Determining the optimal fasting glucose target for patients with type 2 diabetes: Results of the multicentre, open-label, randomized-controlled FPG GOAL trial

Risk factors for fasting blood glucose control in middle-aged and elderly type 2 diabetes patients

This study aimed to investigate and analyze the medication use, fasting blood glucose control, and associated risk factors among residents with type 2 diabetes at the grassroots level in Xinjiang Production and Construction Corps. A multi-stage cluster sampling method was employed to conduct a questionnaire survey among residents aged 45 and above in battalions (communities) as the smallest unit. The medication use was recorded, and fasting blood glucose control was considered as the dependent variable. Logistic regression analysis was performed to identify the risk factors influencing fasting blood glucose control among different population characteristics. A total of 2316 participants were included in the study, of which 1072 were male (45.12%), 1418 were aged 65 and above (61.23%), 2031 were Han Chinese (87.69%), and 1551 were from the surrounding areas of Urumqi (66.97%). The main medications used among the top three classes were metformin, insulin, and α-glucosidase inhibitors. The treatment rate for type 2 diabetes was 71.80%, and the fasting blood glucose control rate was 27.98%. Multivariate analysis identified living outside the Urumqi surrounding area, age 65 and above, body mass index ≥ 24, abnormal blood lipids, and untreated hypertension as independent risk factors for poor fasting blood glucose control, while treatment was a protective factor for achieving blood glucose control. The treatment rate and fasting blood glucose control rate among grassroots residents with type 2 diabetes in Xinjiang Production and Construction Corps need improvement. Efforts should be made to enhance patient medication adherence and health management awareness through education. Targeted interventions should be implemented for high-risk populations with identified risk factors to reduce or delay the occurrence of diabetes and its complications, ultimately aiming to reduce mortality rates and improve quality of life.

Clinical perspectives on the frequency of hypoglycemia in treat-to-target randomized controlled trials comparing basal insulin analogs in type 2 diabetes: a narrative review

The objective of this review was to comprehensively present and summarize trends in reported rates of hypoglycemia with one or two times per day basal insulin analogs in individuals with type 2 diabetes to help address and contextualize the emerging theoretical concern of increased hypoglycemic risk with once-weekly basal insulins.Hypoglycemia data were extracted from treat-to-target randomized clinical trials conducted during 2000-2022. Published articles were identified on PubMed or within the US Food and Drug Administration submission documents. Overall, 57 articles were identified: 44 assessed hypoglycemic outcomes in participants receiving basal-only therapy (33 in insulin-naive participants; 11 in insulin-experienced participants), 4 in a mixed population (insulin-naive and insulin-experienced participants) and 9 in participants receiving basal-bolus therapy. For the analysis, emphasis was placed on level 2 (blood glucose <3.0 mmol/L (<54 mg/dL)) and level 3 (or severe) hypoglycemia.Overall, event rates for level 2 or level 3 hypoglycemia across most studies ranged from 0.06 to 7.10 events/person-year of exposure (PYE) for participants receiving a basal-only insulin regimen; the rate for basal-bolus regimens ranged from 2.4 to 13.6 events/PYE. Rates were generally lower with second-generation basal insulins (insulin degludec or insulin glargine U300) than with neutral protamine Hagedorn insulin or first-generation basal insulins (insulin detemir or insulin glargine U100). Subgroup categorization by sulfonylurea usage, end-of-treatment insulin dose or glycated hemoglobin reduction did not show consistent trends on overall hypoglycemia rates. Hypoglycemia rates reported so far for once-weekly basal insulins are consistent with or lower than those reported for daily-administered basal insulin analogs.

Effectiveness, safety, initial optimal dose, and optimal maintenance dose range of basal insulin regimens for type 2 diabetes: A systematic review with meta-analysis

AIMS

To investigate the effectiveness, safety, optimal starting dose, optimal maintenance dose range, and target fasting plasma glucose of five basal insulins in insulin-naïve patients with type 2 diabetes mellitus.

