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Emad-Eldin M, Balata GF, Elshorbagy EA, Hamed MS, Attia MS. Insulin therapy in type 2 diabetes: Insights into clinical efficacy, patient-reported outcomes, and adherence challenges. World J Diabetes 2024; 15:828-852. [PMID: 38766443 PMCID: PMC11099362 DOI: 10.4239/wjd.v15.i5.828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 02/01/2024] [Accepted: 03/20/2024] [Indexed: 05/10/2024] Open
Abstract
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.
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Affiliation(s)
- Mahmoud Emad-Eldin
- Department of Pharmacy Practice, Faculty of Pharmacy, Zagazig University, Zagazig HFQM+872, Al-Sharqia Governorate, Egypt
| | - Gehan F Balata
- Department of Pharmacy Practice, Faculty of Pharmacy, Heliopolis University, Cairo 44519, Egypt
- Department of Pharmaceutics, Faculty of Pharmacy, Zagazig University, Zagazig 44519, Al-Sharqia Governorate, Egypt
| | - Eman A Elshorbagy
- Department of Internal Medicine, Faculty of Medicine, Zagazig University, Zagazig 44519, Al-Sharqia Governorate, Egypt
| | - Mona S Hamed
- Department of Community at Faculty of Medicine, Zagazig University, Zagazig 44519, Al-Sharqia Governorate, Egypt
| | - Mohamed S Attia
- Department of Pharmaceutics, Faculty of Pharmacy, Zagazig University, Zagazig 44519, Al-Sharqia Governorate, Egypt
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Sethi B, Unnikrishnan AG, Ayyar V, Jabbar PK, Ganguly KK, Bhandari S, Rastogi A, Mukherjee R, Sundaram V, Asirvatham AR. Twenty Years of Insulin Gla-100: A Systematic Evaluation of Its Efficacy and Safety in Type 2 Diabetes Mellitus. Diabetes Ther 2022; 13:1409-1481. [PMID: 35768707 PMCID: PMC9309110 DOI: 10.1007/s13300-022-01284-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 05/19/2022] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION This systematic review aims to present the current evidence base with respect to the initiation and intensification of insulin therapy with glargine 100 U/mL (Gla-100) compared to other insulins in people with type 2 diabetes mellitus (T2DM). METHODS A systematic literature search of PubMed (MEDLINE), EMBASE, and the Cochrane Central Register of controlled clinical trials databases was performed to identify studies published up to September 30, 2020 that compared the effects of Gla-100 to that of other insulin regimens in people with T2DM. Relevant information pertaining to the predefined outcomes of interest was extracted. Glycated hemoglobin (HbA1c) change and response rates along with overall hypoglycemia incidence were the primary efficacy and safety outcomes of interest. RESULTS Seventy-nine studies (63 interventional and 16 non-interventional) in which Gla-100 was either initiated in previously insulin-naïve patients (n = 57) or used in an intensified regimen (n = 22) were identified and evaluated. In insulin-naïve patients, most studies demonstrated that Gla-100 was significantly better compared with premixed insulins and similar compared with neutral protamine Hagedorn (NPH) insulin, second-generation basal insulins, co-formulations, and other first-generation basal insulins in terms of the primary efficacy parameters. Overall hypoglycemia risk with Gla-100 was significantly lower compared with NPH, premixed, coformulation, and other first-generation basal insulins and significantly higher compared with second-generation basal insulins. In studies with intensified regimens, efficacy outcomes with Gla-100 were significantly better compared with insulin detemir (IDet); similar compared with NPH, second-generation basal insulins, co-formulations; and with premixed insulins. In these studies, overall hypoglycemia risk with Gla-100 was significantly lower compared with IDet and comparable to NPH, premixed insulins, co-formulations, and second-generation basal insulins. In addition, most intensification studies also revealed a significantly lower risk of nocturnal hypoglycemia with Gla-100-based regimens versus NPH and premixed insulins and a significantly greater risk compared to second-generation basal insulins. CONCLUSIONS The evidence presented in this review suggests that Gla-100 is an effective option for both insulin initiation and intensification strategies used in the management of T2DM.
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Affiliation(s)
- Bipin Sethi
- Department of Endocrinology, Care Hospitals, Hyderabad, Telangana, India.
| | - A G Unnikrishnan
- Department of Endocrinology, Chellaram Diabetes Institute, Pune, Maharashtra, India
| | - Vageesh Ayyar
- Department of Endocrinology, St. John's Hospital, Bangalore, Karnataka, India
| | - P K Jabbar
- Department of Endocrinology, Medical College, Trivandrum, Kerala, India
| | - K K Ganguly
- Department of Endocrinology, Peerless Hospital, Kolkata, West Bengal, India
| | | | - Ashu Rastogi
- Department of Endocrinology and Metabolism, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, Punjab, India
| | | | - Vivek Sundaram
- Department of Diabetes and Internal Medicine, Sundaram Hospital, Trichy, Tamil Nadu, India
| | - Adlyne R Asirvatham
- Department of Endocrinology, Sri Ramachandra Medical College, Tamil Nadu, Chennai, India
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Forst T, Choudhary P, Schneider D, Linetzky B, Pozzilli P. A practical approach to the clinical challenges in initiation of basal insulin therapy in people with type 2 diabetes. Diabetes Metab Res Rev 2021; 37:e3418. [PMID: 33098260 PMCID: PMC8519070 DOI: 10.1002/dmrr.3418] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 07/17/2020] [Accepted: 08/09/2020] [Indexed: 12/18/2022]
Abstract
Initiating insulin therapy with a basal insulin analogue has become a standard of care in the treatment of type 2 diabetes mellitus (T2DM). Despite increasing choices in pharmacological approaches, intensified glucose monitoring and improvements in quality of care, many patients do not achieve the desired level of glycaemic control. Although insulin therapy, when optimized, can help patients reach their glycaemic goals, there are barriers to treatment initiation on both the side of the patient and provider. Providers experience barriers based on their perceptions of patients' capabilities and concerns. They may lack the confidence to solve the practical problems of insulin therapy and avoid decisions they perceive as risky for their patients. In this study, we review recommendations for basal insulin initiation, focussing on glycaemic targets, titration, monitoring, and combination therapy with non-insulin anti-hyperglycaemic medications. We provide practical advice on how to address some of the key problems encountered in everyday clinical practice and give recommendations where there are gaps in knowledge or guidelines. We also discuss common challenges faced by people with T2DM, such as weight gain and hypoglycaemia, and how providers can address and overcome them.
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Affiliation(s)
- Thomas Forst
- Department of Endocrinology and Metabolic DiseasesUniversitatsmedizin der Johannes GutenbergMainzGermany
- Clinical Research ServicesManhheimGermany
| | - Pratik Choudhary
- Department of Diabetes and Nutritional SciencesKing's CollegeLondonUK
| | | | | | - Paolo Pozzilli
- Department of Endocrinology and Metabolic DiseasesUniversità Campus Bio‐MedicoRomeItaly
- Centre of ImmunobiologyBarts and the London School of MedicineQueen Mary University of LondonUK
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Liu SC, Lee CC, Chuang SM, Sun FJ, Zeng YH. Comparison of efficacy and safety of empagliflozin vs linagliptin added to premixed insulin in patients with uncontrolled type 2 diabetes: A randomized, open-label study. DIABETES & METABOLISM 2021; 47:101184. [DOI: 10.1016/j.diabet.2020.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 08/05/2020] [Accepted: 08/08/2020] [Indexed: 01/10/2023]
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Gabler M, Picker N, Geier S, Foersch J, Aberle J, Martin S, Riedl M, Wilke T. Real-world clinical outcomes and costs in type 2 diabetes mellitus patients after initiation of insulin therapy: A German claims data analysis. Diabetes Res Clin Pract 2021; 174:108734. [PMID: 33737213 DOI: 10.1016/j.diabres.2021.108734] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 02/04/2021] [Accepted: 02/22/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND This study describes real-world treatment-related outcomes and healthcare costs of German type 2 diabetes mellitus (T2D) patients who initiated insulin therapy. METHODS This retrospective analysis includes German claims data from 01/01/2012 until 31/12/2016. Identification of eligible patients took place between 01/01/2013 and 31/12/2015, allowing for at least 1 year of follow-up. Clinical outcomes, such as HbA1c values and body mass index, were observed in a subpopulation participating in a Disease Management Program. Healthcare expenditures were evaluated for the first year of therapy. RESULTS Overall, 27,340 insulin starters with T2D were observed (mean age: 72.2 years, female: 51.4%). Treatment-related outcomes were evaluated in a subsample of 12,034 patients. Patients who started insulin combined with other antidiabetic drugs (ADs) achieved their HbA1c goals more frequently than patients on insulin monotherapy (+10.7 percentage points [pp] vs. +21.1 pp for insulin plus metformin). All-cause costs were by far highest among patients with insulin monotherapy (€ 12,283 per patient-year) compared with patients receiving a combined AD regimen (€ 9,947-10,509 per patient-year). CONCLUSIONS Changes in HbA1c values were not in favor of insulin monotherapy, compared to regimens including other ADs. It was also associated with higher costs, suggesting that insulin alone is a suboptimal treatment.
