least 5 years.

RESULTS

The clinical records of 405 patients were reviewed. The final analysis set included records from 346 patients. At baseline (start of insulin therapy), 51.2% of patients were female; mean (SD) age was 64.6 (9.0) years; body mass index, 29.8 (4-5) kg/m(2); time since diagnosis, 8.8 (6.8) years; HbA1c, 9.4% (1.5); fasting glucose, 223.7 (55.9) mg/dL; and mean 2-hour postprandial glucose, 293.6 (71.0) mg/dL. When insulin therapy was started, <1.0% of patients had an HbA1c value ≤ 6.5%. At 5 years, 10.3% of patients achieved the HbA1c goal of ≤ 6.5% (mean, 7.72%). All glucose parameters (HbA1c, fasting glucose, and 2-hour postprandial glucose) improved at 5 years as compared to values at the start of insulin therapy.

CONCLUSIONS

Glucose parameters improved over time in patients with type 2 diabetes in this naturalistic study. However, blood glucose control exceeded the internationally recommended target values. These results therefore suggest that there is still some margin for improvement in outpatient care in Spain.

Long-term safety and efficacy of tofogliflozin, a selective inhibitor of sodium-glucose cotransporter 2, as monotherapy or in combination with other oral antidiabetic agents in Japanese patients with type 2 diabetes mellitus: multicenter, open-label, randomized controlled trials

OBJECTIVE

To evaluate long-term safety and efficacy of tofogliflozin in Japanese patients with type 2 diabetes as monotherapy or in combination with other oral antidiabetic agents, we conducted 52-week, open-label, randomized controlled trials.

RESEARCH DESIGN AND METHODS

The single-agent trial included patients with inadequate glycemic control on diet and exercise, whereas the add-on trial included those uncontrolled with any of the oral antidiabetic agents. In both trials, patients were randomly assigned to receive tofogliflozin 20 or 40 mg once daily orally for 52 weeks.

MAIN OUTCOME MEASURES

Safety assessments.

RESULTS

A total of 194 patients (65, 20-mg group; 129, 40-mg group) were enrolled into the single-agent trial, whereas 602 (178 and 424, respectively) were enrolled into the add-on trial. Tofogliflozin was well tolerated for 52 weeks in both trials with < 6% of treatment discontinuation because of adverse events in each treatment group. It also reduced hemoglobin A1c. In the single-agent trial, mean reductions at 52 weeks were 0.67 and 0.66% in the 20- and 40-mg groups, respectively. In the add-on trial, mean reductions ranged from 0.71 to 0.93% across the subgroups by dose and background therapy.

CONCLUSION

Tofogliflozin was well tolerated and showed sustained efficacy in both trials.

Clinical outcomes and costs for patients with type 2 diabetes mellitus initiating insulin therapy in Greece: two-year experience from the INSTIGATE study

AIMS

To evaluate the quality of metabolic control, clinical outcomes, resource costs, and quality of life among patients with type 2 diabetes mellitus (T2DM), who initiated insulin for the first time as part of routine clinical practice.

METHODS

The INSTIGATE study is a prospective, multicentric, observational study of patients initiating insulin treatment. This sub-cohort analysis focuses on Hellenic outcomes.

RESULTS

At baseline, 263 Greek patients were enrolled just before initiating insulin for the first time. At the 6-month visit, 237 patients (90.1%) remained and consented to an additional 18-month observation period. In these 237 extension patients, over the 24-month post-initiation period, HbA1c (mean(SD)) decreased from 9.7%(1.6%) to 7.1%(0.9%) and body weight and BMI increased (+3(6)kg and +1.1(2.2)kg/m(2), respectively). At each post-baseline visit approximately one in five patients reported ≥1 episodes of hypoglycaemia in the preceding 3-6 months. Median total costs fluctuated from 438€ at baseline to 538€ up to 6 months and 451€ at 24 months; mean costs were 496(383)€, 573(276)€ and 485(247)€, respectively.