METHODS

MEDLINE, EMBASE, Web of Science, and the Cochrane Library were searched from January 2000 to February 2022. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed and the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach was adopted. The registration ID is CRD42022319078 in PROSPERO.

RESULTS

Among 11 163 citations retrieved, 35 publications met the planned criteria. From meta-analyses and network meta-analyses, we found that when injecting basal insulin regimens at bedtime, the optimal choice in order of most to least effective might be glargine U-300 or degludec U-100, glargine U-100 or detemir, followed by neutral protamine hagedorn (NPH). Injecting glargine U-100 in the morning may be more effective (ie, more patients archiving glycated hemoglobin < 7.0%) and lead to fewer hypoglycemic events than injecting it at bedtime. The optimal starting dose for the initiation of any basal insulins can be 0.10-0.20 U/kg/day. There is no eligible evidence to investigate the optimal maintenance dose for basal insulins.

CONCLUSIONS

The five basal insulins are effective for the target population. Glargine U-300, degludec U-100, glargine U-100, and detemir lead to fewer hypoglycemic events than NPH without compromising glycemic control.

6. Glycemic Targets: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Needle-free injection of basal insulin improves fasting glucose variability as assessed by continuous glucose monitoring in T2DM: a prospective randomized multicenter open-label crossover study

BACKGROUND

Fasting glucose variability (FGV) extensively promotes the onset and development of diabetic complications. This study aimed to evaluate the FGV in type 2 diabetes mellitus (T2DM) patients administered basal insulin using a needle-free insulin injector (NFII).

RESEARCH DESIGN AND METHODS

This was a prospective randomized multicenter open-label crossover study. We randomly assigned 48 T2DM patients to receive basal insulin by NFII or conventional insulin pen (CIP) for 7-14 days and were then crossed over after washout. We conducted continuous glucose monitoring to investigate the FGV, our primary outcome was a composite parameter of the FGV with a fasting blood glucose target between 4.4 and 6.1 mmol/L.

RESULTS

The coefficient of variation for sensor glucose at 6 a.m. with CIP was 11.67 (8.70,14.81)% vs. 9.48 (6.48,12.24)% with NFII (p = 0.003), and the coefficient of variation for mean sensor glucose at 5-6 a.m. with CIP was 12.70 (9.17,16.56)% vs. 9.23 (7.01,11.98)% with NFII (p < 0.001). The overall basal insulin dosage with CIP injection was 18.00 (16.00, 20.00) IU vs. 16.00 (12.00, 19.00) IU during NFII (p < 0.003).

CONCLUSION

Compared with CIP, the use of the NFII to inject basal insulin improved FGV in T2DM.

CLINICAL TRIAL REGISTRATION

https://www.chictr.org.cn Identifier is ChiCTR2000034674.

Unmet Needs of Glycaemic Control and Risk Factors of Residual Hyperglycaemia in a Chinese Population with Type 2 Diabetes Initiating Basal Insulin: A Post Hoc Analysis of the FPG GOAL Study

Introduction

To aim of this analysis was to investigate the extent and evaluate risk factors of residual hyperglycaemia in Chinese individuals with type 2 diabetes (T2D) initiating basal insulin.

Methods

FPG GOAL was a 24-week, open-label, treat-to-target randomised controlled trial in Chinese individuals with T2D inadequately controlled with oral anti-hyperglycaemic drugs initiating treatment with basal insulin. This analysis categorised participants into the following glycaemic control categories: hyperglycaemia [glycated haemoglobin (HbA1c) ≥ 53 mmol/mol (≥ 7%), fasting plasma glucose (FPG) ≥ 7.0 mmol/L], residual hyperglycaemia [HbA1c ≥ 53 mmol/mol (≥ 7%), FPG < 7.0 mmol/L], discordant [HbA1c < 53 mmol/mol (< 7%), FPG ≥ 7.0 mmol/L] and at target [HbA1c < 53 mmol/mol (< 7%), FPG < 7.0 mmol/L]. The proportion of participants in each glycaemic control category was assessed at weeks 12 and 24. Multivariable regression analyses were conducted to evaluate risk factors for residual hyperglycaemia.

