Delayed initiation of subcutaneous insulin therapy after failure of oral glucose-lowering agents in patients with Type 2 diabetes: a population-based analysis in the UK

Trends in clinical characteristics, medication use, and glycemic control in insulin-treated patients with type 1 and type 2 diabetes in Finland in 2012-2019: Nationwide real-world evidence study

AIMS

To describe the clinical characteristics and medication purchases of insulin-treated adults in Finland at index (January 1, 2012 or first insulin purchase) and December 31, 2019. Additionally, to describe basal insulin (BI) treatment patterns and associated changes in hemoglobin A1c (HbA1c) values.

MATERIALS AND METHODS

In this descriptive study using nationwide registries, we included adults with at least two reimbursed insulin purchases within 12 months of the first purchase between January 1, 2012 and December 31, 2019. We formed four study groups: type 1 diabetes (T1D) and type 2 diabetes (T2D)-diagnosed people who were further divided into prevalent or naïve users (start of insulin use before or after January 1, 2012). Insulin treatment patterns were estimated from medication purchase data and glycemic control from HbA1c results.

RESULTS

Out of 145 020 people included, 34 359 had T1D and 110 661 T2D. By 2019, in parallel with the adaptation of new noninsulin medications, second-generation basal insulin (BI) analogues were adopted by 45.9% and 21.1% of prevalent T1D and T2D users. At index, HbA1c target (≤53 mmol/mol) was reached by 17% and 35% of T2D naïve and prevalent users, respectively, and by 17% of T1D prevalent users. At study end, the target was reached respectively by 41%, 34%, and 22% of insulin users. Insulin initiation improved and discontinuation worsened glycemic control in T2D, with lesser effects seen after treatment gaps or switches between BIs.

CONCLUSIONS

Our study showed that glycemic control in insulin users has remained stable or improved between 2012 and 2019 despite aging population and in parallel with introduction of new treatment options, providing valuable insight into Finnish national diabetes care.

What Is the Role of Basal Weekly Insulin in Clinical Practice? The State of the Art

Despite the advent of innovative therapies in the treatment of diabetes, ever-increasing awareness is still directed to the role of insulin since it has continued to be at the centre of diabetes therapy for decades, as a therapeutic integration of innovative agents in type 2 diabetes mellitus (T2DM), as the only replacement therapy in type 1 diabetes mellitus (T1DM) and also in gestational diabetes. In this context, the study of molecules such as weekly basal insulins, both for their technological and pharmacodynamic innovation and their manageability and undoubted benefits in compliance with drug therapy, can only be a turning point in diabetes and for all its phenotypes. This review aims to provide insight into the knowledge of basal weekly insulins and their use in type 1 and 2 diabetes mellitus by examining their safety, efficacy, manageability and increased therapeutic compliance.

Glycated haemoglobin, HOMA2-B, C-peptide to glucose ratio and type 2 diabetes clusters as predictors for therapy failure in individuals with type 2 diabetes without insulin therapy: A registry analysis

AIM

Some people with type 2 diabetes mellitus (T2D) and declining β-cell function do require insulin over time. Various laboratory parameters, indices of glucose metabolism or phenotypes of T2D (clusters) have been suggested, which might predict future therapy failure (TF), indicating the need for insulin therapy initiation. This analysis evaluated glycated haemoglobin (HbA1c), homeostatic model assessment (HOMA)2-B, C-peptide to glucose ratio (CGR) and diabetes clusters as predictive parameters for the occurrence of glycaemic TF in individuals diagnosed with T2D without previous insulin therapy.

MATERIALS AND METHODS

In total, 159 individuals with T2D [41% female, median age 50 (IQR: 53-69) years, diabetes duration 9 (5-15) years], without insulin therapy were prospectively evaluated for the occurrence of a composite primary endpoint, including HbA1c increasing or remaining >8.0% (64 mmol/mol) 3 months after baseline on non-insulin glucose-lowering agents, insulin initiation or hospital admissions because of acute hyperglycaemic events. Diabetes clusters were formed according to previously described characteristics. Only severe autoimmune diabetes clusters were excluded because of a small amount of glutamate decarboxylase antibody-positive participants. The other clusters were distributed as mild age-related diabetes 33%; severe insulin-deficient diabetes 31%; mild obesity-related diabetes 20%; and severe insulin-resistant diabetes 15%.

RESULTS

During a median observation of 57 months, higher tertiles of HbA1c at baseline, HOMA2-B, as well as a lower CGR were significantly predictive for the occurrence of the primary endpoint. The probability of meeting the primary endpoint was the highest for mild obesity-related diabetes [hazard ratio 3.28 (95% confidence interval 1.75-6.2)], followed by severe insulin-deficient diabetes [hazard ratio 2.03 (95% confidence interval 1.1-3.7)], mild age-related diabetes and the lowest for severe insulin-resistant diabetes. The best performance to predict TF with an area under the curve (AUC) of 0.77 was HbA1c at baseline, followed by HOMA2-B (AUC 0.69) and CGR (AUC 0.64).

CONCLUSION

HbA1c, indices of insulin secretion capacity (HOMA2-B and CGR) and T2D clusters might be applicable tools to guide practitioners in the decision of whether insulin is required in people already diagnosed with T2D. These findings need to be validated in prospective studies.