CONCLUSIONS

In this cohort, insulin treatment seems to be effective with little long-term impact on cost. Findings should be interpreted in the context of an observational study.

Clinical outcomes after 24 months of insulin therapy in patients with type 2 diabetes in five countries: results from the TREAT study

OBJECTIVE

To assess factors associated with insulin regimens at initiation, changes in treatment and metabolic control over 2 years of insulin therapy in patients with type 2 diabetes in five countries.

RESEARCH DESIGN AND METHODS

TREAT was a prospective, 24 month, observational study in patients with type 2 diabetes initiating insulin in clinical practice. Patient characteristics were collected at baseline and metabolic outcomes at 3, 6, 12, 18 and 24 months after initiation.

RESULTS

A total of 985 patients were enrolled, 886 assessed at baseline and 734 (82.8%) at 24 months. Baseline characteristics varied between countries: 52.8% of patients were men; mean age was 60.4 years; body mass index, 29.7 kg/m²; time since diagnosis, 10.1 years; HbA1c, 9.6%. Less than 25% of patients met ADA/IDF targets for blood pressure/LDL cholesterol. Overall, 50.1% of patients were initiated on long/intermediate insulin, 39.3% on mixture and 7.8% on basal-bolus; distribution varied between countries. Patients on long/intermediate were more likely to have lower baseline HbA1c and be intensified to other regimens (19.4%). No oral antidiabetic medication was used for 16.4% initiating on long/intermediate, 47.4% on mixture and 62.3% with basal-bolus. Overall, mean HbA1c decreased from 9.6% to 7.6%, with little difference between regimens at endpoint. The percentage of patients with hypoglycaemia was highest at 6 months and with basal-bolus.

LIMITATIONS

Sites were not selected at random. Drop-out of patients prior to 24 months may have introduced a bias that favoured responders.

CONCLUSIONS

Mean baseline HbA1c was high, indicating delayed initiation of insulin treatment. Blood pressure and lipids were suboptimally controlled. Insulin regimens varied between countries, changed little and resulted in similar HbA1c levels after 24 months.

Barriers and solutions to diabetes management: An Indian perspective

India, with one of the largest and most diverse populations of people living with diabetes, experiences significant barriers in successful diabetes care. Limitations in appropriate and timely use of insulin impede the achievement of good glycemic control. The current article aims to identify solutions to barriers in the effective use of insulin therapy viz. its efficacy and safety, impact on convenience and life-style and lack of awareness and education. Therapeutic modalities, which avoid placing an undue burden on patients' life-style, must be built. These should incorporate patient-centric paradigms of diabetes care, team-based approach for life-style modification and monitoring of patients' adherence to therapy. To address the issues in efficacy and safety, long-acting, flat profile basal insulin, which mimics physiological insulin and show fewer hypoglycemic events is needed. In addition, therapy must be linked to monitoring of blood glucose to enable effective use of insulin therapy. In conjunction, wide-ranging efforts must be made to remove negative perception of insulin therapy in the community. Patient- and physician - targeted programs to enhance awareness in various aspects of diabetes care must be initiated across all levels of health-care ensuring uniformity of information. To successfully address the challenges in facing diabetes care, partnerships between various stakeholders in the care process must be explored.

Determinants and consequences of insulin initiation for type 2 diabetes in France: analysis of the National Health and Wellness Survey

BACKGROUND

The aim of the study was to identify the intrinsic patient characteristics and extrinsic environmental factors predicting prescription and use and, more specifically, early initiation (up to 5 years of disease duration) of insulin for type 2 diabetes in France. A secondary objective was to evaluate the impact of insulin therapy on mental and physical quality of life and patient adherence.

METHODS

The data used in this study were derived from the 2008, 2010, and 2011 France National Health and Wellness Survey. This survey is an annual, cross-sectional, self-administered, Internet-based questionnaire among a nationwide representative sample of adults (aged 18 years or older). Of the total of 45,958 persons recruited in France, 1,933 respondents (deduped) were identified as diagnosed with type 2 diabetes. All unique respondents from the three waves, currently using insulin or oral bitherapy or tritherapy at the time of assessment, were included in this analysis.