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Affiliation(s)
- Maximilian Gabler
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | - Nils Picker
- Ingress-Health HWM GmbH, Alter Holzhafen 19, 23966 Wismar, Germany.
| | - Silke Geier
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | - Johannes Foersch
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | - Jens Aberle
- Universitätsklinikum Hamburg-Eppendorf (UKE), Martinistr. 52, 20246 Hamburg, Germany
| | - Stephan Martin
- Westdeutsches Diabetes- und Gesundheitszentrum (WDGZ), Hohensandweg 37, 40591 Düsseldorf, Germany
| | - Matthias Riedl
- Medicum Hamburg MVZ GmbH, Beim Strohhause 2, 20097 Hamburg, Germany
| | - Thomas Wilke
- IPAM, University of Wismar, Alter Holzhafen 19, 23966 Wismar, Germany
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Mbanya JC, Lamptey R, Uloko AE, Ankotche A, Moleele G, Mohamed GA, Ramracheya I, Ramaiya K, Ndiweni M, Mbaye MN, Bahendeka S, Kalra S. African Cuisine-Centered Insulin Therapy: Expert Opinion on the Management of Hyperglycaemia in Adult Patients with Type 2 Diabetes Mellitus. Diabetes Ther 2021; 12:37-54. [PMID: 33169346 PMCID: PMC7843662 DOI: 10.1007/s13300-020-00958-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 10/23/2020] [Indexed: 12/17/2022] Open
Abstract
The prevalence of diabetes in sub-Saharan Africa (SSA) is growing rapidly, and a steadily increasing number of adults are estimated to be living with type 2 diabetes mellitus (T2DM). Insulin therapy is the treatment of choice in patients who present with severe hyperglycaemia and in most of those who do not achieve target goals on oral hypoglycaemic agents. Initiating treatment with the appropriate type of insulin based on the meal patterns and lifestyle of the individual patient is a strategy that is more likely than others to improve glycaemic control and adherence. African cuisine typically has a high carbohydrate load. Given these predominantly carbohydrate-rich food habits, it is essential to modify this dietary pattern whilst at the same time ensuring that insulin therapy is initiated, titrated and maintained in a timely manner, as needed to suit the patient's habits. To date, there are no published clinical guidelines to guide practitioners and patients on tailoring insulin to match the high carbohydrate content in African cuisine. To address this gap, we have reviewed current insulin therapy practices and propose a patient-centric guide to insulin therapy based on African cuisine. A literature search was conducted for studies published in English up to November 2019 that focused on the choice of insulin and its dosing in relation to African foods. All articles extracted were reviewed by an expert group. The recommendation of the expert group was that basal-bolus and premix insulin regimens are best suited to manage post-meal glycaemia in African cuisine. The timing and constituents of the meal, portion sizes, glycaemic load and glycaemic index of meals should be considered when choosing the type of insulin and insulin regimen. Assessment of individual preferences and comorbidities should be prioritised and form an integral part of diabetes management.
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Affiliation(s)
- Jean Claude Mbanya
- Laboratory of Molecular Medicine and Metabolism, Biotechnology Center, University of Yaoundé, Yaoundé, Cameroon
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé, Yaoundé, Cameroon
| | - Roberta Lamptey
- Department of Family Medicine, Korle Bu Teaching Hospital–University of Ghana, Accra, Ghana
- Department of Community Health, University of Ghana Medical School, Accra, Ghana
| | - Andrew E. Uloko
- Department of Medicine, Bayero University Kano / Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Amos Ankotche
- Department of Internal Medicine, Enocrinology and Geriatrics, Unit of Training and Research, Medical Science of Abidjan, University of Côte D’Ivoire, Abidjan, Ivory Coast
| | - Gontle Moleele
- Department of Endocrinology, Bokamoso Private Hospital, Mmopane, Botswana
| | | | | | - Kaushik Ramaiya
- Shree Hindu Mandal Hospital, Chusi Street, Dar es Salaam, Tanzania
| | | | | | - Silver Bahendeka
- Department of Internal Medicine, Mother Kevin Postgraduate Medical School, Uganda Martyrs University, Kampala, Uganda
| | - Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, India
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Altemimi MT, Odhaib SA, Imran HJ, Alhamza A, Almomin A, Mansour AA. Comparison of Human Premixed and Basal Plus Short-Acting Insulin Regimens for Individuals With Type 2 Diabetes During Ramadan Fasting. Cureus 2020; 12:e11976. [PMID: 33425548 PMCID: PMC7788008 DOI: 10.7759/cureus.11976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Premixed insulin and basal insulin plus short-acting insulin regimens may be of value for treating individuals with type 2 diabetes (T2DM) who are fasting during Ramadan due to simplicity and better compliance. The objective of this study was to compare the effectiveness of human premixed insulin to basal plus short-acting insulin regimens in the management of fasting individuals with T2DM during Ramadan. Methods We conducted a prospective observational study in Basrah (southern Iraq) on 30 individuals with T2DM who fast during Ramadan. The enrolled patients were assigned into two groups at random: one group received a human premixed insulin regimen, the other received a basal plus short-acting insulin regimen. A baseline clinical and biochemical analysis was gathered for all patients at recruitment two weeks before fasting and within four weeks after the end of fasting. Patients were assessed twice during fasting month for insulin dose adjustment and documentation for any hyperglycemia or hypoglycemia. Results Fourteen patients were assigned to the premixed group, and 16 patients were assigned to the basal plus short-acting insulin group. The mean patient age was 53 ± 8 years, and the mean T2DM duration was 9.3 ± 4.2 years. The two groups were matched by age, body mass index, and glycated hemoglobin (HbA1c). There was no significant difference between the initial and final mean HbA1c in both groups. However, there was more non-significant HbA1c reduction in the premixed group as compared to the basal plus short-acting insulin group. The number of hypoglycemic events and weight changes among the two groups was not significant. Conclusions Both human premixed and basal plus short-acting insulin regimens are equally useful for glycemic control for patients with T2DM who choose to fast in observance of the month-long holiday of Ramadan.
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Affiliation(s)
- Mahmood Thamer Altemimi
- Adult Endocrinology, Faiha Specialized Diabetes, Endocrine and Metabolism Center, University of Basrah, Basrah Health Directorate, Basrah, IRQ
| | - Samih A Odhaib
- Adult Endocrinology, Faiha Specialized Diabetes, Endocrine and Metabolism Center, University of Basrah, Basrah Health Directorate, Basrah, IRQ
| | - Husam J Imran
- Adult Endocrinology, Faiha Specialized Diabetes, Endocrine and Metabolism Center, University of Basrah, Basrah Health Directorate, Basrah, IRQ
| | - Ali Alhamza
- Adult Endocrinology, Faiha Specialized Diabetes, Endocrine and Metabolism Center, University of Basrah, Basrah Health Directorate, Basrah, IRQ
| | - Ammar Almomin
- Adult Endocrinology, Faiha Specialized Diabetes, Endocrine and Metabolism Center, University of Basrah, Basrah Health Directorate, Basrah, IRQ
| | - Abbas A Mansour
- Adult Endocrinology, Faiha Specialized Diabetes, Endocrine and Metabolism Center, University of Basrah, Basrah Health Directorate, Basrah, IRQ
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Home P, Blonde L, Kalra S, Ji L, Guyot P, Brulle-Wohlhueter C, Murray E, Shah R, Sayre T, Shaunik A. Insulin glargine/lixisenatide fixed-ratio combination (iGlarLixi) compared with premix or addition of meal-time insulin to basal insulin in people with type 2 diabetes: A systematic review and Bayesian network meta-analysis. Diabetes Obes Metab 2020; 22:2179-2188. [PMID: 32700442 DOI: 10.1111/dom.14148] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 07/10/2020] [Accepted: 07/21/2020] [Indexed: 12/17/2022]
Abstract
AIM To assess the efficacy and safety of iGlarLixi, a fixed-ratio combination of insulin glargine 100 U/mL and lixisenatide, relative to premix insulin and other insulin options through network meta-analysis. METHODS A systematic literature search identified randomized controlled trials (RCTs) comparing iGlarLixi, premix insulin or basal insulin (BI) in combination with meal-time insulin, in people inadequately controlled with BI. Eligible RCTs were compared using Bayesian network meta-analysis. RESULTS Eight RCTs, some open-label, involving 3538 participants, with a study duration of 24-30 weeks were included. The estimated difference in HbA1c reduction with iGlarLixi compared with premix insulin was -0.50%-units (95% credible interval: -0.93 to -0.06) with 98% probability of iGlarLixi being superior to premix. Estimates for iGlarLixi versus meal-time + BI (thrice-daily meal-time insulin + basal) and basal-plus (once-daily meal-time insulin + BI) were -0.35 (-0.89 to +0.13)%-units and -0.68 (-1.18 to -0.17)%-units with probabilities of real difference of 94% and 99%, respectively. Safety outcome analysis suggested that iGlarLixi had lower rates of both confirmed and documented symptomatic hypoglycaemia compared with premix insulin (probabilities of 85% and 93%, respectively) and lower weight gain (probability 98%). CONCLUSIONS iGlarLixi showed similar or improved efficacy and safety versus other intensification choices from BI included in this study, providing a clinically relevant treatment option in people with type 2 diabetes not well controlled on BI.