Results

Of the 914 participants included, 22.1% had residual hyperglycaemia, 31.9% had hyperglycaemia, 11.1% were discordant and 29.3% were at target at week 24. More participants who were randomised to a fasting blood glucose (FBG) target of > 3.9 to ≤ 5.6 mmol/L had residual hyperglycaemia compared with participants randomised to a FBG target of > 3.9 to ≤ 6.1 mmol/L or > 3.9 to ≤ 7.0 mmol/L. Multivariable analysis indicated that higher HbA1c and lower FPG levels at baseline were associated with greater proportion of residual hyperglycaemia.

Conclusion

Some Chinese individuals with T2D may have residual hyperglycaemia 3–6 months after initiating basal insulin treatment and require further intensified treatment. Higher HbA1c and lower FPG levels could be risk factors for residual hyperglycaemia.

Trial Registration

ClinicalTrials.gov identifier NCT02545842.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-022-02128-y.

6. Glycemic Targets: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Influence of Fasting Plasma Glucose Targets on Glycemic Variability in Chinese Participants With Type 2 Diabetes: A Post Hoc Analysis of the FPG GOAL Trial (BEYOND III)

INTRODUCTION

This post hoc analysis examines the relationship between glycemic variability (GV) and fasting plasma glucose (FPG) targets used to achieve glycated hemoglobin (HbA1c) < 7%, and HbA1c levels after 24 weeks of treatment with insulin glargine and oral antidiabetic drugs (OADs) in Chinese participants with type 2 diabetes mellitus (T2DM) from the BEYOND III FPG GOAL trial (NCT02545842).

METHODS

Participants were randomized for three FBG targets (≤ 5.6 mmol/L, ≤ 6.1 mmol/L, and ≤ 7.0 mmol/L) receiving insulin glargine 100 U/mL were analyzed for mean change from baseline to 24 weeks in postprandial glucose (PPG) excursion and FPG coefficient of variation (FPG-CV). The study analyzed change from baseline in HbA1c and the proportion of participants who achieved HbA1c < 7% at 24 weeks, according to their baseline FPG-CV and change from baseline in PPG excursion.

RESULTS

The change in PPG excursion and FPG-CV from baseline to 24 weeks was not significantly different between the three groups stratified by randomization or by 24-week FPG levels. While the change in HbA1c from baseline to 24 weeks was slightly higher among participants with baseline FPG-CV < 33.3% (vs. > 66.7%; P = 0.023), a higher proportion of participants with baseline FPG-CV < 33.3% achieved HbA1c < 7% (P = 0.021).

CONCLUSIONS

GV was not associated with either target FPG levels or HbA1c < 7.0% after 24 weeks of treatment with insulin glargine and OADs.

TRIAL REGISTRATION

Clinicaltrials.gov identifier NCT02545842.

Fasting Glucose of 6.1 mmol/L as a Possible Optimal Target for Type 2 Diabetic Patients with Insulin Glargine: A Randomized Clinical Trial

To observe whether different insulin glargine titration algorithms based on fasting blood glucose (FBG) levels lead to different glycaemic variations (GVs) in type 2 diabetes (T2D) patients, a prospective, randomized, single-centre, comparative, three-arm parallel-group, open-label, treat-to-target, 24-week study was performed. A total of 71 uncontrolled T2D patients were recruited and randomized 1 : 3 : 3 into Groups 1, 2, and 3 (insulin titration goals of FBG ≤ 5.6, ≤6.1, and ≤7.0) for this study. The initiated insulin glargine dose was recommended at 0.2 U/kg/day and was then titrated following the FBG target. Patients were subjected to two 3-day continuous glucose monitoring (CGM) at baseline and the endpoint, wherein the CGM data were analysed, and the study's primary endpoint was the difference in 24 hrs mean amplitude of glycaemic excursion (MAGE) among the three groups. We observed that patients in the three groups had similar MAGE levels at the endpoint; however, Group 2 achieved a significant decrease in the MAGE level from baseline to the endpoint as compared to Groups 1 and 3 (all p < 0.05). We also observed that these patients had significant glycated haemoglobin A1c (HbA1c) value improvements as compared to the other two groups (all p < 0.05). Therefore, choosing an FBG level of 6.1 mmol/L as an insulin titration target provided significant GVs and HbA1c value improvements in T2D patients. Moreover, our data indicated that an FBG of 6.1 mmol/L could possibly be an insulin glargine titration target in T2D patients.

