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Giaccari A, Bonadonna RC, Buzzetti R, Perseghin G, Cucinotta D, Fanelli C, Avogaro A, Aimaretti G, Larosa M, Pagano V, Bolli GB. Similar glycaemic control and risk of hypoglycaemia with patient- versus physician-managed titration of insulin glargine 300 U/mL across subgroups of patients with T2DM: a post hoc analysis of ITAS. Acta Diabetol 2021; 58:789-796. [PMID: 33586058 PMCID: PMC8110495 DOI: 10.1007/s00592-021-01675-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 01/09/2021] [Indexed: 12/02/2022]
Abstract
AIMS The Italian Titration Approach Study (ITAS) demonstrated comparable HbA1c reductions and similarly low hypoglycaemia risk at 6 months in poorly controlled, insulin-naïve adults with T2DM who initiated self- or physician-titrated insulin glargine 300 U/mL (Gla-300) in the absence of sulphonylurea/glinide. The association of patient characteristics with glycaemic and hypoglycaemic outcomes was assessed. METHODS This post hoc analysis investigated whether baseline patient characteristics and previous antihyperglycaemic drugs were associated with HbA1c change and hypoglycaemia risk in patient- versus physician-managed Gla-300 titration. RESULTS HbA1c change, incidence of hypoglycaemia (any type) and nocturnal rates were comparable between patient- and physician-managed arms in all subgroups. Hypoglycaemia rates across subgroups (0.03 to 3.52 events per patient-year) were generally as low as observed in the full ITAS population. Small increases in rates of 00:00-pre-breakfast and anytime hypoglycaemia were observed in the ≤ 10-year diabetes duration subgroup in the patient- versus physician-managed arm (heterogeneity of effect; p < 0.05). CONCLUSIONS Comparably fair glycaemic control and similarly low hypoglycaemia risk were achieved in almost all patient subgroups with patient- versus physician-led Gla-300 titration. These results reinforce efficacy and safety of Gla-300 self-titration across a range of phenotypes of insulin-naïve people with T2DM. CLINICAL TRIAL REGISTRATION EudraCT 2015-001167-39.
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Affiliation(s)
- Andrea Giaccari
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome and Università Cattolica del Sacro Cuore, Rome, Italy
| | - R. C. Bonadonna
- Division of Endocrinology and Metabolic Diseases and Department of Medicine and Surgery, University of Parma and AOU of Parma, Parma, Italy
| | - R. Buzzetti
- Sapienza University of Rome, Piazzale Aldo Moro, 5, 00185 Rome, RM Italy
| | - G. Perseghin
- University of Milan Bicocca, Piazza dell’Ateneo Nuovo, 1, 20126 Milan, MI Italy
| | - D. Cucinotta
- University of Messina, Piazza Pugliatti, 1, 98122 Messina, Italy
| | - C. Fanelli
- Section of Endocrinology and Metabolism, Department of Medicine, Perugia University Medical School, Piazzale Gambuli, 1, 06129 Perugia, PG Italy
| | - A. Avogaro
- University of Padua, Via 8 Febbraio 1848, 2, 35122 Padua, PD Italy
| | - G. Aimaretti
- University of the Eastern Piedmont, Via del Duomo, 6, 13100 Vercelli, VC Italy
| | | | - V. Pagano
- OPIS s.r.l., Palazzo Aliprandi, Via Matteotti, 10, 20832 Desio, Italy
| | - G. B. Bolli
- Section of Endocrinology and Metabolism, Department of Medicine, Perugia University Medical School, Piazzale Gambuli, 1, 06129 Perugia, PG Italy
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Bolli GB, Porcellati F, Lucidi P, Fanelli CG. The physiological basis of insulin therapy in people with diabetes mellitus. Diabetes Res Clin Pract 2021; 175:108839. [PMID: 33930505 DOI: 10.1016/j.diabres.2021.108839] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
Insulin therapy has been in use now for 100 years, but only recently insulin replacement has been based on physiology. The pancreas secretes insulin at continuously variable rates, finely regulated by sensitive arterial glucose sensing. Pancreatic insulin is delivered directlyin the portal blood to insulinize preferentially the liver. In the fasting state, insulin is secreted at a low rate to modulate hepatic glucose output. After liver extraction (50%), insulin concentrations in peripheral plasma are 2.4-4 times lower than in portal, but still efficacious to restrain lipolysis. In the prandial condition, insulin is secreted rapidly in large amounts to increase portal and peripheral concentrations to peaks 10-20 times greater vs the values of fasting within 30-40 min from meal ingestion. The prandial portal hyperinsulinemia fully suppresses hepatic glucose production while peripheral hyperinsulinemia increases glucose utilization, thus limitating the post-prandial plasma glucose elevation. Physiology of insulin indicates that insulin should be replaced in people with diabetes mimicking the pancreas, i.e. in a basal-bolus mode, for fasting and prandial state, respectively. Despite the presently ongoing limitations (subcutaneous and peripheral rather than portal and intravenous insulin delivery), basal-bolus insulin allows people with diabetes to achieve A1c in the range with minimal risk of hypoglycaemia, to prevent vascular complications and to ensure good quality of life.
