Differences in insulin treatment satisfaction following randomized addition of biphasic, prandial or basal insulin to oral therapy in type 2 diabetes

Use of Patient-Reported Outcomes for Assessing Diabetes Outcomes

The treatment of diabetes can be complex and overwhelming for patients as it demands persistent attention to lifestyle management, adherence to medications, monitoring of side effects of drugs, and management of devices for glucose monitoring and/or insulin infusion. Therefore, understanding patient-reported outcomes (PROs) that provide direct insight into the patient's experience with diabetes is crucial for optimizing diabetes management.This review provides an overview of commonly used PRO questionnaires that assess different aspects of diabetes management.

Exploring ethnic representativeness in diabetes clinical trial enrolment from 2000 to 2020: a chronological survey

AIMS/HYPOTHESIS

Ethnic representativeness of participant enrolment in diabetes RCTs involving multiple ethnicities remains unknown. The aims of this study were to evaluate the status and temporal trend of ethnic representativeness in enrolment to diabetes RCTs, and to assess under-enrolment of non-white ethnic groups and explore trial characteristics associated with under-enrolment.

METHODS

We conducted a chronological survey by systematically searching the literature to include eligible RCTs published between January 2000 and December 2020. We assessed temporal trends in enrolment of ethnic groups in the included trials. Univariable logistic regression was used to explore the association between trial characteristics and under-enrolment of non-white groups, using a participant to prevalence ratio of <0.8 to define under-enrolment. This study was registered in PROSPERO (CRD42021229100).

RESULTS

We included 405 RCTs for analysis (327 multi-country trials, 69 conducted in the USA and nine conducted in the UK). The median enrolment rate of all non-white groups was 24.0% in the overall RCTs. Trials conducted in the USA and the UK had median enrolment rates of 29.0% and 12.0% for all non-white groups, respectively. There was a temporal trend towards increased participation of non-white ethnic groups in the overall RCTs; however, no significant improvement over time was found in the US or UK trials. Non-white groups were under-enrolled in most included trials: 62.3% (43/69) in US trials and 77.8% (7/9) in UK trials. The US trials with a high female proportion were associated with lower odds of under-enrolment of all non-white groups (OR 0.22; 95% CI 0.07, 0.65), while trials receiving funding from industry showed increased odds of under-enrolment (OR 4.64; 95% CI 1.50, 14.35). Outpatient enrolment and intervention duration were significantly associated with under-enrolment of Black participants. Only a small proportion of trials reported subgroup results or explored the effect modification by ethnicity.

CONCLUSIONS/INTERPRETATION

A temporal trend towards increased non-white ethnic enrolment was found in diabetes RCTs globally, but not in the USA or the UK. Non-white ethnic groups were under-represented in the majority of diabetes trials conducted in the USA and the UK. Some trial characteristics may be associated with non-white under-enrolment in diabetes trials. These findings provide some evidence for non-white ethnic representativeness in diabetes trials over the past two decades, and highlight the need for more effective strategies and endeavours to alleviate under-enrolment of non-white ethnic groups.

Effects of Metabolic Medicine and Metabolic Surgery on Patient-Reported Outcomes Among Patients with Type 2 Diabetes

The assessment and management of patient-reported outcomes (PROs) is considered secondary to that of cardiometabolic outcomes. When assessed, health-related quality of life (HRQOL), a PRO, can yield pertinent information that cannot be obtained from cardiometabolic assessments. For instance, physical and mental distress can be quantified and treated. Moreover, treatment convenience and satisfaction can be gaged. Behavioral modification, bariatric surgery, and pharmacotherapy can improve PROs. Typically, HRQOL is responsive to changes in weight. Specifically, weight loss and weight gain are associated with positive and negative changes in quality of life, respectively. In addition, patient satisfaction can be influenced by glycemic control. Therefore, hypoglycemia and hyperglycemic episodes can negatively affect patient satisfaction. When managing type 2 diabetes (T2D), it is important to consider how therapies impact PROs. Generally, changes in clinical outcomes mirror changes in PROs. To best manage T2D, integrating the assessment of PROs with clinical outcomes is needed.

Achieving Glycaemic Control with Concentrated Insulin in Patients with Type 2 Diabetes

The recent introduction of the second-generation long-acting analogue insulins degludec and insulin glargine U300 have increased the choice of basal insulin therapy for patients with type 2 diabetes. The pharmacokinetic and pharmacodynamic properties of these insulins result in a flatter profile that lasts over 24 h and provides an increased window of administration of 6 h once daily. Large-scale multicentre randomised clinical trial programmes (BEGIN for degludec U100 and U200 and EDITION for glargine U300) evaluating these insulin therapies against glargine U100 have demonstrated that they are either non-inferior or superior for glycaemic efficacy and safety, but less likely to result in severe or nocturnal hypoglycaemia than glargine U100. The disposable pen devices for these insulins have been designed with patient satisfaction and convenience in mind. No concerns have arisen with adverse events with insulin analogues or cardiovascular safety from the ORIGIN and DEVOTE trials. As they demonstrate equivalent glycaemic efficacy to other basal insulins, they should be considered more in selected patient groups including those with recurrent or increased risk of hypoglycaemia, especially severe or nocturnal episodes, in the elderly or those living alone, and in patients with multiple co-morbidities such as cardiovascular or renal disease.