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Affiliation(s)
- Philip Home
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Lawrence Blonde
- Ochsner Diabetes Clinical Research Unit, Frank Riddick Diabetes Institute, Department of Endocrinology, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, India
| | - Linong Ji
- Peking University People's Hospital, Beijing, China
| | - Patricia Guyot
- Global Medical Affairs, Sanofi, Bridgewater, New Jersey, USA
| | | | - Erin Murray
- Doctor Evidence, Santa Monica, California, USA
| | - Roshan Shah
- Doctor Evidence, Santa Monica, California, USA
| | - Toby Sayre
- Doctor Evidence, Santa Monica, California, USA
| | - Alka Shaunik
- Global Medical Affairs, Sanofi, Bridgewater, New Jersey, USA
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Men P, Qu S, Luo W, Li C, Zhai S. Comparison of lixisenatide in combination with basal insulin vs other insulin regimens for the treatment of patients with type 2 diabetes inadequately controlled by basal insulin: Systematic review, network meta-analysis and cost-effectiveness analysis. Diabetes Obes Metab 2020; 22:107-115. [PMID: 31469217 DOI: 10.1111/dom.13871] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 08/08/2019] [Accepted: 08/28/2019] [Indexed: 12/26/2022]
Abstract
AIMS To evaluate the comparative efficacy and safety of lixisenatide combined with basal insulin (BI) vs intensive premix insulin (premix), BI plus prandial insulin with the main meal (basal-plus) or progressively covering all meals (basal-bolus) in patients with type 2 diabetes mellitus (T2DM) inadequately controlled by BI, and the long-term cost-effectiveness of lixisenatide from a Chinese healthcare system perspective. MATERIALS AND METHODS Randomized controlled trials (RCTs) published between 1998 and 2018 were systematically searched. The clinical efficacy and safety of each treatment were compared by network meta-analysis (NMA). The IQVIA CORE Diabetes Model was used to estimate the lifetime quality-adjusted life-years (QALYs) and direct medical costs of patients treated with different strategies. RESULTS Eight RCTs were finally included. Lixisenatide plus BI showed a similar reduction in HbA1c from baseline compared with premix, basal-plus and basal-bolus. There were significant differences in the change of body weight in favour of lixisenatide plus BI compared with the three insulin regimens. The risk of symptomatic hypoglycaemia of lixisenatide plus BI was significantly lower compared with premix and basal-bolus. Lixisenatide plus BI was cost-effective compared with premix, basal-plus and basal-bolus with incremental cost-effectiveness ratios of Chinese yuan (CNY) 87 219, 48 173 and 48 670 per QALY gained, respectively, under the threshold of three times the gross domestic product (GDP) per capita in China. CONCLUSIONS Lixisenatide plus BI shows a similar HbA1c reduction compared with insulin regimens, accompanied by lower risk of hypoglycaemia and greater body weight reduction. It is a cost-effective treatment alternative for patients with T2DM inadequately controlled by BI in China.
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Affiliation(s)
- Peng Men
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Shuli Qu
- Real World Insights, IQVIA, Shanghai, China
| | | | - Chaoyun Li
- Health Economics & Outcome Research, Shanghai, China
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
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Hong T, Lu J, Zhang P, Zhang Z, Xu Q, Li Y, Cui N, Grijalva A, Murray EM, Del Aguila MA, Bi Y. Efficacy and Safety of Basal Analog Regimens in Type 2 Diabetes Mellitus: Systematic Review and Meta-Analysis of Randomized Controlled Trials. Diabetes Ther 2019; 10:1051-1066. [PMID: 30955140 PMCID: PMC6531585 DOI: 10.1007/s13300-019-0606-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION This study compared basal analog (BA: glargine U100/mL and detemir) and premix (PM: human, lispro and aspart biphasic) insulin regimens in terms of their efficacy and safety in type 2 diabetes mellitus patients. METHODS Searches of MEDLINE, Embase, and CENTRAL identified primary randomized controlled trials (RCTs) ≥ 12 weeks in duration that compared BA or PM insulin regimens in adults with T2DM, with ≥ 30 patients per arm. A systematic literature review and a pairwise meta-analysis were performed using a random effects model adjusted for between-study variability. Analyses were conducted based on frequency of bolus insulin and PM injections, PM ratio and type, BA type, race, follow-up period, and baseline glycosylated hemoglobin (HbA1c). RESULTS Twenty-two primary RCTs with 9691 patients were included. The BA and PM regimens yielded similar changes in HbA1c and postprandial glucose levels, with a statistically significant reduction in fasting glucose [mean difference (MD) - 0.61 mmol/L (95% confidence interval (CI) - 0.90, - 0.32), I2 = 89.6%]. The BA regimens showed significantly reduced rates of total hypoglycemia [odds ratio (OR) 0.77 (95% CI 0.64, 0.92), I2 = 65.3%] and changes in body weight [MD - 0.48 kg (95% CI - 0.86, - 0.11), I2 = 75.7%] compared to PM regimens. Stratification by PM type and dosing ratio demonstrated statistically significant reductions in HbA1c favoring BA compared to human [MD - 0.39% (95% CI - 0.60, - 0.18), I2 = 61.8%] or 50/50-ratio [MD - 0.22% (95% CI - 0.40, - 0.04), I2 = 0.0%] PM regimens. Other subgroup analyses found no difference in HbA1c change between the BA and PM regimens. CONCLUSION When compared to PM regimens, BA regimens yielded similar efficacies and better safety profiles in patients with type 2 diabetes mellitus. FUNDING Sanofi (Shanghai, China).
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Affiliation(s)
- Ting Hong
- Department of Endocrinology, Drum Tower Hospital Affiliated with Nanjing University Medical School, Nanjing, China
| | - Jing Lu
- Department of Endocrinology, Drum Tower Hospital Affiliated with Nanjing University Medical School, Nanjing, China
| | - Pengzi Zhang
- Department of Endocrinology, Drum Tower Hospital Affiliated with Nanjing University Medical School, Nanjing, China
| | - Zhou Zhang
- Department of Endocrinology, Drum Tower Hospital Affiliated with Nanjing University Medical School, Nanjing, China
| | - Qianyue Xu
- Department of Endocrinology, Drum Tower Hospital Affiliated with Nanjing University Medical School, Nanjing, China
| | - Yunguang Li
- Sanofi (China) Investment Co., Ltd., Shanghai Branch, China Medical Affairs, Shanghai, China
| | - Nan Cui
- Sanofi (China) Investment Co., Ltd., Shanghai Branch, China Medical Affairs, Shanghai, China
| | | | | | | | - Yan Bi
- Department of Endocrinology, Drum Tower Hospital Affiliated with Nanjing University Medical School, Nanjing, China.
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Yang W, Ersoy C, Wang G, Ye S, Liu J, Miao H, Asirvatham A, Werther S, Kadu P, Chow F. Efficacy and safety of three-times-daily versus twice-daily biphasic insulin aspart 30 in patients with type 2 diabetes mellitus inadequately controlled with basal insulin combined with oral antidiabetic drugs. Diabetes Res Clin Pract 2019; 150:158-166. [PMID: 30872064 DOI: 10.1016/j.diabres.2019.02.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 12/23/2018] [Accepted: 02/25/2019] [Indexed: 11/25/2022]
Abstract
AIMS To compare the efficacy and safety of biphasic insulin aspart 30 (BIAsp 30) administered three times daily (TID) vs. twice daily (BID), plus metformin, in patients with type 2 diabetes mellitus (T2DM) inadequately controlled on basal insulin ± 1 oral antidiabetic drug (OAD). METHODS Randomised, multinational, open-label, treat-to-target trial. Subjects inadequately controlled (HbA1c 7.5-10.0%) on basal insulin and metformin ± 1 OAD were randomised to BIAsp30 TID (n = 220) or BIAsp30 BID (n = 217). Primary endpoint was change from baseline in HbA1c after 24 weeks of treatment. RESULTS Most (400/437, 91.5%) subjects completed the trial. The majority (276/400 [69.0%]) were from the China region. After 24 weeks, HbA1c decreased comparably in both BIAsp 30 groups (-1.7% vs. -1.6% [-19 vs. -18 mmol/mol], for TID and BID dosing, respectively; estimated treatment difference: -0.09% [-0.23; 0.06]95% CI, -1 mmol/mol [-3; 1], p = 0.26). Safety profiles, including number of subjects experiencing hypoglycaemia, were similar. CONCLUSIONS BIAsp 30 administered either TID or BID with metformin was a safe and effective option when intensifying treatment after failure of basal insulin and OADs in patients with T2DM. Adding a third injection at lunchtime may be preferable if HbA1c remains above target, if the lunchtime meal is the largest meal of the day, or if persistent postprandial hyperglycaemia after lunch is observed. TRIAL REGISTRATION NUMBER ClinicalTrials.gov, NCT02582242.
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Affiliation(s)
- Wenying Yang
- China-Japan Friendship Hospital, East Yinghuayuan Street, Hepingli, Beijing 100029, China.
| | - Canan Ersoy
- Division of Endocrinology and Metabolism, School of Medicine, Uludag University, Bursa, Turkey.
| | - Guixia Wang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, Jilin Province 130021, China.
| | - Shandong Ye
- School of Medicine, Shandong University, Jinan, Shandong, China; Department of Endocrinology, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, China
| | - Jun Liu
- Department of Endocrinology, Shanghai Fifth People's Hospital Affiliated to Fudan University, 801 Heqing Road, Minhang District, Shanghai 200240, China
| | - Heng Miao
- The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China.
| | - Arthur Asirvatham
- Department of Medicine, Government Medical College, Madurai, Tamil Nadu, India
| | | | | | - Francis Chow
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China.