Time in uncontrolled hyperglycemia before insulin initiation in people living with type 2 diabetes: A systematic literature review

BACKGROUND

This systematic literature review (PROSPERO registration: CRD42022327974) examined the duration of uncontrolled hyperglycemia (glycated hemoglobin [HbA1c] ≥ 7.0%; ≥ 53 mmol/mol) before basal insulin initiation in insulin-naive people with type 2 diabetes who were receiving concomitant oral glucose-lowering agents or injectable glucagon-like peptide-1 receptor agonist therapy.

METHODS

Databases (Embase and MEDLINE) were searched to identify relevant articles published between January 1, 2001, and April 19, 2023. Supplementary searches were completed for relevant congresses between 2018 and 2023.

RESULTS

Of the 4260 de-duplicated publications identified, 18 eligible publications (conducted in: Europe, n = 5; USA, n = 8; Asia/Middle East, n = 4; and Africa, n = 1) reported time spent with HbA1c 7.0% or higher (≥ 53 mmol/mol). Overall, time in uncontrolled hyperglycemia ranged from 1.9 months to 86.4 months (Europe, 9.0-86.4 months; USA, 1.9-58.3 months; Asia/Middle East, 3.3-40.1 months; Africa, 36 months).

CONCLUSIONS

There is a widespread delay in insulin treatment initiation in clinical practice. This delay exists despite availability of novel insulin types and the development of evidence-based treatment guidelines, suggesting that further efforts are needed to improve implementation of these guidelines in clinical practice.

Factors associated with therapeutic inertia in individuals with type 2 diabetes mellitus started on basal insulin

AIM

In this study we aim to identify the factors associated with treatment inertia in patients with type 2 diabetes mellitus (T2DM) who have been recently started on basal insulin (BI).

METHODS

Using UK CPRD GOLD, we identified adults with T2DM with suboptimal glycaemia (HbA1c within 12 months of BI ≥ 7% (≥53 mmol/mol)). We used multivariable Cox regression model to describe the association between patient characteristics and the time to treatment intensification.

RESULTS

A total of 12,556 patients were analysed. Compared to individuals aged < 65 years, those aged ≥ 65 years had lower risk of treatment intensification (HR: 0.69; 95% CI: 0.64-0.73). Other factors included being female (0.93, 0.89-0.99), longer T2DM duration (0.99, 0.98-0.99), living in the most deprived areas (0.90, 0.83-0.98), being a current smoker (0.91, 0.84-0.98), having one (0.91, 0.85-0.97) or more than one comorbidity (0.88, 0.82-0.94), and patients who were on metformin (0.71, 0.63-0.80), or 2nd generation sulphonylureas (0.85; 0.79-0.92) or DPP4 inhibitors (0.87, 0.82-0.93) compared to those who were not.

CONCLUSION

Therapeutic inertia still remains a major barrier, with multiple factors associated with delay in intensification. Interventions to overcome therapeutic inertia need to be implemented at both patient and health care professional level.

COMBINSI (COMBat to INSufficient Insulin therapy) - A Portuguese project in type 2 diabetes

BACKGROUND

Inadequate glycemic control in type 2 diabetes (T2D) increases the risk of diabetes-related complications. Insulin initiation is often delayed for several years. This study aims to estimate the adequacy of insulin therapy prescription to people living with T2D in a primary care setting.

MATERIAL AND METHODS

This was a cross-sectional study based on adults with T2D in a Portuguese local health unit between January 2019 and January 2020. Subjects under insulin therapy were compared with non-insulin-treated subjects with Hemoglobin A1c (HbA1c) ≥9% regarding clinical and demographic characteristics. The proportion of insulin-treated subjects in both of these groups was defined as insulin therapy index.

RESULTS

Our study included 13,869 adults living with T2D, among whom 11.5% were treated with insulin therapy and 4.1% had HbA1c ≥ 9% and were not under insulin therapy. Insulin therapy index was 73.9%. When comparing with non-insulin-treated subjects with HbA1c ≥ 9%, insulin-treated subjects were significantly older (75.8 vs 66.2 years p < 0.001), had lower HbA1c (8.3 vs 10.3% p < 0.001), lower estimated glomerular filtration rate (66.4 vs 74.0 ml/min/1.73 m²p < 0.001), lower LDL-cholesterol (87.1 vs 105.8 mg/dl), and higher rates of atherosclerotic cardiovascular disease (32.7 vs 16.7% p < 0.001).

CONCLUSION

Insulin therapy is underprescribed in T2D, with over 1-in-4 people living with T2D not being prescribed insulin despite deficient glycemic control. These findings highlight the need for insulin therapy when glycemic control is inadequate under other interventions.

Pharmacokinetic and pharmacodynamic properties of the novel basal insulin Fc (insulin efsitora alfa), an insulin fusion protein in development for once-weekly dosing for the treatment of patients with diabetes

AIM

To assess the safety, tolerability, pharmacokinetics (PK) and pharmacodynamics (PD) of basal insulin Fc (BIF; LY3209590), a fusion protein combining a novel single-chain insulin variant together with human IgG2 Fc domain, following single and multiple once-weekly BIF administration.