Short-Term Outcomes for Veterans Receiving Basal Insulin, Metformin, and a Sulfonylurea Who Are Started on a Third Noninsulin Agent Versus Prandial Insulin

AIMS

Despite numerous recent advances in the management of patients with type 2 diabetes, there remains a paucity of data to guide sequential treatment intensification.

METHODS

This was a single-center, retrospective cohort study of patients receiving metformin, basal insulin, and a sulfonylurea who were started on a third noninsulin agent or prandial insulin. The primary outcome for this study was change in A1C at 6 months after treatment intensification. Secondary outcomes included change in weight at 6 months, change in A1C at 1 year, percentage of patients achieving an A1C <7.5% at 1 year, documented episodes of hypoglycemia, and time to progression to prandial insulin.

RESULTS

A total of 62 patients were identified for inclusion in the study: 28 receiving prandial insulin and 34 treated with a noninsulin agent. There was no significant difference in A1C change between the two treatment arms at either 6 months (-0.53 vs. -0.84%, P = 0.31) or 1 year (-0.67 vs. -0.86%, P = 0.61) after intervention. Patients receiving noninsulin agents gained significantly less weight at 6 months (-2.09 vs. 1.99 kg, P <0.01) and experienced fewer annual episodes of hypoglycemia (1.0 vs. 2.6, P = 0.01). Among patients treated with noninsulin agents, those receiving a glucagon-like peptide 1 receptor agonist were more likely to have an A1C <7.5% at 1 year than patients receiving a dipeptidyl peptidase 4 inhibitor (50 vs. 13%, P = 0.05).

CONCLUSION

These results highlight that, in select patients, noninsulin therapies can be added to a backbone of metformin, basal insulin, and a sulfonylurea with similar A1C reductions but improved metabolic parameters relative to intensive insulin therapy.

Treat-to-target trials in diabetes

Treat-to-target is a therapeutic concept that considers well defined and specific physiologic targets as aims in controlling the pathophysiology of the disease. It has been widely used in diseases that pathophysiology includes, chronic metabolic and physiological disturbances, namely rheumatic conditions, vascular medicine and diabetes. In diabetes, the availability of "gold-standard" quantitative measures like fasting plasma glucose and glycated hemoglobin make the application of treat-to-target trials especially pertinent. Treatment modalities which have used single therapeutic agents or combinations or in combination with a variety of titration algorithms and implementation protocols have broadened our understanding of diabetes management with specific reference to insulin initiation and maintenance. Treat-to-target trials have been used to investigate a wide variety of questions including efficacy, safety, effect of treatment on comorbidities and patient satisfaction, ideal mechanisms to implement insulin initiation etc. A more generalized acceptance and implementation of treat-to-target trials may finally revolutionize diabetes management by combining aspects of individual care with standard treatment protocols.

Advances in pharmacologic therapies for type 2 diabetes

Type 2 diabetes (T2DM) is a multi-causal, heterogeneous and progressive cardiometabolic condition, with an increasing prevalence worldwide. T2DM is associated with multiple comorbidities that may impact patients' quality of life. Treatment is multifactorial, but pharmacologic treatment of hyperglycemia is still regarded as the mainstay of diabetes management. Current established therapies include metformin, sulfonylurea agents and insulin, the long-term use of which was associated with reduced micro- and macrovascular events in the United Kingdom Prospective Diabetes Study. Despite major recent advances in diabetes care, a large proportion of patients remain in poor glycemic control, necessitating the development of new therapeutic options. The recently published position statement of the American Diabetes Association and European Association for the Study of Diabetes for the management of hyperglycemia in T2DM has accommodated this wider range of therapy choices, as it is less prescriptive and advocates an individualized treatment approach, taking into account many relevant patient- and disease-related factors. This review summarizes the updates on various established agents as well as the recent developments with regard to incretin-based therapies, inhibitors of the renal tubular sodium-glucose-linked-transporter-2 and ultra-long acting basal insulin formulations.

A systematic review of patient-reported measures of burden of treatment in three chronic diseases

Background

Burden of treatment refers to the workload of health care and its impact on patient functioning and well-being. There are a number of patient-reported measures that assess burden of treatment in single diseases or in specific treatment contexts. A review of such measures could help identify content for a general measure of treatment burden that could be used with patients dealing with multiple chronic conditions. We reviewed the content and psychometric properties of patient-reported measures that assess aspects of treatment burden in three chronic diseases, ie, diabetes, chronic kidney disease, and heart failure.

Methods

We searched Ovid MEDLINE, Ovid EMBASE, Ovid PsycINFO, and EBSCO CINAHL through November 2011. Abstracts were independently reviewed by two people, with disagreements adjudicated by a third person. Retrieved articles were reviewed to confirm relevance, with patient-reported measures scrutinized to determine consistency with the definition of burden of treatment. Descriptive information and psychometric properties were extracted.

Results

A total of 5686 abstracts were identified from the database searches. After abstract review, 359 full-text articles were retrieved, of which 76 met our inclusion criteria. An additional 22 articles were identified from the references of included articles. From the 98 studies, 57 patient-reported measures of treatment burden (full measures or components within measures) were identified. Most were multi-item scales (89%) and assessed treatment burden in diabetes (82%). Only 15 measures were developed using direct patient input and had demonstrable evidence of reliability, scale structure, and multiple forms of validity; six of these demonstrated evidence of sensitivity to change. We identified 12 content domains common across measures and disease types.

Conclusion

Available measures of treatment burden in single diseases can inform derivation of a patient-centered measure of the construct in patients with multiple chronic conditions. Patients should take part in developing the measure to ensure salience and relevance.