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12
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Seufert J, Borck A, Bramlage P. Addition of a single short-acting insulin bolus to basal insulin-supported oral therapy: a systematic review of data on the basal-plus regimen. BMJ Open Diabetes Res Care 2019; 7:e000679. [PMID: 31641521 PMCID: PMC6777409 DOI: 10.1136/bmjdrc-2019-000679] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/28/2019] [Accepted: 09/12/2019] [Indexed: 12/01/2022] Open
Abstract
We summarize here clinical and trial data on a once-daily administration of a single bolus to the meal with the largest expected postprandial glucose excursion (basal-plus), and comment on its clinical utility in the treatment of type 2 diabetes. A PubMed search of data published until September 2018 was taken into consideration and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. Eighteen reports representing 15 studies were identified (age: 18-80 years; 50-890 patients; follow-up: 8 days to 60 weeks). Data suggest basal-plus is efficacious for improving glycemic control, with a low incidence of (severe) hypoglycemia and minor increases in bodyweight. The timing of short-acting insulin administration and use of different monitoring/titration approaches appear to have minimal impact. When compared with premixed insulin, basal-plus results in largely comparable outcomes. Compared with basal-bolus, it may result in non-inferior glycemic improvements with less weight gain, less hypoglycemia and fewer daily injections. A basal insulin/glucagon-like peptide-1 receptor agonist fixed ratio combination may offer several advantages over the basal-plus regimen, at the cost of gastrointestinal side effects. We conclude that the stepwise introduction of short-acting insulin via the basal-plus strategy represents a viable alternative to a full basal-bolus regimen and may help to overcome barriers associated with multiple injections and anticipated complexity of the insulin regimen.
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Affiliation(s)
- Jochen Seufert
- Division of Endocrinology and Diabetoligy, Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
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13
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Sun D, Zhang X, Hou XX. Effects of Insulin Treatment with Glargine or Premixed Insulin Lispro Programs in Type 2 Diabetes Mellitus Patients: A Meta-analysis of Randomized Clinical Trials. Diabetes Technol Ther 2018; 20:622-627. [PMID: 30095984 DOI: 10.1089/dia.2018.0132] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The purpose of this study was to compare the efficacy and safety of intensive insulin therapy (premixed insulin lispro vs. insulin glargine) in patients with type 2 diabetes mellitus (T2DM). METHODS MEDLINE, EMBASE, the Cochrane Library, and www.clinicaltrials.gov were systematically searched for randomized clinical trials (RCTs) of patients with T2DM treated with either premixed insulin lispro or insulin glargine for a duration of 24 weeks. RESULTS A total of 13 RCTs and 5401 patients were included in this study. In parallel trials and crossover trials, premixed insulin lispro was found to be superior to insulin glargine at reducing glycosylated hemoglobin (HbA1c) (parallel trials: weighted mean difference [WMD] -0.18%; 95% confidence interval [CI] -0.31 to -0.06; P = 0.004; crossover trials: WMD 0.37%; 95% CI -0.51 to -0.23; P < 0.00001). Premixed insulin lispro resulted in more weight gain than insulin glargine (parallel trials: WMD +0.64 kg; 95% CI +0.14 to +1.15; P = 0.01; crossover trials: WMD +0.74 kg; 95% CI +0.19 to +1.29; P = 0.009), and premixed insulin lispro was associated with a higher risk of hypoglycemia than insulin glargine (parallel trials: odds ratio [OR] 1.20; 95% CI 1.06-1.36; P = 0.005; crossover trials: OR 2.24; 95% CI 1.45-3.46; P = 0.0003). CONCLUSIONS Premixed insulin lispro provides a larger reduction in HbA1c and is associated with a significantly higher risk of hypoglycemia and greater weight gain in patients with T2DM. These findings may be helpful in selecting therapy for individual subjects.
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Affiliation(s)
- Di Sun
- 1 Nursing Teaching and Research Department, The First Affiliated Hospital of Liaoning University of Traditional Chinese Medicine , Shenyang, China
| | - Xu Zhang
- 2 School of Nursing, Liaoning University of Traditional Chinese Medicine , Shenyang, China
| | - Xiu-Xin Hou
- 1 Nursing Teaching and Research Department, The First Affiliated Hospital of Liaoning University of Traditional Chinese Medicine , Shenyang, China
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14
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Candido R, Wyne K, Romoli E. A Review of Basal-Bolus Therapy Using Insulin Glargine and Insulin Lispro in the Management of Diabetes Mellitus. Diabetes Ther 2018; 9:927-949. [PMID: 29654514 PMCID: PMC5984925 DOI: 10.1007/s13300-018-0422-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Indexed: 12/29/2022] Open
Abstract
UNLABELLED Basal-bolus therapy (BBT) refers to the combination of a long-acting basal insulin with a rapid-acting insulin at mealtimes. Basal insulin glargine 100 U/mL and prandial insulin lispro have been available for many years and there is a substantial evidence base to support the efficacy and safety of these agents when they are used in BBT or basal-plus therapy for patients with type 1 or type 2 diabetes mellitus (T1DM, T2DM). With the growing availability of alternative insulins for use in such regimens, it seems timely to review the data regarding BBT with insulin glargine 100 U/mL and insulin lispro. In patients with T1DM, BBT with insulin glargine plus insulin lispro provides similar or better glycemic control and leads to less nocturnal hypoglycemia compared to BBT using human insulin as the basal and/or prandial component, and generally provides similar glycemic control and rates of severe hypoglycemia to those achieved with insulin lispro administered by continuous subcutaneous insulin infusion (CSII). Studies evaluating BBT with insulin glargine plus insulin lispro in patients with T2DM also demonstrate the efficacy and safety of these insulins. Available data suggest that BBT with insulin glargine and insulin lispro provides similar levels of efficacy and safety in pediatric and adult populations with T1DM and in adult patients and those aged more than 65 years with T2DM. These insulin preparations also appear to be safe and effective for controlling T2DM in people of different ethnicities and in patients with T1DM or T2DM and comorbidities. FUNDING Eli Lilly and Company.
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Affiliation(s)
- Riccardo Candido
- Diabetes Centre District 3, Azienda Sanitaria Universitaria Integrata di Trieste, Via Puccini 48/50, 34100, Trieste, Italy.
| | - Kathleen Wyne
- The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA
| | - Ester Romoli
- Eli Lilly Italia SPA, via A. Gramsci 731/733, 50019, Sesto Fiorentino, Italy
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15
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Linjawi S, Lee BW, Tabak Ö, Lövdahl S, Werther S, Abusnana S. A 32-Week Randomized Comparison of Stepwise Insulin Intensification of Biphasic Insulin Aspart (BIAsp 30) Versus Basal-Bolus Therapy in Insulin-Naïve Patients with Type 2 Diabetes. Diabetes Ther 2018; 9:1-11. [PMID: 29129018 PMCID: PMC5801220 DOI: 10.1007/s13300-017-0334-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION This 32-week, open-label, randomized, parallel-group, multinational trial aimed to compare the efficacy and safety of stepwise insulin intensification of biphasic insulin aspart 30 (BIAsp 30) relative to stepwise intensification of a basal-bolus regimen in insulin-naïve adults with type 2 diabetes (T2D) who continued pretrial treatment with metformin and sulfonylurea. METHODS Adults with T2D were randomized into one of two treatment arms for 32 weeks: (1) BIAsp 30 once daily (OD), with the possibility of stepwise treatment intensification up to BIAsp 30 three times daily (TID); (2) insulin glargine OD, with the possibility of stepwise treatment intensification with insulin aspart up to TID. The primary endpoint was change from baseline in HbA1c after 32 weeks. RESULTS After 32 weeks, the estimated mean change in HbA1c from baseline was statistically significantly lower in the BIAsp 30 arm (- 1.18%) versus basal-bolus (- 1.36%) [estimated treatment difference 0.18%; 95% confidence interval (95% CI) 0.01; 0.36; p < 0.05]. The proportion of patients with HbA1c below 7.0% was statistically significantly lower with BIAsp 30 (42.9%) compared with basal-bolus (56.9%) (odds ratio 0.58; 95% CI 0.37; 0.89; p = 0.01). The overall rate of severe or blood glucose (BG)-confirmed hypoglycemic events was numerically lower for BIAsp 30 compared with basal-bolus, and a statistically significantly lower rate in nocturnal severe or BG-confirmed hypoglycemia in the BIAsp 30 arm relative to basal-bolus was observed: estimated rate ratio 0.32 (95% CI 0.13; 0.79), p = 0.0131. The proportion of patients with adverse events was similar in both treatment arms. CONCLUSION Insulin intensification with BIAsp 30 and basal-bolus showed an improvement in glycemic control; the change in HbA1c was statistically significantly lower for BIAsp 30 compared to basal-bolus. Basal-bolus treatment was accompanied by a numerically, and statistically significantly, higher rate of overall and nocturnal severe or BG-confirmed hypoglycemia, respectively, compared with BIAsp 30. FUNDING Novo Nordisk A/S. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT02453685.
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Affiliation(s)
- Sultan Linjawi
- Coffs Endocrine and Diabetes Service, Coffs Harbour, NSW, Australia.
| | - Byung-Wan Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Ömür Tabak
- Internal Medicine Clinic, Ministry of Health Istanbul Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
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16
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Jia N, Kindracki Z, Rodriguez A. Baseline factors associated with better response to insulin lispro low mixture or insulin glargine: A post hoc analysis of the DURABLE study. Diabetes Res Clin Pract 2018; 135:134-142. [PMID: 29155123 DOI: 10.1016/j.diabres.2017.10.006] [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] [Received: 03/10/2017] [Revised: 09/25/2017] [Accepted: 10/09/2017] [Indexed: 11/30/2022]
Abstract
AIMS To identify baseline characteristics associated with better efficacy and safety responses to twice-daily insulin lispro low mixture (LM) or once-daily insulin glargine (IG) in insulin-naïve patients with type 2 diabetes (T2D). METHODS This post hoc analysis of the DURABLE study used the gradient-boosting method to generate hypothetical outcomes with the alternative treatment to assigned study drug to evaluate the potential additional benefit of one insulin over the other in association with influential baseline covariates in the same patient. The magnitude of additional benefit was further quantified by the generalized linear model and recursive partitioning regression tree method. RESULTS Baseline characteristics with the highest relative influence on 24-week outcomes in the overall population (LM, n = 1045; IG, n = 1046) were: for HbA1c change: fasting plasma glucose (FPG) (29.31%), age (28.57%); for reaching target HbA1c <7% (<53 mmol/mol): weight (22.41%); for weight change: weight (18.54%); for FPG: FPG (43.66%), age (20.8%); for 30-day hypoglycemia: FPG (57.09%), weight (10.1%). LM showed superiority over IG for HbA1c reduction and reaching HbA1c <7% overall, with clinically significant differences in HbA1c reduction (>0.4%) in some subpopulations. IG was superior over LM in most patients for less weight gain and hypoglycemia and lower FPG. CONCLUSIONS Differences in magnitude of response to twice-daily LM and once-daily IG in association with baseline characteristics of insulin-naïve patients with T2D were found. Future real-world studies using these statistical methods could help identify patients who respond better to certain insulin regimens to help guide clinicians in treatment decisions.