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Affiliation(s)
- Geremia B Bolli
- Section of Endocrinology and Metabolism, Department of Medicine and Surgery, Perugia University School of Medicine, Perugia, Italy.
| | - Francesca Porcellati
- Section of Endocrinology and Metabolism, Department of Medicine and Surgery, Perugia University School of Medicine, Perugia, Italy
| | - Paola Lucidi
- Section of Endocrinology and Metabolism, Department of Medicine and Surgery, Perugia University School of Medicine, Perugia, Italy
| | - Carmine G Fanelli
- Section of Endocrinology and Metabolism, Department of Medicine and Surgery, Perugia University School of Medicine, Perugia, Italy
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Cheng AYY, Wong J, Freemantle N, Acharya SH, Ekinci E. The Safety and Efficacy of Second-Generation Basal Insulin Analogues in Adults with Type 2 Diabetes at Risk of Hypoglycemia and Use in Other Special Populations: A Narrative Review. Diabetes Ther 2020; 11:2555-2593. [PMID: 32975710 PMCID: PMC7547921 DOI: 10.1007/s13300-020-00925-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/03/2020] [Indexed: 12/16/2022] Open
Abstract
Hypoglycemia is a major barrier impeding glycemic control in persons with type 2 diabetes mellitus and creates a substantial burden on the healthcare system. Certain populations that require special attention, such as older adults and individuals with renal impairment, a longer duration of diabetes or those who have experienced prior hypoglycemia, may be at a higher risk of hypoglycemia, particularly with insulin treatment. Second-generation basal insulin analogues (insulin glargine 300 U/mL and degludec) have demonstrated reductions in hypoglycemia compared with insulin glargine 100 U/mL although evidence of this benefit across specific populations is less clear. In this review we summarize the literature with respect to the efficacy and safety data for second-generation basal insulin analogues in adults with type 2 diabetes mellitus who are at risk of hypoglycemia or who require special attention. Randomized controlled trials, meta-analyses and real-world evidence demonstrate that the use of second-generation basal insulin analogues is associated with less hypoglycemia compared with insulin glargine 100 U/mL without compromising glycated hemoglobin control. A reduced risk of hypoglycemia with second-generation basal insulin analogues was evident in older adults and in individuals with obesity, renal impairment, a history of cardiovascular disease or a long duration of insulin use. Further studies are needed in other populations, including those with more severe renal impairment or hepatic dysfunction, the hospitalized population and those with cognitive impairment. Overall, less hypoglycemia associated with second-generation basal insulin analogues may help reduce barriers for insulin use, improve adherence and offset the costs of hypoglycemia-related healthcare resource utilization.