RESULTS

Early (versus late) initiation of insulin therapy was 9.9 times more likely to be prescribed by an endocrinologist or diabetologist than by a primary care physician (P < 0.0001). Younger age at diagnosis and current smoking habits were significant predictors of early (versus late) insulin initiation (odds ratio [OR] 1.031, 95% confidence interval [CI] 1.005-1.059, P = 0.0196, and OR 2.537, 95% CI 1.165-5.524, P = 0.0191, respectively). Patients with a yearly income ≥€50,000 were less likely to be put on insulin early (P = 0.0399). A link between insulin prescription and complications was shown only in univariate analysis. Mental quality of life was lower in patients on early (versus late) insulin, but only in patients with diabetes-related complications. Insulin users (versus oral bitherapy or tritherapy users) had 3.0 times greater odds of being adherent than uncontrolled oral bitherapy or tritherapy users (OR 2.983, 95% CI 1.37-6.495, P = 0.0059).

CONCLUSION

This study confirms the role of specialists in early initiation of insulin, and the data presented herein reflect the fact that early initiation is more frequent in younger patients, patients with diabetes-related complications, and current smokers, and less frequent in patients with a higher income. Moreover, we observed that being treated with insulin was not associated with deterioration in quality of life, and insulin-treated patients were more often adherent than uncontrolled oral bitherapy or tritherapy users. These data suggest that doctors' concerns about patient adherence and detrimental effects on quality of life should not be a barrier to their decision regarding early initiation of insulin therapy. Due to the nature of this cross-sectional survey (eg, inability to assess treatment flow), further research is needed to confirm its findings.

Low risk of severe hypoglycaemia in patients with type 2 diabetes mellitus starting insulin therapy with premixed insulin analogues BID in outpatient settings

AIMS

The choice of insulin at initiation in type 2 diabetes remains controversial. The aim of this study was to assess the occurrence of self-reported severe hypoglycaemia associated with premixed insulin analogues in routine clinical care.

METHODS

A 12-month, prospective, observational, multicentre study in patients starting a commonly prescribed premixed insulin analogue (either insulin lispro 25/75 or biphasic insulin aspart 30/70, twice daily) after suboptimal glycaemic control on oral antidiabetic agents. Treatment decisions were made solely in the course of usual practice.

RESULTS

Study follow-up was completed by 991 (85.5%) of the 1150 patients enrolled. At baseline, mean (SD) age was 57.9 (10.1) years; mean diabetes duration was 9.2 (5.9) years; mean haemoglobin A(1c) (HbA(1c)) was 9.9 (1.8) % and the rate of severe hypoglycaemia was 0.03 episode/patient-year. At 12 months, the rate of severe hypoglycaemia was 0.04 episode/patient-year (95% CI 0.023, 0.055 episode/patient-year) and mean insulin dose was 41.5 (19.4) units. Changes from baseline to 12 months for mean fasting plasma glucose and HbA(1c) were -5.1 mmol/l and -2.5%, respectively.

CONCLUSIONS

After initiation of premixed insulin analogues in patients with type 2 diabetes in real-world settings, the incidence of severe hypoglycaemia was lower than expected from previously reported studies.

Weight changes and their predictors amongst 11 140 patients with type 2 diabetes in the ADVANCE trial

AIMS

To determine the baseline characteristics and glucose-lowering therapies associated with weight change among patients with type 2 diabetes.

METHODS

Eleven thousand one hundred and forty participants in the ADVANCE trial were randomly assigned to an intensive [aiming for a haemoglobin A1c (HbA1c) ≤6.5%] or a standard blood glucose-control strategy. Weight was measured at baseline and every 6 months over a median follow-up of 5 years. Multivariable linear regression and linear-mixed effect models were used to examine predictors of weight change.