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Affiliation(s)
- Nan Jia
- Eli Lilly and Company, Inpolis, IN, USA.
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17
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Nawaz MS, Shah KU, Khan TM, Rehman AU, Rashid HU, Mahmood S, Khan S, Farrukh MJ. Evaluation of current trends and recent development in insulin therapy for management of diabetes mellitus. Diabetes Metab Syndr 2017; 11 Suppl 2:S833-S839. [PMID: 28709853 DOI: 10.1016/j.dsx.2017.07.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 07/01/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Diabetes mellitus is a major health problem in developing countries. There are various insulin therapies to manage diabetes mellitus. This systematic review evaluates various insulin therapies for management of diabetes mellitus worldwide. This review also focuses on recent developments being explored for better management of diabetes mellitus. RESEARCH DESIGN AND METHOD We reviewed a number of published articles from 2002 to 2016 to find out the appropriate management of diabetes mellitus. The paramount parameters of the selected studies include the insulin type & its dose, type of diabetes, duration and comparison of different insulin protocols. In addition, various newly developed approaches for insulin delivery with potential output have also been evaluated. RESULTS A great variability was observed in managing diabetes mellitus through insulin therapy and the important controlling factors found for this therapy include; dose titration, duration of insulin use, type of insulin used and combination therapy of different insulin. CONCLUSION A range of research articles on current trends and recent advances in insulin has been summarized, which led us to the conclusion that multiple daily insulin injections or continuous subcutaneous insulin infusion (insulin pump) is the best method to manage diabetes mellitus. In future perspectives, development of the oral and inhalant insulin would be a tremendous breakthrough in Insulin therapy.
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Affiliation(s)
- Muhammad Sarfraz Nawaz
- Department of Pharmacy, Quaid-i-Azam University Islamabad, Pakistan; Faculty of Pharmaceutical Sciences, UCSI University, Cheras, Kuala Lumpur, Malaysia
| | - Kifayat Ullah Shah
- Department of Pharmacy, Quaid-i-Azam University Islamabad, Pakistan; Faculty of Pharmaceutical Sciences, UCSI University, Cheras, Kuala Lumpur, Malaysia.
| | - Tahir Mehmood Khan
- School of Pharmacy, Monash University, Jalan Lagoon Selatan,47500 Bandar SunwaySelangor DarulEhsan, Malaysia
| | - Asim Ur Rehman
- Department of Pharmacy, Quaid-i-Azam University Islamabad, Pakistan; Faculty of Pharmaceutical Sciences, UCSI University, Cheras, Kuala Lumpur, Malaysia
| | - Haroon Ur Rashid
- Department of Pharmacy, Quaid-i-Azam University Islamabad, Pakistan; Faculty of Pharmaceutical Sciences, UCSI University, Cheras, Kuala Lumpur, Malaysia
| | - Sajid Mahmood
- Department of Pharmacy, Quaid-i-Azam University Islamabad, Pakistan; Faculty of Pharmaceutical Sciences, UCSI University, Cheras, Kuala Lumpur, Malaysia
| | - Shahzeb Khan
- Department of Pharmacy, University of Malakand, KPK, Pakistan; Faculty of Pharmaceutical Sciences, UCSI University, Cheras, Kuala Lumpur, Malaysia
| | - Muhammad Junaid Farrukh
- Department of Pharmacy, University of Malakand, KPK, Pakistan; Faculty of Pharmaceutical Sciences, UCSI University, Cheras, Kuala Lumpur, Malaysia
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Ghosh S, Unnikrishnan AG, Saboo B, Kesavadev J, Aravind SR, Bajaj S, Rajput R, Seshadri K, Verma N, Gupta A, Makkar BM, Saikia M, Kale S, Damodaran S, Dengra A, Eashwar TKM, Maheshwari A, Pendsey S, Phatak SR, Sharma SK, Singh SK, Ramachandran A, Zargar AH, Joshi SR, Sadikot SM. Evidence-based recommendations for insulin intensification strategies after basal insulin in type 2 diabetes. Diabetes Metab Syndr 2017; 11 Suppl 1:S507-S521. [PMID: 28433618 DOI: 10.1016/j.dsx.2017.03.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Indexed: 01/27/2023]
Abstract
Over the time due to progressive nature of diabetes, proactive intensification of the existing insulin therapy becomes imminent as it minimizes patients' exposure to chronic hypo/hyperglycaemia and reduces weight gain while achieving individualized glycaemic targets. This review focuses on the strength of evidence behind various options for intensification, primarily the insulins as also the GLP-1 analogues. The recommendations presented here are meant to serve as a guide for the physician managing type 2 diabetes patients requiring insulin intensification upon failing of basal insulin therapy.
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Affiliation(s)
- Sujoy Ghosh
- Department of Endocrinology and Metabolism, Institute of Post-Graduate Medical Education and Research, Kolkata, India.
| | | | | | | | | | - Sarita Bajaj
- Department of Medicine, Motilal Nehru Medical College, Allahabad, India
| | - Rajesh Rajput
- Department of Endocrinology, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, India
| | - Krishna Seshadri
- Department of Endocrinology and Metabolism, Shri Rama Chandra University, Chennai, India
| | | | | | | | | | | | | | - Ashish Dengra
- Mahi Diabetes & Thyroid Care and Research Center, Jabalpur, India
| | | | - Anuj Maheshwari
- Department of Medicine, Babu Banarasi Das University, Lucknow, India
| | | | | | | | - Surya Kumar Singh
- Department of Endocrinology and Metabolism, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | | | - Abdul H Zargar
- Advanced Center for Diabetes and Endocrine Care, Srinagar, India
| | - Shashank R Joshi
- Lilavati and Bhatia Hospital and Grant Medical College, Mumbai, India
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19
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Jeong IK, Chung CH, Zhou Z, Han JH, Duan R, Edralin DM, Rodriguez A. Comparison of insulin intensification strategies with insulin lispro low mixture twice daily versus basal insulin glargine and prandial insulin lispro once daily in East Asian and Caucasian patients with type 2 diabetes mellitus. J Diabetes 2017; 9:396-404. [PMID: 27171584 DOI: 10.1111/1753-0407.12426] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Revised: 04/11/2016] [Accepted: 05/02/2016] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND This analysis evaluated efficacy and safety of insulin lispro low mixture (LM25) twice daily (breakfast and dinner) versus basal insulin glargine (bedtime) plus prandial insulin lispro (IGL) once daily before the largest meal in East Asian (EA) and Caucasian patients with type 2 diabetes mellitus who failed to reach glycemic targets on basal insulin glargine with metformin and/or pioglitazone. METHODS Included patients had an HbA1c ≥7.5% and ≤10.5% and fasting plasma glucose ≤6.7 mmol/L. Primary outcome was HbA1c change at 24 weeks. RESULTS Baseline mean HbA1c was numerically similar between groups in EA (n = 79) and Caucasian (n = 278) patients. Mean (± SD) HbA1c decreased significantly from baseline to 24 weeks for LM25 and IGL in both subpopulations (EA: -1.32 ± 0.96% and -0.89 ± 0.96%; Caucasian: -1.24 ± 0.98% and -1.04 ± 0.97; all P < 0.0001). The respective proportions reaching HbA1c ≤7.0% at Week 24 in the LM25 and IGL groups were 33.3% and 22.9% (EA) and 37.2% and 34.1% (Caucasian). Mean (± SD) rates of hypoglycemia per 30 days in the LM25 and IGL groups were 0.74 ± 1.16 and 1.22 ± 1.36 (EA) and 1.38 ± 2.04 and 1.65 ± 2.43 (Caucasian). Mean (± SD) weight gain changes in the LM25 and IGL groups were 0.62 ± 2.78 and 0.51 ± 2.63 kg (EA) and 1.77 ± 2.91 and 0.67 ± 3.09 kg (Caucasian). CONCLUSIONS Both strategies improved glycemic control in a small group of EA and Caucasian patients not adequately controlled on insulin glargine plus metformin and/or pioglitazone.