MATERIALS AND METHODS

The single ascending dose, 15-day study assessed four BIF doses (5-35 mg) in healthy participants and people with type 2 diabetes (T2D). In the 6-week multiple ascending dose study, people with T2D, previously treated with basal insulin, received insulin glargine daily or a one-time loading dose of BIF followed by 5 weeks of once-weekly dosing (1-10 mg). Safety, tolerability and PK and glucose PD were examined.

RESULTS

Mean ages of people with T2D (N = 57) and healthy participants (N = 16) in the single-dose study were 58.4 and 35.8 years, respectively; mean body mass index values were 29.5 and 26.1 kg/m² . BIF had a PK half-life of approximately 17 days, which led to a sustained, dose-dependent decrease in fasting blood glucose for 5 days or longer. No severe hypoglycaemia was observed. The 6-week ascending dose study included 33 people with T2D aged 40-69 years. BIF showed a low peak-to-trough ratio of 1.14 after the last dose at week 6 (steady state). Over 6 weeks, BIF seven-point glucose profiles remained constant and were similar to insulin glargine. Rates and duration of BIF hypoglycaemic events were similar to insulin glargine.

CONCLUSIONS

BIF was well tolerated and the PK/PD profile enabled once-weekly dosing with minimal variation in exposure in a treatment interval of 1 week. The findings suggest BIF is suitable for further development as a weekly basal insulin in people with diabetes.

Factors influencing insulin initiation in primary care facilities in Cape Town, South Africa

BACKGROUND

Type 2 diabetes (T2DM) is a leading cause of mortality in South Africa and resistance to the use of insulin is common. This study aimed to explore factors that influence the initiation of insulin in patients with T2DM in primary care facilities in Cape Town, South Africa.

METHODS

An exploratory descriptive qualitative study was conducted. Seventeen semi-structured interviews were held with patients eligible for insulin, on insulin and primary care providers. Participants were selected by maximum variation purposive sampling. Data were analysed using the framework method in Atlas-ti.

RESULTS

Factors related to the health system, service delivery, clinical care and patients. Systemic issues related to the required inputs of workforce, educational materials, and supplies. Service delivery issues related to workload, poor continuity and parallel coordination of care. Clinical issues related to adequate counselling. Patient factors included a lack of trust, concerns about injections, impact on lifestyle and disposal of needles.

CONCLUSION

Although resource constraints are likely to remain, district and facility managers can improve supplies, educational materials, continuity and coordination. Counselling must be improved and may require innovative alternative approaches to support clinicians who face high number of patients. Alternative approaches using group education, telehealth and digital solutions should be considered.Contribution: This study identified key factors influencing insulin initiation in patients with T2DM in primary care. These can be addressed by those responsible for clinical governance, service delivery and in further research.

Barriers and Facilitators to the Initiation of Injectable Therapies for Type 2 Diabetes Mellitus: A Mixed Methods Study

INTRODUCTION

Initiation of injectable therapies in type 2 diabetes (T2D) is often delayed, however the reasons why are not fully understood.

METHODS

A mixed methods study performed in sequential phases. Phase 1: focus groups with people with T2D (injectable naïve [n = 12] and experienced [n = 5]) and healthcare professionals (HCPs; nurses [n = 5] and general practitioners (GPs) [n = 7]) to understand their perceptions of factors affecting initiation of injectables. Phase 2: video-captured GP consultations (n = 18) with actor-portrayed patient scenarios requiring T2D treatment escalation to observe the initiation in the clinical setting. Phase 3: HCP surveys (n = 87) to explore external validity of the themes identified in a larger sample.

RESULTS

Focus groups identified patients' barriers to initiation; fear, lack of knowledge and misconceptions about diabetes and treatment aims, concerns regarding lifestyle restrictions and social stigma, and feelings of failure. Facilitators included education, good communication, clinician support and competence. HCP barriers included concerns about weight gain and hypoglycaemia, and limited consultation time. In simulated consultations, GPs performed high-quality consultations and recognised the need for injectable initiation in 9/12 consultations where this was the expert recommended option but did not provide support for initiation themselves. Survey results demonstrated HCPs believe injectable initiation should be performed in primary care, although many practitioners reported inability to do so or difficulty in maintaining skills.

CONCLUSION

People with T2D have varied concerns and educational needs regarding injectables. GPs recognise the need to initiate injectables but lack practical skills and time to address patient concerns and provide education. Primary care nurses also report difficulties in maintaining these skills. Primary care HCPs initiating injectables require additional training to provide practical demonstrations, patient education and how to identify and address concerns. These skills should be concentrated in the hands of a small number of primary care providers to ensure they can maintain their skills.

Oral delivery of systemic monoclonal antibodies, peptides and small molecules using gastric auto-injectors

Oral administration provides a simple and non-invasive approach for drug delivery. However, due to poor absorption and swift enzymatic degradation in the gastrointestinal tract, a wide range of molecules must be parenterally injected to attain required doses and pharmacokinetics. Here we present an orally dosed liquid auto-injector capable of delivering up to 4-mg doses of a bioavailable drug with the rapid pharmacokinetics of an injection, reaching an absolute bioavailability of up to 80% and a maximum plasma drug concentration within 30 min after dosing. This approach improves dosing efficiencies and pharmacokinetics an order of magnitude over our previously designed injector capsules and up to two orders of magnitude over clinically available and preclinical chemical permeation enhancement technologies. We administered the capsules to swine for delivery of clinically relevant doses of four commonly injected medications, including adalimumab, a GLP-1 analog, recombinant human insulin and epinephrine. These multi-day dosing experiments and oral administration in awake animal models support the translational potential of the system.