6. Glycemic Targets: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Influence of Fasting Glucose Levels on Achieving Glycemic Target in Individuals with Type 2 Diabetes: a Post Hoc Analysis

INTRODUCTION

FPG GOAL was a 24-week, open-label, treat-to-target randomized controlled trial which demonstrated that the optimal self-monitored fasting blood glucose (SM-FBG) target for most Chinese individuals with type 2 diabetes (T2D) using insulin glargine 100 IU/mL was 3.9-6.1 mmol/L. Individuals who achieved lower fasting plasma glucose (FPG) levels might achieve the target HbA1c of < 7% without increasing the risk of hypoglycemia.

METHODS

For this post hoc analysis, individuals were redivided into three groups based on their actual laboratory FPG levels at 24 weeks: level 1, ≤ 5.6 mmol/L; level 2, > 5.6 to ≤ 6.1 mmol/L; and level 3, > 6.1 to ≤ 7.0 mmol/L.

RESULTS

At week 24, 863 individuals with diabetes had available FPG data and 179, 122, and 179 individuals achieved FPG levels 1, 2, and 3, respectively. The proportion of individuals with HbA1c < 7% or HbA1c < 7% without hypoglycemia (≤ 3.9 or ≤ 3.0 mmol/L) was significantly higher in FPG levels 1 (p < 0.01) and 2 (p < 0.05) than in level 3. The least squares mean changes from baseline in HbA1c (- 1.77% and - 1.66% vs - 1.34%; both p < 0.001) and 2-h postprandial glucose (- 3.88 mmol/L and - 3.98 mmol/L vs - 3.22 mmol/L; both p < 0.05) were also significantly higher in FPG levels 1 and 2 compared with level 3. Linear regression analysis showed a moderate relationship between FPG and HbA1c levels at 24 weeks (r = 0.449).

CONCLUSIONS

Chinese individuals with T2D who achieved lower FPG levels with insulin glargine 100 IU/mL were more likely to achieve the recommended target HbA1c of < 7% compared with those with higher FPG levels. ClinicalTrials.gov identifier NCT02545842.

6. Glycemic Targets: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Determining the optimal fasting glucose target for patients with type 2 diabetes: Results of the multicentre, open-label, randomized-controlled FPG GOAL trial

The optimal fasting blood glucose (FBG) target of achieving HbA1c less than 7.0% in type 2 diabetes (T2D) patients remains controversial. This open-label trial randomized (1:3:3) 947 adults with uncontrolled T2D (HbA1c >7% to ≤10.5%) who were using one to three oral antidiabetic drugs to achieve an FBG target of 3.9 < FBG ≤5.6 mmol/L (Group 1), 3.9 < FBG ≤6.1 mmol/L (Group 2) or of 3.9 < FBG ≤7.0 mmol/L (Group 3). Targets were achieved using a pre-defined insulin glargine 100 U/mL titration scheme. The primary endpoint was proportion of patients achieving HbA1c <7.0% at 24 weeks. At 24 weeks, 44.4%, 46.1% and 37.7% of patients achieved HbA1c <7.0% in Groups 1, 2 and 3, respectively (P = 0.017; Group 2 vs Group 3). Alert hypoglycaemia (glucose ≤3.9 mmol/L) was significantly more frequent in Group 1 than in Group 3 (38.9 vs 23.3%; P < 0.001) but was not in Group 2 vs Group 3 (27.5% vs 23.3%; P = 0.177). Clinically important hypoglycaemia (glucose ≤3.0 mmol/L) was reported in 4.8%, 2.0% and 3.8% of patients in Groups 1, 2 and 3, respectively. In conclusion, the optimal FBG target for most Chinese patients with T2D appears to be 3.9-6.1 mmol/L.