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Affiliation(s)
| | - Choon Hee Chung
- Yonsei University, Wonju College of Medicine, Wonju-si, Korea
| | - Zhiguang Zhou
- Diabetes Center, Institute of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, National Clinical Research Center For Metabolic Diseases, Changsha, China
| | | | - Ran Duan
- Eli Lilly and Company, Indianapolis, Indiana, USA
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20
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Raccah D. Basal insulin treatment intensification in patients with type 2 diabetes mellitus: A comprehensive systematic review of current options. DIABETES & METABOLISM 2017; 43:110-124. [PMID: 28169086 DOI: 10.1016/j.diabet.2016.11.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 10/27/2016] [Accepted: 11/08/2016] [Indexed: 12/16/2022]
Abstract
AIM As type 2 diabetes mellitus progresses, most patients require treatment with basal insulin in combination with another agent to achieve recommended glycaemic targets. The purpose of this systematic review was to examine the evidence supporting the use of the available add-on treatments [rapid-acting insulin (RAI), glucagon-like peptide-1 receptor agonists (GLP-1 RAs), dipeptidyl peptidase (DPP)-4 inhibitors and sodium-glucose cotransporter-2 (SGLT-2) inhibitors] to basal insulin. METHODS MEDLINE, EMBASE and EBSCOhost were searched for English-language articles, and all those captured were original articles (case studies and narrative reviews were omitted). Data on study design, population demographics, interventions and outcomes were tabulated. The extracted outcome data included changes in glycated haemoglobin (HbA1c), fasting plasma glucose (FPG) and postprandial plasma glucose (PPG), as well as body weight and safety data. RESULTS A total of 88 publications were deemed relevant. All treatments reduced HbA1c and FPG. The most pronounced reductions in PPG, an unmet need in patients not controlled by basal insulin, were seen following administration of RAIs and short-acting GLP-1 RAs, although data for this outcome are generally lacking. Body weight benefits were observed with GLP-1 RAs and SGLT-2 inhibitors. However, as only articles in English were included, the result was a possible publication bias, while the diversity of study designs and drug combinations limited comparisons between studies. CONCLUSION The evidence supports effectiveness of the available add-on treatments to basal insulin. However, other factors, such as potential body-weight increases, convenience/compliance and adverse events, particularly hypoglycaemia, should be considered on a patient-by-patient basis to optimalize treatment outcomes.
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Affiliation(s)
- D Raccah
- Department of Diabetology, University Hospital Sainte-Marguerite, Marseille, France.
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21
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Siegmund T, Pfohl M, Forst T, Pscherer S, Bramlage P, Foersch J, Borck A, Seufert J. Titration of basal insulin or immediate addition of rapid acting insulin in patients not at target using basal insulin supported oral antidiabetic treatment - A prospective observational study in 2202 patients. Diabetes Metab Syndr 2017; 11:51-57. [PMID: 27578616 DOI: 10.1016/j.dsx.2016.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/22/2016] [Indexed: 11/23/2022]
Abstract
AIM Optimal treatment intensification strategies in patients with type-2 diabetes mellitus (T2DM) receiving basal insulin supported oral antidiabetic therapy (BOT) remain controversial. The objective of the present study was to compare outcomes of BOT-intensification by either the uptitration of long-acting insulin glargine or by the immediate addition of a rapid acting insulin analogue (RAIA). METHODS This was a prospective, observational, 24-week study in T2DM patients with BOT using insulin glargine and baseline glycated hemoglobin (HbA1c) between 7.0 and 8.5%. Patients were stratified by their physicians to one of the following treatment intensification strategies: Basal insulin titration to target with discretionary subsequent addition of RAIA at weeks 12 or 24 (GLAR), or immediate addition of RAIA at baseline (GLARplus). RESULTS A total of 3266 patients were prescreened of whom 2202 fulfilled the selection criteria. Of these, 1684 patients were documented in the GLAR group and 518 in the GLARplus group. In the GLAR group, in 91 (5.5%) and 21 patients (1.3%) RAIA was added at weeks 12 and 24, respectively. The groups displayed similar baseline characteristics; except, mean diabetes duration was slightly shorter in the GLAR group (8.7 vs. 9.4 years). During the study, insulin glargine dose was increased from 18.7 to 26.4U (plus 7.7U) in GLAR and from 24.9 to 27.3U (plus 2.4U) in GLARplus patients. Mean RAIA dose was 9.6±4.7U at the final visit. After 24 weeks, HbA1c was reduced by 0.8 and 0.9% in the GLAR and GLARplus groups, respectively (both p<0.001). An HbA1c of ≤7.0% was achieved in 49.2% of GLAR and 48.5% of GLARplus patients. In both groups, we observed improvements in cardiovascular risk factors such as lipids and blood pressure. The rates of symptomatic (1.6 vs. 1.7%) and severe (0.18 vs. 0.19%) hypoglycemic episodes were low and comparable in both groups. CONCLUSION These findings provide evidence that treatment intensification in patients with type 2 diabetes not at glycemic target on BOT with insulin glargine is equally safe and effective using either long-acting insulin titration alone or the addition of a rapid-acting insulin analogue.
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Affiliation(s)
- Thorsten Siegmund
- Department for Endocrinology, Diabetes and Metabolism, Isar Klinikum München GmbH, Sonnen Str. 24-26, 80331 Munich, Germany.
| | - Martin Pfohl
- Evang. Krankenhaus BETHESDA GmbH, Heerstraße 219, 47053 Duisburg, Germany.
| | - Thomas Forst
- Profil Institut für Stoffwechselforschung GmbH, Hellersbergerstraße 9, 41460 Neuss, Germany.
| | - Stefan Pscherer
- Klinik für Innere Medizin III, Sophien- und Hufeland-Klinikum, Henry-van-de-Velde-Straße 2, 99425 Weimar, Germany.
| | - Peter Bramlage
- Institut für Pharmakologie und Präventive Medizin, Menzelstraße 21, 15831 Mahlow, Germany.
| | - Johannes Foersch
- Medical Department, Sanofi, Potsdamer Straße 8, 10785 Berlin, Germany.
| | - Anja Borck
- Medical Department, Sanofi, Potsdamer Straße 8, 10785 Berlin, Germany.
| | - Jochen Seufert
- Universitätsklinikum Freiburg, Hugstetter Straße 55, 79106 Germany.
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Maiorino MI, Bellastella G, Esposito K, Giugliano D. Premixed insulin regimens in type 2 diabetes: pros. Endocrine 2017; 55:45-50. [PMID: 27003435 DOI: 10.1007/s12020-016-0917-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Accepted: 03/04/2016] [Indexed: 01/16/2023]
Abstract
Because of the increasing prevalence of type 2 diabetes, the need to intensify treatment to manage hyperglycemia is expanding. Premixed insulin regimens were designed to maximize patient convenience and reduce the number of daily injections required by providing both rapid-acting and intermediate-acting components in one formulation. Although the basal bolus insulin regimen is considered by many as "the golden standard" in reaching goals of glycemic control, proper use of intensified insulin regimens, such as basal bolus or premixed, will result in similar HbA1c reduction, hypoglycemic events, and weight gain. At the same number of daily insulin injections (2 shots/day), the premixed regimen is associated with a significant 0.2 % HbA1c decrease, as compared with the basal plus regimen (one shot of long-acting plus one shot of short-acting insulin). The choice of insulin regimen should consider the preferences, and resources of the individual and the family for adapting treatment to the patient needs. At last, the process of insulin initiation and intensification in type 2 diabetes must be carried out in the context of patient safety, minimizing the risk of hypoglycemia, weight gain, and injection burden.
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Affiliation(s)
- Maria Ida Maiorino
- Diabetes Unit, Department of Clinical and Experimental Medicine, Second University of Naples, Naples, Italy
| | - Giuseppe Bellastella
- Division of Endocrinology and Metabolic Diseases, Department of Medical, Surgical, Neurological, Metabolic Sciences and Aging, Second University of Naples, Naples, Italy
| | - Katherine Esposito
- Division of Endocrinology and Metabolic Diseases, Department of Medical, Surgical, Neurological, Metabolic Sciences and Aging, Second University of Naples, Naples, Italy
| | - Dario Giugliano
- Diabetes Unit, Department of Clinical and Experimental Medicine, Second University of Naples, Naples, Italy.
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Scheen AJ, Schmitt H, Jiang HH, Ivanyi T. Factors associated with reaching or not reaching target HbA 1c after initiation of basal or premixed insulin in patients with type 2 diabetes. DIABETES & METABOLISM 2016; 43:69-78. [PMID: 27988180 DOI: 10.1016/j.diabet.2016.10.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 10/18/2016] [Accepted: 10/24/2016] [Indexed: 12/14/2022]
Abstract
AIMS To evaluate factors associated with reaching or not reaching target glycated haemoglobin (HbA1c) levels by analysing the respective contributions of fasting hyperglycaemia (FHG), also referred to as basal hyperglycaemia, vs postprandial hyperglycaemia (PHG) before and after initiation of a basal or premixed insulin regimen in patients with type 2 diabetes. METHODS This post-hoc analysis of insulin-naïve patients in the DURABLE study randomised to receive either insulin glargine or insulin lispro mix 25 evaluated the percentages of patients achieving a target HbA1c of <7.0% (<53mmol/mol) per baseline HbA1c quartiles, and the effect of each insulin regimen on the relative contributions of PHG and FHG to overall hyperglycaemia. RESULTS Patients had comparable demographic characteristics and similar HbA1c and FHG values at baseline in each HbA1c quartile regardless of whether they reached the target HbA1c. The higher the HbA1c quartile, the greater was the decrease in HbA1c, but also the smaller the percentage of patients achieving the target HbA1c. HbA1c and FHG decreased more in patients reaching the target, resulting in significantly lower values at endpoint in all baseline HbA1c quartiles with either insulin treatment. Patients not achieving the target HbA1c had slightly higher insulin doses, but lower total hypoglycaemia rates. CONCLUSION Smaller decreases in FHG were associated with not reaching the target HbA1c, suggesting a need to increase basal or premixed insulin doses to achieve targeted fasting plasma glucose and improve patient response before introducing more intensive prandial insulin regimens.