Basal weekly insulins: the way of the future!

Basal insulin treatment is indispensable for patients with type 1 diabetes and often required by many with type 2 diabetes. Incremental advances lengthening the duration of action of insulin analogs and reducing pharmacodynamic variability have resulted in truly once-daily, long-acting basal insulin analogs. In the quest for better basal insulins to facilitate improvements in glycemic control and long-term outcomes, the driving need is to remove barriers delaying timely initiation of basal insulin, to maximize treatment adherence and persistence and reduce treatment burden without increasing risk of hypoglycemia. We review the range of investigational once-weekly insulins and their molecular strategies and profiles. Currently, the two most advanced clinical development programs are: (1) basal insulin icodec, an insulin analog acylated with a C20 fatty diacid (icosanedioic acid) side chain (Novo Nordisk) and (2) basal insulin Fc, a fusion protein that combines a single-chain insulin variant with a human immunoglobulin G fragment crystallizable domain (Eli Lilly). Available phase 2 data for these two once-weekly agents show comparable glycemic control to existing once-daily insulin analogs, with no greater risk of hypoglycemia. While phase 3 data are awaited to confirm efficacy and safety, we provide future clinical perspectives on practical considerations for the potential use of once-weekly insulins.

Ethnic, social and multimorbidity disparities in therapeutic inertia: A UK primary care observational study in patients newly diagnosed with type 2 diabetes

AIM

To investigate factors associated with delays in receiving glucose-lowering therapy in patients newly diagnosed with type 2 diabetes mellitus (T2DM), and explore the preferential order and time of intensifications.

MATERIALS AND METHODS

Retrospective cohort study including 120 409 adults with T2DM initiating first- to fourth-line glucose-lowering therapy in primary care between 2000 and 2018, using the UK Clinical Practice Research Datalink linked to Hospital Episode Statistics, Office of National Statistics death registration, and 2007 Index of Multiple Deprivation data. Associations were investigated using time-to-event analysis.

RESULTS

The longest delays to prescription of first-line therapy were observed in older patients, of black or other ethnicities, and with multimorbidity. People from the most deprived areas received earlier first-line treatment than those from the least deprived areas. The majority were treated with metformin (82.4%) as the first-line prescription, sulphonylurea (50.4%) as second-line, dipeptidyl peptidase-4 inhibitor (27.7%) as third-line, and insulin (28.0%) as fourth-line. In the past 5 years, there was an increase in prescriptions of dipeptidyl peptidase-4-inhibitor and sodium-glucose transport protein-2 inhibitor. The median time was 0.5 years for first-line prescription, 4.1 for second-line, 4.6 for third-line and 4.7 for fourth-line. After T2DM diagnosis, 25% of patients developed cardiovascular disease and non-cardiovascular disease complications within a median time of 12-14 years, and received intensification 5-6 years later.

CONCLUSIONS

Within the complex challenges of managing blood glucose levels and risk of additional comorbidities, future health care research and guidelines should focus on overcoming therapeutic inertia particularly at an earlier stage for older patients, from ethnic minorities and with multimorbidities.

Perception towards Insulin Therapy and Factors Related to Insulin Refusal among Insulin Naive Type 2 Diabetes Mellitus Patients in Primary Care Clinics PKD Lipis

Introduction: Insulin is one of the suggested treatments to prevent and reduce long-term diabetes complications. However, due to many factors such as socio-demographic factors, many Type 2 diabetes mellitus patients refuse this treatment. This study aimed to determine perception towards insulin among naive Type 2 diabetes mellitus patients, to calculate the prevalence of rejecting insulin therapy, and to find out factors related to the refusal. Materials and methods: This cross-sectional study involved 188 insulin naive Type 2 diabetes mellitus patients attending five primary health clinics in Lipis district, Pahang from October to November 2017. A five-point Likert Scale was used to determine perception towards insulin therapy and the Chi-square test was used to assess the proportion of acceptance of the therapy. Simple and multiple logistic regressions were utilised to study the associated factor(s). Results: Mean score of 60.5 ± 8.2 pointed towards a negative appraisal of insulin therapy. Embarrassment to inject in public (69.1%) and concern of frequent hypoglycaemia (52.7%) were the most common perception. Nearly half of the respondents (46.3%) refused insulin therapy upon suggestion. After adjusting the variables using multiple logistic regressions, only gender (Adjusted OR=0.20, 95% CI=0.10-0.40, p<0.001), educational level (Adjusted OR=0.17, 95% CI=0.06-0.50, p=0.001), age (Adjusted OR=1.04, 95% CI=1.01-1.08, p=0.012) and glycated haemoglobin level (Adjusted OR=1.33, 95% CI=1.07-1.67, p=0.013) remained significant. Conclusion: In conclusion, insulin refusal among insulin naive patients was common in Lipis with an overall negative perception towards therapy. By tailoring strategies according to the patient’s factors such as gender, educational level, age, and glycated haemoglobin level, the insulin refusal rate might decrease in the future.