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Affiliation(s)
- Alice Y Y Cheng
- Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
| | - Jencia Wong
- Diabetes Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Central Clinical School, Faculty of Medicine and Health, Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - Nick Freemantle
- Institute for Clinical Trials and Methodology, University College London, London, UK
| | - Shamasunder H Acharya
- Department of Diabetes, John Hunter Hospital, Hunter New England Health-University of Newcastle, New Lambton, NSW, Australia
| | - Elif Ekinci
- Department of Medicine, Austin Health-University of Melbourne, Melbourne, VIC, Australia
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Danne T, Matsuhisa M, Sussebach C, Goyeau H, Lauand F, Niemoeller E, Bolli GB. Lower risk of severe hypoglycaemia with insulin glargine 300 U/mL versus glargine 100 U/mL in participants with type 1 diabetes: A meta-analysis of 6-month phase 3 clinical trials. Diabetes Obes Metab 2020; 22:1880-1885. [PMID: 32515543 PMCID: PMC7540568 DOI: 10.1111/dom.14109] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 05/20/2020] [Accepted: 06/04/2020] [Indexed: 02/06/2023]
Abstract
Severe hypoglycaemia (SH) remains a challenge to people with type 1 diabetes (T1DM), and new-generation basal insulins may improve patient outcomes. This post hoc meta-analysis explored the risk of SH with insulin glargine 300 U/mL (Gla-300) versus glargine 100 U/mL (Gla-100) in a pooled population with T1DM from three randomized, multicentre, 6-month similarly designed phase 3 trials: EDITION 4, EDITION JP 1 and EDITION JUNIOR. Endpoints included incidence and time to first occurrence of SH. Among 629 and 626 participants randomized to Gla-300 and Gla-100, respectively, glycated haemoglobin reductions were similar. Fewer participants experienced ≥1 SH event with Gla-300 (6.2%) than with Gla-100 (9.3%). From baseline to month 6, the risk of a first SH event was lower with Gla-300: hazard ratio 0.65 [95% confidence interval (CI) 0.44-0.98; stratified log-rank test P = 0.038]. SH event rates were numerically lower with Gla-300 versus Gla-100 from baseline to month 6 [relative risk (RR) 0.80 (95% CI 0.49-1.29); P = 0.356] and baseline to week 8 [RR 0.73 (95% CI 0.37-1.44); P = 0.369]. Thus, Gla-300 demonstrated similar glycaemic control with lower risk of SH versus Gla-100, particularly during the titration period.
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Affiliation(s)
- Thomas Danne
- Children's Hospital Auf der BultHannover Medical SchoolHannoverGermany
| | - Munehide Matsuhisa
- Diabetes Therapeutics and Research Center, Institute of Advanced Medical SciencesTokushima UniversityTokushimaJapan
| | | | | | | | | | - Geremia B. Bolli
- Section of Endocrinology and Metabolism, Department of MedicinePerugia University Medical SchoolPerugiaItaly
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Freemantle N, Bonadonna RC, Gourdy P, Mauricio D, Mueller-Wieland D, Bigot G, Ciocca A, Mauquoi C, Rollot M, Bonnemaire M. Rationale and methodology for a European pooled analysis of postmarketing interventional and observational studies of insulin glargine 300 U/mL in diabetes: protocol of REALI project. BMJ Open 2020; 10:e033659. [PMID: 32350009 PMCID: PMC7213840 DOI: 10.1136/bmjopen-2019-033659] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Type 2 diabetes mellitus (T2DM) is a common and heterogeneous disease. Using advanced analytic approaches to explore real-world data may identify different disease characteristics, responses to treatment and progression patterns. Insulin glargine 300 units/mL (Gla-300) is a second-generation basal insulin analogue with preserved glucose-lowering efficacy but reduced risk of hypoglycaemia. The purpose of the REALI pooled analysis described in this paper is to advance the understanding of the effectiveness and real-world safety of Gla-300 based on a large European patient database of postmarketing interventional and observational studies. METHODS AND ANALYSIS In the current round of pooling, REALI will include data from up to 10 000 subjects with diabetes mellitus (mostly T2DM) from 20 European countries. Outcomes of interest include change from baseline to week 24 in haemoglobin A1c, fasting plasma glucose, self-measured plasma glucose, body weight, insulin dose, incidence and rate of any-time-of-the-day and nocturnal hypoglycaemia. The data pool is being investigated using two complementary methodologies: a conventional descriptive, univariate and multivariable prognostic analysis; and a data-mining approach using subgroup discovery to identify phenotypic clusters of patients who are highly associated with the outcome of interest. By mid-2019, deidentified data of 7584 patients were included in the REALI database, with a further expected increase in patient number in 2020 as a result of pooling additional studies. ETHICS AND DISSEMINATION The proposed study does not involve collection of primary data. Moreover, all individual study protocols were approved by independent local ethics committees, and all study participants provided written informed consent. Furthermore, patient data is deidentified before inclusion in the REALI database. Hence, there is no requirement for ethical approval. Results will be disseminated via peer-reviewed publications and presentations at international congresses as data are analysed.