RESULTS

The mean difference in weight between the intensive and standard glucose-control arm during follow-up was 0.75 kg (95% CI: 0.56-0.94), p-value <0.001. The mean weight decreased by 0.70 kg (95% CI: 0.53-0.87), p < 0.001 by the end of follow-up in the standard arm but remained stable in the intensive arm, with a non-significant gain of 0.16 kg (95% CI: -0.02 to 0.34), p = 0.075. Baseline factors associated with weight gain were younger age, higher HbA1c, Caucasian ethnicity and number of glucose-lowering medications. Treatment combinations including insulin [3.22 kg (95% CI: 2.92-3.52)] and thiazolidinediones [3.06 kg (95% CI: 2.69-3.43)] were associated with the greatest weight gain while treatment combinations including sulphonylureas were associated with less weight gain [0.71 kg (95%CI: 0.39-1.03)].

CONCLUSIONS

Intensive glucose-control regimens are not necessarily associated with substantial weight gain. Patient characteristic associated with weight change were age, ethnicity, smoking and HbA1c. The main treatment strategies predicting weight gain were the use of insulin and thiazolidinediones.

[Therapeutic approach to dyslipidemia and goal achievement in a Spanish population with type 2 diabetes without cardiovascular disease]

OBJECTIVE

To assess the therapeutic approach and lipid goal achievement in a spanish diabetic population at high cardiovascular risk.

SUBJECTS AND METHODS

A multicenter, descriptive, cross-sectional study consecutively recruited the first 10 patients who attended the primary care office and had been seen in the 12 months prior to the study visit. Inclusion criteria were type 2 diabetes without cardiovascular disease, LDL cholesterol levels ≤160mg/dL, triglyceride levels ≤600mg/dL, and at least one of the following: retinopathy, albuminuria, current smoking, or hypertension.

RESULTS

A total of 2412 patients were evaluated (aged 61.3±8.3 years, 46.8% women, diabetes duration 8.6±7.4 years). As compared to the previous visit (8.1±5 months before), the proportion of patients who achieved LDL-C levels <100mg/dL (22.7% vs 28.6%), non-HDL-C levels <130mg/dL (27.7% vs 33.8%) and both goals (17.6% vs 22.1%) significantly increased at the time of assessment. Statins were the most widely prescribed lipid-lowering drugs (65.5%) and the lipid-lowering drug was changed from the previous visit in 38.7% of patients, drug dosage was increased in 17.3%, and another drug was added in 5%.

CONCLUSION

Use of more potent statins and higher statin doses were the most commonly used therapeutic strategies for improving control of dyslipidemia in patients with type 2 diabetes, but these changes were clearly inadequate to achieve lipid goals in most patients with type 2 diabetes.

A look into the future: improving diabetes care by 2015

Insulin initiation, which was traditionally the province of specialists, is increasingly undertaken by primary care. However, significant barriers to appropriate and timely initiation still exist. Whilst insulin is recognized as providing the most effective treatment in type 2 diabetes, it is also widely considered to be the most challenging and time consuming. This editorial identifies that the organization of existing healthcare services, the challenges faced by patients, and the treatments themselves contribute to suboptimal insulin management. In order to improve future diabetes care, it will be necessary to address all three problem areas: (1) re-think the best use of existing human and financial resources to promote and support patient self-management and adherence to treatment; (2) empower patients to participate more actively in treatment decision making; and (3) improve acceptance, persistence and adherence to therapy by continuing to refine insulin therapy and treatment regimens in terms of safety, simplicity and convenience. The principles discussed are also applicable to the successful management of any chronic medical illness.

Renal glucose reabsorption inhibitors to treat diabetes

Current therapies to reduce hyperglycaemia in type 2 diabetes mellitus (T2DM) mostly involve insulin-dependent mechanisms and lose their effectiveness as pancreatic β-cell function declines. In the kidney, filtered glucose is reabsorbed mainly via the high-capacity, low-affinity sodium glucose cotransporter-2 (SGLT2) at the luminal surface of cells lining the first segment of the proximal tubules. Selective inhibitors of SGLT2 reduce glucose reabsorption, causing excess glucose to be eliminated in the urine; this decreases plasma glucose. In T2DM, the glucosuria produced by SGLT2 inhibitors is associated with weight loss, and mild osmotic diuresis might assist a reduction in blood pressure. The mechanism is independent of insulin and carries a low risk of hypoglycaemia. This review examines the potential of SGLT2 inhibitors as a novel approach to the treatment of hyperglycaemia in T2DM.