Clinical inertia in patients with type 2 diabetes treated with oral antidiabetic drugs: Results from a Japanese cohort study (JDDM53)

AIMS/INTRODUCTION

Treatment intensification is commonly delayed in people with type 2 diabetes, resulting in poor glycemic control for an unacceptable length of time and increased risk of complications.

MATERIALS AND METHODS

This retrospective study investigated clinical inertia in 33,320 Japanese adults with type 2 diabetes treated with oral antidiabetic drugs (OADs) between 2009 and 2018, using data from the Computerized Diabetes Care (CoDiC® ) database.

RESULTS

The median time from first reported glycated hemoglobin (HbA1c) ≥7.0% (≥53 mmol/mol) to treatment intensification was considerably longer and HbA1c levels were higher the more OADs the patient was exposed to. For patients receiving three OADs, the median times from HbA1c ≥7.0% (53 mmol/mol) to intensification with OAD, glucagon-like peptide-1 receptor agonist or insulin were 8.1, 9.1 and 6.7 months, with a mean HbA1c level at the time of intensification of 8.4%, 8.9% and 9.3%, respectively. The cumulative incidence for time since the first reported HbA1c ≥7.0% (≥53 mmol/mol) to intensification confirmed the existence of clinical inertia, identifying patients whose treatment was not intensified despite poor glycemic control. HbA1c levels ≥7.0% (≥53 mmol/mol) after ≥6 months on one, two or three OADs were observed in 42%, 51% and 58% of patients, respectively, showing that approximately 50% of patients are above HbA1c target regardless of how many OADs they take.

CONCLUSIONS

Real-world data here show clinical inertia in Japanese adults with type 2 diabetes from early diabetes stages when they are receiving OADs, and illustrate a need for earlier, more effective OADs or injectable treatment intensification and better communication around the existence of clinical inertia.

Challenges in insulin initiation among Hispanics/Latinos with diabetes in the United States

PURPOSE

The prevalence of diagnosed diabetes in the United States (U.S.) is particularly high among people of Hispanic/Latino ethnicity, placing this population at risk of developing diabetes-related complications. We conducted a systematic literature review to understand and communicate the current gaps and disparities, including myths and misconceptions, regarding insulin initiation among the Hispanic/Latino population in the U.S.

METHODS

We searched MEDLINE and MEDLINE In-process, e-pubs ahead of print (OvidSP), EMBASE (OvidSP), and the Cochrane Central Register of Controlled Trials (CENTRAL). The search strategy combined free text and controlled vocabulary terms and was developed to identify challenges associated with insulin use and initiation, as well as myths/misconceptions associated with insulin use. The quality of included studies was assessed using the National Institutes of Health (NIH) quality assessment tool.

PRINCIPAL RESULTS

In total, 777 articles were identified, with 13 articles included for data synthesis. Frequently reported barriers to initiating diabetes treatment among the Hispanic/Latino community related to socioeconomic and sociocultural factors. In particular, limited health literacy and access to health care, as well as low education and economic status, were common factors preventing treatment initiation for diabetes. Cultural factors, including language, food preferences, and lack of family support were also evident, with misconceptions and fears concerning insulin being commonly reported. Patients also described barriers concerning health care providers, including interpersonal issues and difficulties with communication and language.

MAJOR CONCLUSIONS

Overall, the current literature highlights many obstacles facing Hispanic/Latino patients in initiating insulin treatment for diabetes. Although limited research was identified, we describe common barriers and themes among this minority population. Awareness of these barriers is important for health care providers, enabling them to identify and address insulin-related fears and misconceptions and to be mindful of their cultural competency. Additionally, knowledge of current barriers will guide further research aimed at developing tailored strategies and tools to improve long-term health outcomes and quality of life in this population.

Key Strategies for Overcoming Psychological Insulin Resistance in Adults with Type 2 Diabetes: The UK Subgroup in the EMOTION Study

INTRODUCTION

Many patients with type 2 diabetes mellitus (T2DM) delay initiation of insulin therapy despite healthcare professional (HCP) advice. This phenomenon has been referred to as 'psychological insulin resistance' (PIR), and various contributing factors have been identified. Studies discussing approaches to overcoming PIR are lacking. Our aim was to identify the key strategies used by HCPs that most helped adults with T2DM and PIR in the UK to initiate insulin.

METHODS

As part of a global study, UK adults with T2DM and PIR were recruited (N = 125) to take a survey that included 38 HCP statements and actions about insulin initiation. Data assessed were perceived occurrence and helpfulness of these strategies in facilitating insulin initiation.

RESULTS

The most helpful strategies involved demonstrating the injection process (e.g. HCP talked patient through the process of taking insulin [83.6%]) and adopting a collaborative approach (HCP encouraged patient to contact the clinic immediately in case of any problems/questions [80.5%]). Additionally, HCPs highlighting the benefits of insulin (HCP explained that insulin was a natural substance needed by patient's body [81.2%]) and allaying patients' concerns (HCP explained that patient might not have to take insulin forever [78.0%]) helped patients initiate insulin. The least helpful action was HCPs repeatedly persuading patients to initiate insulin (40.9%).

CONCLUSIONS

The study recommends key strategies that HCPs can adopt to help adults with T2DM overcome PIR in the UK.