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Affiliation(s)
- A J Scheen
- University Hospital Center, University of Liège, 4000 Liège, Belgium.
| | - H Schmitt
- Eli Lilly Benelux, 1000 Brussels, Belgium
| | - H H Jiang
- Eli Lilly and Company, 46225 Indianapolis, IN, USA
| | - T Ivanyi
- Lilly Hungary, 1075 Budapest, Hungary
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Downie M, Kilov G, Wong J. Initiation and Intensification Strategies in Type 2 Diabetes Management: A Comparison of Basal Plus and Premix Regimens. Diabetes Ther 2016; 7:641-657. [PMID: 27658921 PMCID: PMC5118237 DOI: 10.1007/s13300-016-0199-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Indexed: 12/17/2022] Open
Abstract
UNLABELLED The progressive nature of type 2 diabetes (T2D) often results in the need for initiation and subsequent intensification of insulin treatment to achieve glycemic control. The aim of this review is to examine published clinical evidence that has directly compared two recommended treatment approaches in patients with T2D: (1) a 'basal plus' regimen, whereby 1-2 injections of prandial insulin are added to basal insulin; or (2) the use of once- or twice-daily premix insulin analogs, which contain both basal and prandial insulin in a single injection. Broadly, the available evidence suggests that both basal plus and premix regimens are comparable in terms of efficacy and safety when used for insulin initiation in insulin-naïve patients and intensification in patients who have failed on basal insulin; instances of greater glycemic control are observed with premix insulin; however, these are often accompanied by increases in hypoglycemia and/or weight relative to basal plus treatment, and results should be interpreted within the context of total insulin doses used. Relatively low numbers of patients achieved glycemic control when both regimens were used for insulin intensification following failure of basal insulin, suggesting that a full basal-bolus regimen and/or the use of different treatments is clinically indicated in certain patients. In summary, the current review argues that both basal plus and premix insulin regimens are relatively efficacious and safe options for patients with T2D during both insulin initiation in insulin-naïve patients and intensification in patients who have failed on basal insulin. This emphasizes the important role of patient-centered factors in clinical decision-making. FUNDING Novo Nordisk.
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Affiliation(s)
- Michelle Downie
- Department of Endocrinology, Southland Hospital, Invercargill, New Zealand.
| | - Gary Kilov
- Seaport Diabetes Practice, Launceston, Australia
| | - Jencia Wong
- Department of Endocrinology, Royal Prince Alfred Hospital, Sydney, Australia
- Discipline of Medicine, University of Sydney, Sydney, Australia
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Giugliano D, Sieradzki J, Stefanski A, Gentilella R. Personalized intensification of insulin therapy in type 2 diabetes - does a basal-bolus regimen suit all patients? Curr Med Res Opin 2016; 32:1425-34. [PMID: 27126277 DOI: 10.1080/03007995.2016.1181051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Many patients with type 2 diabetes mellitus (T2DM) require insulin therapy. If basal insulin fails to achieve glycemic control, insulin intensification is one possible treatment intensification strategy. We summarized clinical data from randomized clinical trials designed to compare the efficacy and safety of basal-bolus and premixed insulin intensification regimens. We defined a between-group difference of ≥0.3% in end-of-study glycated hemoglobin (HbA1c) as clinically meaningful. A PubMed database search supplemented by author-identified papers yielded 15 trials which met selection criteria: randomized design, patients with T2DM receiving basal-bolus (bolus injection ≤3 times/day) vs. premixed (≤3 injections/day) insulin regimens, primary/major endpoint(s) HbA1c- and/or hypoglycemia-related, and trial duration ≥12 weeks. Glycemic control improved with both basal-bolus and premixed insulin regimens with - in most cases - acceptable levels of weight gain and hypoglycemia. A clinically meaningful difference between regimens in glycemic control was recorded in only four comparisons, all of which favored basal-bolus therapy. The incidence of hypoglycemia was significantly different between regimens in only three comparisons, one of which favored premixed insulin and two basal-bolus therapy. Of the four trials that reported a significant difference between regimens in bodyweight change, two favored basal-bolus therapy and two favored premixed insulin. Thus, on a population level, neither basal-bolus therapy nor premixed insulin showed a consistent advantage in terms of glycemic control, hypoglycemic risk, or bodyweight gain. It is therefore recommended that clinicians should adopt an individualized approach to insulin intensification - taking into account the benefits and risks of each treatment approach and the attitude and preferences of each patient - in the knowledge that both basal-bolus and premixed regimens may be successful.
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Affiliation(s)
- D Giugliano
- a Department of Medical, Surgical, Neurological, Metabolic Sciences and Aging , Second University of Naples , Naples , Italy
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Giugliano D, Maiorino MI, Bellastella G, Esposito K. Comment on American Diabetes Association. Approaches to Glycemic Treatment. Sec. 7. In Standards of Medical Care in Diabetes-2016. Diabetes Care 2016;39(Suppl. 1):S52-S59. Diabetes Care 2016; 39:e86-7. [PMID: 27222559 DOI: 10.2337/dc15-2829] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Dario Giugliano
- Division of Endocrinology and Metabolic Diseases, Department of Medical, Surgical, Neurological, Metabolic Sciences and Aging, Second University of Naples, Naples, Italy
| | - Maria Ida Maiorino
- Diabetes Unit, Department of Clinical and Experimental Medicine, Second University of Naples, Naples, Italy
| | - Giuseppe Bellastella
- Division of Endocrinology and Metabolic Diseases, Department of Medical, Surgical, Neurological, Metabolic Sciences and Aging, Second University of Naples, Naples, Italy
| | - Katherine Esposito
- Diabetes Unit, Department of Clinical and Experimental Medicine, Second University of Naples, Naples, Italy
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Gross JL, Rojas A, Shah S, Tinahones FJ, Cleall S, Rodríguez A. Efficacy and safety of a premixed versus a basal-plus insulin regimen as intensification for type 2 diabetes by timing of the main meal. Curr Med Res Opin 2016; 32:1109-16. [PMID: 26934128 DOI: 10.1185/03007995.2016.1161609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To describe the efficacy and safety of premixed insulin lispro protamine suspension 75%/insulin lispro solution 25% (LM25) twice daily (bid) versus basal insulin glargine plus prandial insulin lispro (IGL), both once daily, according to main meal timing. METHODS Data were obtained post hoc from a 24 week, randomized, open-label study comparing LM25 and IGL as insulin intensification in patients with type 2 diabetes inadequately controlled with once daily basal insulin glargine plus metformin and/or pioglitazone (ClinicalTrials.gov identifier: NCT01175824). Patients administered LM25 bid before breakfast and the evening meal, insulin glargine at bedtime and insulin lispro before the day's main meal (meal with the highest 2 hour postprandial glucose level during screening). Patients were grouped by main meal. Changes in glycosylated hemoglobin (HbA1c) and bodyweight were summarized using likelihood-based mixed models; hypoglycemia incidence was compared between treatments using Fisher's exact test. RESULTS Overall, 476 patients (LM25, n = 236; IGL, n = 240) were randomized. In all main meal groups, with both insulin regimens, mean HbA1c significantly decreased from baseline to 24 weeks (p < 0.0001). Patients whose main meal was in the evening had a greater bodyweight increase with LM25 than with IGL (p = 0.015), and a smaller proportion of these patients experienced total (p = 0.027) and nocturnal (p = 0.006) hypoglycemia with LM25 compared with IGL. Patients whose main meal was lunch experienced more nocturnal hypoglycemia with LM25 than with IGL (p = 0.030). Study limitations include that this was a post hoc analysis and no assessments ensured that: SMBG results determined timing of the main meal, each patient's main meal remained unchanged throughout the study, or patients administered insulin lispro with that meal. CONCLUSIONS Glycemic control improved in patients receiving either LM25 or IGL, irrespective of main meal timing. Both regimens can be used in patients with inadequate glycemic control who are in need of insulin intensification.
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Affiliation(s)
- Jorge L Gross
- a Centro de Pesquisas em Diabetes , Porto Alegre , Rio Grande do Sul , Brazil
| | - Arturo Rojas
- b Centro de Diabetes de Coatzacoalcos , Veracruz , México
| | | | - Francisco J Tinahones
- d Hospital Universitario Virgen de la Victoria , Málaga , Spain
- e IBIMA, CIBER Fisiopatología de la Obesidad y la Nutrición, Instituto de Salud Carlos III , Málaga , Spain
| | - Simon Cleall
- f Eli Lilly and Company , Windlesham , United Kingdom
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Jin SM, Kim JH, Min KW, Lee JH, Ahn KJ, Park JH, Jang HC, Park SW, Lee KW, Won KC, Kim YI, Chung CH, Park TS, Lee JH, Lee MK. Basal-prandial versus premixed insulin in patients with type 2 diabetes requiring insulin intensification after basal insulin optimization: A 24-week randomized non-inferiority trial. J Diabetes 2016; 8:405-13. [PMID: 25952532 DOI: 10.1111/1753-0407.12312] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 03/30/2015] [Accepted: 05/05/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The aim of the present 24-week multicentre randomized non-inferiority trial was to compare the efficacy and safety of two insulin intensification strategies in uncontrolled type 2 diabetes despite optimized basal insulin therapy. METHODS Patients with fasting plasma glucose (FPG) <130 mg/dL and HbA1c 7.0%-10.0% while on insulin glargine were randomized to a basal-prandial group (stepwise addition of insulin glulisine) or a premixed insulin group (insulin aspart/insulin aspart protamine 30/70 starting with 6 IU twice daily). The primary endpoint was the change in HbA1c after 24 weeks (non-inferiority margin 0.4%). RESULTS At Week 24, the adjusted mean change from baseline HbA1c was -0.94 ± 0.09% and -1.04 ± 0.09% in basal-prandial and premixed insulin groups, respectively, with a mean difference of -0.09% (95% confidence interval [CI] -0.35, 0.16). A lower rate of hypoglycemia with a similar reduction in HbA1c was observed during stabilization of the total daily insulin dose in the premixed insulin group (Weeks 0-12). After stabilization of the total daily insulin dose, the rate of hypoglycemia and the total daily insulin dose were similar in the two groups. CONCLUSIONS The efficacy and safety of the two intensifying regimens were similar after stabilization of the total daily insulin dose when oral agents were maintained. Starting with a lower total daily insulin dose with a gradual change in the treatment regimen was helpful in reducing the rate of hypoglycemia during initial stabilization of the total daily insulin dose.