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Affiliation(s)
- Nick Freemantle
- Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Riccardo C Bonadonna
- Azienda Ospedaliero-Universitaria di Parma, Parma, Emilia-Romagna, Italy
- School of Medicine, University of Parma, Parma, Emilia-Romagna, Italy
| | - Pierre Gourdy
- University Hospital Centre Toulouse Cardiovascular and Metabolic Medicine Section, Toulouse, Midi-Pyrénées, France
- INSERM, Paul Sabatier University, Toulouse, Occitanie, France
| | - Didac Mauricio
- Endocrinology & Nutrition, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
- Hospital de la Santa Creu i Sant Pau Institut de Recerca, Barcelona, Catalunya, Spain
| | | | | | - Alice Ciocca
- Global Diabetes, Sanofi SA, Paris, Île-de-France, France
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Bolli GB, Wysham C, Fisher M, Chevalier S, Cali AMG, Leroy B, Riddle MC. A post-hoc pooled analysis to evaluate the risk of hypoglycaemia with insulin glargine 300 U/mL (Gla-300) versus 100 U/mL (Gla-100) over wider nocturnal windows in individuals with type 2 diabetes on a basal-only insulin regimen. Diabetes Obes Metab 2019; 21:402-407. [PMID: 30160030 PMCID: PMC6586031 DOI: 10.1111/dom.13515] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 08/24/2018] [Accepted: 08/26/2018] [Indexed: 12/19/2022]
Abstract
The EDITION trials in type 2 diabetes demonstrated comparable glycaemic control with less nocturnal and anytime (24-hour) hypoglycaemia for insulin glargine 300 U/mL (Gla-300) versus glargine 100 U/mL (Gla-100). However, the predefined nocturnal window (0:00-5:59 AM) may not be the most relevant for clinical practice. This post-hoc analysis compared expansions of the predefined nocturnal interval during basal insulin treatment without prandial insulin. Patient-level, 6-month data, pooled from the EDITION 2 and 3 trials and the EDITION JP 2 trial (N = 1922, basal insulin only) were analysed. Accompanying hypoglycaemia during treatment with Gla-300 was compared to that during treatment with Gla-100, using predefined (0:00-5:59 AM) and expanded (10:00 PM-5:59 AM, 0:00-7:59 AM, 10:00 PM to pre-breakfast SMPG) windows. Confirmed (≤3.9 mmol/L [≤70 mg/dL]) or severe hypoglycaemic events were reported most frequently between 6:00 AM and 8:00 AM. Windows expanded beyond 6:00 AM included more events than other windows. The percentage of participants with at least one event was lower with Gla-300 than Gla-100 in all windows examined. Expanding the nocturnal interval allows better assessment of the risk of hypoglycaemia associated with basal insulin. The risk of nocturnal hypoglycaemia was consistently lower with Gla-300 versus Gla-100 using all four windows.
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Affiliation(s)
| | - Carol Wysham
- Diabetes and Endocrinology CenterRockwood ClinicSpokaneWashington
| | - Miles Fisher
- Glasgow Royal InfirmaryUniversity of GlasgowGlasgowUK
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