Tele-rounds and Case-Based Training: Project ECHO Telementoring Model Applied to Complex Diabetes Care

Lack of access to subspecialty care and persistent suboptimal outcomes for insulin-requiring patients with diabetes mandates development of innovative health care delivery models. The workforce shortage of endocrinologists in the United States results in primary care providers taking on the role of diabetes specialists despite lack of confidence and knowledge in complex diabetes management. The telementoring model Project ECHO amplifies and democratizes specialty knowledge to reduce disparities in care and improve health outcomes. Project ECHO can be applied to type 1 diabetes and other complex medical conditions to address health disparities and urgent needs of complex patients throughout the lifespan.

Ethnic disparities in initiation and intensification of diabetes treatment in adults with type 2 diabetes in the UK, 1990-2017: A cohort study

BACKGROUND

Type 2 diabetes mellitus (T2DM) disproportionately affects individuals of nonwhite ethnic origin. Timely and appropriate initiation and intensification of glucose-lowering therapy is key to reducing the risk of major vascular outcomes. Given that ethnic inequalities in outcomes may stem from differences in therapeutic management, the aim of this study was to identify ethnic differences in the timeliness of initiation and intensification of glucose-lowering therapy in individuals newly diagnosed with T2DM in the United Kingdom.

METHODS AND FINDINGS

An observational cohort study using the Clinical Practice Research Datalink was conducted using 162,238 adults aged 18 and over diagnosed with T2DM between 1990 and 2017 (mean age 62.7 years, 55.2% male); 93% were of white ethnicity (n = 150,754), 5% were South Asian (n = 8,139), and 2.1% were black (n = 3,345). Ethnic differences in time to initiation and intensification of diabetes treatment were estimated at three time points (initiation of noninsulin monotherapy, intensification to noninsulin combination therapy, and intensification to insulin therapy) using multivariable Cox proportional hazards regression adjusted for factors a priori hypothesised to be associated with initiation and intensification: age, sex, deprivation, glycated haemoglobin (HbA1c), body mass index (BMI), smoking status, comorbidities, consultations, medications, calendar year, and clustering by practice. Odds of experiencing therapeutic inertia (failure to intensify treatment within 12 months of HbA1c >7.5% [58 mmol/mol]), were estimated using multivariable logistic regression adjusted for the same hypothesised confounders. Noninsulin monotherapy was initiated earlier in South Asian and black groups (South Asian HR 1.21, 95% CI 1.08-1.36, p < 0.001; black HR 1.29, 95% CI 1.05-1.59, p = 0.017). Correspondingly, no ethnic differences in therapeutic inertia were evident at initiation. Intensification with noninsulin combination therapy was slower in both nonwhite ethnic groups relative to white (South Asian HR 0.80, 95% CI 0.74-0.87, p < 0.001; black HR 0.79, 95% CI 0.70-0.90, p < 0.001); treatment inertia at this stage was greater in nonwhite groups relative to white (South Asian odds ratio [OR] 1.45, 95% CI 1.23-1.70, p < 0.001; black OR 1.43, 95% CI 1.09-1.87, p = 0.010). Intensification to insulin therapy was slower again for black groups relative to white groups (South Asian HR 0.49, 95% CI 0.41-0.58, p < 0.001; black HR 0.69, 95% CI 0.53-0.89, p = 0.012); correspondingly, treatment inertia was significantly higher in nonwhite groups at this stage relative to white groups (South Asian OR 2.68, 95% CI 1.89-3.80 p < 0.001; black OR 1.82, 95% CI 1.13-2.79, p = 0.013). At both stages of treatment intensification, nonwhite groups had fewer HbA1c measurements than white groups. Limitations included variable quality and completeness of routinely recorded data and a lack of information on medication adherence.

CONCLUSIONS

In this large UK cohort, we found persuasive evidence that South Asian and black groups intensified to noninsulin combination therapy and insulin therapy more slowly than white groups and experienced greater therapeutic inertia following identification of uncontrolled HbA1c. Reasons for delays are multifactorial and may, in part, be related to poorer long-term monitoring of risk factors in nonwhite groups. Initiatives to improve timely and appropriate intensification of diabetes treatment are key to reducing disparities in downstream vascular outcomes in these populations.

A survey of physician experience and treatment satisfaction using fast-acting insulin aspart in people with type 1 or type 2 diabetes

AIMS

This survey aimed to explore real-world physician experiences and treatment satisfaction with fast-acting insulin aspart (faster aspart) in clinical practice across Europe and Canada.

MATERIALS AND METHODS

An online web-based survey was used for physicians treating people with type 1 or type 2 diabetes. General practitioners and specialists, with experience using faster aspart, were interviewed.

RESULTS

A total of 191 physicians participated in the survey. Most of their patients (68% of those with T1D and 63% of those with T2D) were previously treated with another mealtime insulin before switching to faster aspart. At the time of initiating faster aspart, nearly half of patients had an HbA_1c level between 7.5% (59 mmol/mol) and 8.5% (69 mmol/mol). The main prescription drivers for faster aspart, versus other mealtime insulins, were faster onset of action, improved postprandial glucose (PPG) control, and dosing flexibility. Most physicians were more satisfied with faster aspart than other mealtime insulins regarding at-meal (66%) and post-meal (71%) dosing flexibility, improved PPG levels (66%), and onset of action (61%). Main reasons for not prescribing faster aspart included a good response to current treatment (76%) or patient reluctance to switch (57%). Overall, 12% of patients discontinued faster aspart, for reasons including concerns of hypoglycemia (17%), poor adherence (17%), and level of patient co-pay (17%). More than half of physicians had fewer concerns regarding postprandial hyperglycemia, and were more confident in their patients reaching their HbA_1c target with faster aspart than with other mealtime insulins.