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Affiliation(s)
- Sang-Man Jin
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jae Hyeon Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kyung Wan Min
- Diabetes Center, Eulji General Hospital, Eulji University School of Medicine, Seoul, South Korea
| | | | - Kue Jeong Ahn
- Kyung Hee University School of Medicine, Seoul, South Korea
| | - Jeong Hyun Park
- College of Medicine, Paik Institute for Clinical Research, Inje University, Busan, South Korea
| | - Hak Chul Jang
- Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Seok Won Park
- CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, South Korea
| | - Kwan Woo Lee
- Ajou University School of Medicine, Suwon, South Korea
| | - Kyu Chang Won
- Yeungnam University College of Medicine, Daegu, South Korea
| | - Young-Il Kim
- Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Choon Hee Chung
- Wonju College of Medicine, Yonsei University, Wonju, South Korea
| | - Tae Sun Park
- Chonbuk National University Medical School, Jeonju, South Korea
| | - Jee-Hyun Lee
- Departments of Internal Medicine, Sanofi-Aventis Korea Co. Ltd, Seoul, South Korea
| | - Moon-Kyu Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Giugliano D, Chiodini P, Maiorino MI, Bellastella G, Esposito K. Intensification of insulin therapy with basal-bolus or premixed insulin regimens in type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials. Endocrine 2016; 51:417-28. [PMID: 26281001 DOI: 10.1007/s12020-015-0718-3] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 08/07/2015] [Indexed: 10/23/2022]
Abstract
The purpose of this study was to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing the effect of intensified insulin regimens (basal-bolus versus premixed) on glycemic control in patients with type 2 diabetes. We conducted an electronic search until March 2015 on many electronic databases including online registries of ongoing trials. All RCTs comparing basal-bolus with premixed insulin regimens, with a duration of >12 weeks and with >30 patients per arm, were included. Investigators extracted data on study characteristics, outcome measures, and methodological quality. We found thirteen RCTs lasting 16-60 weeks and involving 5255 patients assessed for the primary endpoint (reduction of HbA1c from baseline). Meta-analysis of change in HbA1c level between basal-bolus and premixed insulin regimens resulted in a small and non-significant difference of 0.09% (95% CI -0.03 to 0.21), with substantial heterogeneity between studies (I(2) = 74.4%). There was no statistically significant difference in the event rate for overall hypoglycemia (0.16 episode/patient/year, 95%CI -2.07 to 2.3), weight change (-0.21 kg, -0.164 to 0.185), and daily insulin dose (-0.54 U/day, -2.7 to 1.6). The likelihood for reaching the HbA1c <7% was 8% higher (3-13%, I(2) = 68.8%) with the basal-bolus as compared with the premixed regimen. There is no clinically relevant difference in the efficacy of basal-bolus versus premixed insulin regimens for HbA1c decrease in type 2 diabetic patients. These findings may be helpful to adapt treatment to individual patient needs.
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Affiliation(s)
- Dario Giugliano
- Division of Endocrinology and Metabolic Diseases, Department of Medical, Surgical, Neurological, Metabolic Sciences and Aging, Second University of Naples, Naples, Italy.
| | - Paolo Chiodini
- Department of Mental and Physical Health, Second University of Naples, Naples, Italy
- Medical Statistics Unit, Second University of Naples, Naples, Italy
| | - Maria Ida Maiorino
- Diabetes Unit, Department of Clinical and Experimental Medicine, Second University of Naples, Naples, Italy
| | - Giuseppe Bellastella
- Division of Endocrinology and Metabolic Diseases, Department of Medical, Surgical, Neurological, Metabolic Sciences and Aging, Second University of Naples, Naples, Italy
| | - Katherine Esposito
- Diabetes Unit, Department of Clinical and Experimental Medicine, Second University of Naples, Naples, Italy
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Rojas A, Sposetti G, Gross JL, Barbieri DE, Duan R, Linetzky B, De Lana JM, Stempa O, Rodriguez A. Insulin lispro low mixture twice daily vs basal insulin glargine once daily and prandial insulin lispro once daily as insulin intensification strategies in patients with type 2 diabetes: Latin American subpopulation analysis of a randomized trial. Diabetol Metab Syndr 2016; 8:69. [PMID: 27660663 PMCID: PMC5027076 DOI: 10.1186/s13098-016-0163-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 07/10/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This post hoc analysis examined the efficacy and safety of twice-daily insulin lispro low mixture (LM25) and once-daily basal insulin glargine plus once-daily prandial insulin lispro (IGL) in a Latin American subpopulation with type 2 diabetes mellitus (T2DM). METHODS A phase 4, randomized, open-label, parallel-arm trial included participants aged 18-75 years with T2DM taking once-daily insulin glargine and stable doses of metformin and/or pioglitazone with glycated hemoglobin (HbA1c) 7.5-10.5 % and fasting plasma glucose ≤121 mg/dL. Participants were randomized 1:1 to receive their stable dose of metformin and/or pioglitazone plus twice-daily LM25 or IGL for 24 weeks. The primary efficacy outcome was change in HbA1c after 24 weeks of treatment. Results from participants in Argentina, Brazil, and Mexico are presented here. RESULTS 162 participants (80 LM25; 82 IGL) with mean ± standard deviation (SD) age = 57.3 ± 9.0 years and body mass index = 31.3 ± 5.2 kg/m(2) were included. Mean ± SD change in HbA1c from baseline to week 24 was -1.5 ± 1.0 % (LM25) and -1.1 ± 1.2 % (IGL). At week 24, 35.1 % (LM25) and 31.6 % (IGL) of participants achieved HbA1c <7.0 %. Mean ± SD weight gain from baseline to week 24 was 2.4 ± 2.9 kg in the LM25 group and 1.0 ± 3.1 kg in the IGL group. The mean ± SD rates of total hypoglycemia per year were 18.9 ± 27.3 (LM25) and 21.6 ± 31.1 (IGL). Rates of treatment-emergent adverse events were 46 % (LM25) and 39 % (IGL). CONCLUSIONS Our results suggest that both LM25 and IGL are viable treatment options for insulin intensification in Latin American patients with T2DM with suboptimal glycemic control on basal insulin glargine. The safety and tolerability profiles of LM25 and IGL are consistent between this Latin American population and the global trial-level population. Trial registration NCT01175824.
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Affiliation(s)
- Arturo Rojas
- Direccion-investigacion, Servicio Medico Nutricional S.C. (Centro de Diabetes de Coatzacoalcos), Revolucion # 522, 96400 Coatzacoalcos, VER México
| | - Georgina Sposetti
- Diabetes and Metabolism Research Department, Head en Instituto de Investigaciones Clínicas, Mar del Plata, Argentina
| | - Jorge L. Gross
- Centro de Pesquisas em Diabetes, Porto Alegre, Rio Grande do Sul Brazil
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Darmon P, Raccah D. Options for intensification of basal insulin in type 2 diabetes: Premeal insulin or short-acting GLP-1 receptor agonists? DIABETES & METABOLISM 2015; 41:6S21-6S27. [PMID: 26774016 DOI: 10.1016/s1262-3636(16)30005-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Abstract
This article describes a number-based system for the classification of insulin regimes. It utilizes a patient-centered variable (number of injections per day) and pharmacokinetic/dynamic characteristics to craft a taxonomic system that is able to incorporate all available insulin preparations and coformulations. This framework of systematics is robust enough to include various molecules that have been recently developed. It serves to enhance understanding of the subject, and facilitates the practical or clinical usage of theoretical knowledge. We propose that number-based insulin taxonomic models should be used in clinical guidelines and recommendations rather than restricting ourselves to pharmaceutical-based classifications. PubMed articles including both review articles and clinical trials published since the year 1990 were searched, to gather evidence and information on the various types of insulins available, and how they can be used, based on the number or frequency of injections prescribed per day.
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Affiliation(s)
- Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, India.
| | - Yashdeep Gupta
- Department of Endocrinology, All India Institute of Medical Sciences, New Delhi, India
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Prasanna Kumar KM, Shah S, Shah P, Cleall S, Chen S, Uppal S. Insulin lispro low mixture twice daily versus basal insulin glargine once daily and prandial insulin lispro once daily in patients with type 2 diabetes mellitus requiring insulin intensification—a randomized phase IV trial: Indian subpopulation analyses. Int J Diabetes Dev Ctries 2015. [DOI: 10.1007/s13410-015-0387-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Scheen A, Schmitt H, Jiang H, Ivanyi T. Individualizing treatment of type 2 diabetes by targeting postprandial or fasting hyperglycaemia: Response to a basal vs a premixed insulin regimen by HbA1c quartiles and ethnicity. DIABETES & METABOLISM 2015; 41:216-22. [DOI: 10.1016/j.diabet.2015.03.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Revised: 02/17/2015] [Accepted: 03/02/2015] [Indexed: 11/16/2022]
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