Clinical inertia in management of T2DM

Diabetes is highly prevalent and serious chronic debilitating disease and reported to be the fourth main cause of death in Europe. Despite extensive evidence of benefits of tight glycemic control, large proportions of people with diabetes do not achieve target glycemic control. One major reason for this is clinical inertia which is "recognising the problem but failure to act" by health care professionals in primary care. The key issues in the management of people with T2DM include early detection of problems, realistic goal setting, improved patient adherence, better knowledge and understanding of pharmacotherapeutic treatment options and prompt intervention. Health care professionals must need to overcome clinical inertia and need to intensify therapy in an appropriate and timely manner.

Therapeutics of diabetes mellitus: focus on insulin analogues and insulin pumps

Aim. Inadequately controlled diabetes accounts for chronic complications and increases mortality. Its therapeutic management aims in normal HbA1C, prandial and postprandial glucose levels. This review discusses diabetes management focusing on the latest insulin analogues, alternative insulin delivery systems and the artificial pancreas. Results. Intensive insulin therapy with multiple daily injections (MDI) allows better imitation of the physiological rhythm of insulin secretion. Longer-acting, basal insulin analogues provide concomitant improvements in safety, efficacy and variability of glycaemic control, followed by low risks of hypoglycaemia. Continuous subcutaneous insulin infusion (CSII) provides long-term glycaemic control especially in type 1 diabetic patients, while reducing hypoglycaemic episodes and glycaemic variability. Continuous subcutaneous glucose monitoring (CGM) systems provide information on postprandial glucose excursions and nocturnal hypo- and/or hyperglycemias. This information enhances treatment options, provides a useful tool for self-monitoring and allows safer achievement of treatment targets. In the absence of a cure-like pancreas or islets transplants, artificial “closed-loop” systems mimicking the pancreatic activity have been also developed. Conclusions. Individualized treatment plans for insulin initiation and administration mode are critical in achieving target glycaemic levels. Progress in these fields is expected to facilitate and improve the quality of life of diabetic patients.

Medication use for diabetes, hypertension, and hypercholesterolemia from 1988-1994 to 2001-2006

The objective of this study was to compare rates of use of medications for diabetes, hypertension, and hypercholesterolemia between 1988-1994 and 2001-2006 and determine whether increased medication use may be partly attributable to nonadherence to healthy lifestyle habits. This study analyzed and compared data from two different time periods in the National Health and Nutrition Examination Survey (NHANES). Disease prevalence rates increased 23% (P < 0.01), and medication use increased 121% (P < 0.05) over the study's period. Diabetes medication use increased from 5.3% to 8.7%, antihypertension medication from 23.0% to 32.4%, and cholesterol-lowering medication from 4.5% to 16.7% (all P < 0.05). By race, diabetes medication use increased most among Hispanics (7.2% to 13.2%), antihypertension use increased most among non-Hispanic blacks (30.8% and 39.6%), and cholesterol medication increased most in non-Hispanic whites (4.9% to 17.8%) (all P < 0.05). Greater adherence to healthy lifestyle habits was associated with less use of medication (P < 0.01). Medication use for diabetes, hypertension, and hypercholesterolemia has increased between 1988-1994 and 2001-2006 and is greater in people with fewer healthy lifestyle habits.

Health Care Disparities and Diabetes Care: Practical Considerations for Primary Care Providers

Disparities in diabetes care are prevalent in the United States. This article provides an overview of these disparities and discusses both potential causes and efforts to address them to date. The authors focus the discussion on aspects relevant to the patient-provider dyad and provide practical considerations for the primary care provider's role in helping to diminish and eliminate disparities in diabetes care.