LIMITATIONS

The findings of this survey are based heavily on physicians' experiences, and could therefore be subject to recall bias.

CONCLUSIONS

Reported physician and patient experiences of using faster aspart have been positive, and better PPG control and increased dosing flexibility are expected to improve glycemic management.

Clinical Inertia in Poorly Controlled Type 2 Diabetes Mellitus Patients with Obesity: An Observational Retrospective Study

INTRODUCTION

To evaluate clinical inertia in patients with type 2 diabetes mellitus (T2DM), obesity and poor glycaemic control in routine clinical practice.

METHODS

This was a retrospective, observational study based on the analysis of medical records from the BIG-PAC® database. Subjects who required medical care in 2013 with the following characteristics were enrolled in the study: age ≥ 30 years, diagnosis of T2DM, glycosylated haemoglobin (HbA1c) ≥ 8%, obesity (body mass index [BMI] ≥ 30 kg/m²) and treatment with ≥ 2 oral antidiabetic drugs (OADs). Inertia was evaluated by time (days) to the first intensification during the period while HbA1c levels were ≥ 8% and percentage of patients whose treatment was not intensified at 6 months, 1, 2 and 3 years and the end of follow-up. The minimum length of follow-up was 4 years. Descriptive analyses and Kaplan-Meier survival curves were performed.

RESULTS

A total of 13,824 patients with T2DM receiving ≥ 2 OADs were identified; of these 2709 (19.6%) had HbA1c ≥ 8% and BMI ≥ 30 kg/m², thus fulfilling the inclusion criteria. Of these 2709 patients, the mean age was 65.5 (standard deviation [SD] 12.0) years; 54.9% were male, mean HbA1c level was 9.2% (SD 1.3%); mean BMI was 32.1 (SD 0.9) kg/m²; and mean time from diagnosis was 8.2 (SD 3.0) years. HbA1c remained ≥ 8% for a median of 440 (95% confidence interval [CI] 421-459) days. The median time to first intensification was 456 (95% CI 429-483) days. No intensification had occurred in 77.8, 59.5, 41.5, 28.1 and 22.4% of patients at 6 months, 1, 2, 3 years and the end of follow-up, respectively.

CONCLUSIONS

The patients with T2DM analysed in this study had a mean HbA1c of 9.2% at baseline, and this remained at ≥ 8% for > 1 year. The time to the first treatment intensification was longer than that recommended by guidelines. Treatment was not intensified in a large percentage of patients, with almost 60% of patients not receiving intensification at 1 year of follow-up.

Delays in Insulin Initiation among Patients with Type 2 Diabetes Mellitus in Southeast China: A Retrospective, Real-World Study

PURPOSE

To describe the extent of delays in insulin initiation, analyze its impact on glycemic control, and explore factors influencing delayed insulin initiation among Chinese type 2 diabetes mellitus (T2DM) patients.

METHODS

A real-world, retrospective cohort study with regional electronic health records from Fuzhou, southeast China was conducted among T2DM patients. Adult patients uncontrolled with oral antidiabetic drugs (OADs; HbA_1c ≥7%) and initiated on insulin treatment were included. Time to insulin initiation was described. After propensity-score matching, Wilcoxon rank-sum test and chi-square test were used to compare follow-up HbA_1c (first HbA_1c 3 months after insulin initiation) between timely (initiated insulin within 6 months after OAD failure) and delayed (initiated after 6 months) insulin-initiation groups. Sensitivity analysis was also performed by linear and logistic regression. Factors associated with delayed insulin initiation were explored using logistic regression.

RESULTS

A total of 940 patients were included, with mean±SD age 66.3±11.9 years. In sum, 328 had HbA_1c recorded 3 months after insulin initiation. After propensity-score matching (1:1 matching), 184 patients were included for further analysis. Median follow-up HbA_1c was lower in the timely-initiation group than the delayed-initiation group (7.25% vs 8.25%, P=0.009). Patients in the timely initiation group also had higher odds of achieving HbA_1c <7% (OR=3.15, P=0.001). Results were confirmed by logistic regression. Hypertension, coronary artery disease, baseline HbA_1c, and hospital level at insulin initiation were associated with delays in insulin initiation.

CONCLUSION

Timely insulin initiation after OAD failure is associated with better glycemic control.

Cost-effectiveness of insulin degludec versus insulin glargine U100 in adults with type 1 and type 2 diabetes mellitus in Bulgaria

BACKGROUND

This analysis evaluates the cost-effectiveness of insulin degludec (degludec) versus biosimilar insulin glargine U100 (glargine U100) in patients with type 1 (T1DM) and type 2 diabetes mellitus (T2DM) in Bulgaria.

METHODS

A simple, short-term model was used to compare the treatment costs and outcomes associated with hypoglycaemic events with degludec versus glargine U100 in patients with T1DM and T2DM from the perspective of the Bulgarian National Health Insurance Fund. Cost-effectiveness was analysed over a 1-year time horizon using data from clinical trials. The incremental cost-effectiveness ratio (ICER) was the main outcome measure.

RESULTS

In Bulgaria, degludec was highly cost-effective versus glargine U100 in people with T1DM and T2DM. The ICERs were estimated to be 4493.68 BGN/quality-adjusted life year (QALY) in T1DM, 399.11 BGN/QALY in T2DM on basal oral therapy (T2DM_BOT) and 7365.22 BGN/QALY in T2DM on basal bolus therapy (T2DM_B/B), which are below the cost-effectiveness threshold of 39,619 BGN in Bulgaria. Degludec was associated with higher insulin costs in all three patient groups; however, savings from a reduction in hypoglycaemic events with degludec versus glargine U100 partially offset these costs. Sensitivity analysis demonstrated that the results were robust and largely insensitive to variations in input parameters. At a willingness-to-pay threshold of 39,619 BGN/QALY, the probability of degludec being cost-effective versus glargine U100 was 60.0% in T1DM, 99.4% in T2DM_BOT and 91.3% in T2DM_B/B.

CONCLUSION

Degludec is a cost-effective alternative to biosimilar glargine U100 for patients with T1DM and T2DM in Bulgaria. Degludec could be of particular benefit to those patients suffering recurrent hypoglycaemia and those who require additional flexibility in the dosing of insulin.

Appropriateness of insulin commencement and adequacy of glycemic control among ambulatory patients with type 2 diabetes in Ethiopia

Background

Knowing when to start insulin is central to optimal management of Type 2 diabetes mellitus (T2DM) but a real clinical challenge. Poor glycemic control is critical for development of the deadly diabetic complications.

Objective

The aim of the study was to assess the appropriateness of insulin commencement, adequacy of glycemic control and associated factors among patients with T2DM.

Settings

The study was conducted at three public hospitals in Southwest Ethiopia.

Methods

Cross sectional study was conducted using structured questionnaire and data abstraction format. All patients with T2DM who were available during the data collection period and fulfilling study criteria were included.

Main outcome measure

Multivariable binary logistic regression analysis was done for identifying factors associated with poor glycemic control by taking statistical significance at p value ≤0.05.

Results

One hundred sixty nine patient data was considered for analysis. Insulin was initiated in 28 patients, but only 10(35.7%) insulin commencements were appropriate. More than two third (70.4%) of the studied population had poor glycemic control. Addition of second antidiabetic medication (Adjusted Odds Ratio (AOR) = 2.5, 95% CI = 1.3-6.2) and living in urban areas (AOR = 2.5, 95% CI = 1.1-5.7) were associated with poor glycemic control while having regular diabetic care follow up of every >1 month (AOR = 0.4, 95% CI = 0.2-0.9) was negatively associated with poor glycemic control.

Conclusions

About two third of insulin commencements were inappropriate and majority of patients could not stay on optimal glycemic control. Addition of second antidiabetic medication and living in urban areas were found to be associated with poor glycemic control.

Impact of findings on practice statements

• Initiation of insulin before optimization of oral agents increase cost of care.• Proper titration of the first oral agent is important prior to adding other antidiabetic agents.• Emphasis should be given to improve glycemic control, and hence halt subsequent complications.

Predictors of glycemic control after decline of insulin therapy by patients with type 2 diabetes

AIM

Decline of insulin therapy by patients is common but poorly investigated. We conducted this study to determine patient and treatment characteristics predictive of glycemic control after declining clinician recommendation to initiate insulin therapy.

METHODS

We retrospectively studied adults with type 2 diabetes mellitus treated at two academic medical centers between 1993 and 2014 who declined their healthcare provider recommendation to initiate insulin.

RESULTS

In a multivariable analysis of 300 study patients adjusted for demographics, comorbidities and clustering within providers, higher baseline HbA1c (OR 1.85; 95% CI 1.40 to 2.39; p < 0.001) and lifestyle changes (OR 8.39; 95% CI 3.26 to 21.55; p < 0.001) were associated with greater, while non-adherence to diabetes medications (OR 0.014; 95% CI 0.0025 to 0.085; p < 0.001) and discontinuation of a non-insulin diabetes medication (OR 0.30; 95% CI 0.11 to 0.80; p = 0.016) were associated with lower probability of HbA1c decrease after declining insulin therapy.

CONCLUSION

We identified patient characteristics and treatment strategies associated with success and failure of glycemic control after insulin therapy decline by the patient. This information can assist in selection of optimal therapeutic approaches for these individuals.

Effect of Remote Glucose Monitoring Utilizing Computerized Insulin Dose Adjustment Algorithms: A Pilot Project

INTRODUCTION

Primary care physicians are often challenged to adjust insulin doses. To facilitate this process, we evaluated in a safety net clinic the work flow and glycemic effects of remote glucose monitoring utilizing Federal Drug Administration (FDA) cleared, Conformité Européenne (CE) registered software that contained computerized algorithms for insulin dose adjustments to help clinicians make dosing decisions for insulin-requiring patients.

METHODS

Patients taking insulin for at least 6 months with HbA1_c levels of at least 8.0% measured glucose levels with a meter attached to their smartphones. Readings were automatically transmitted to a secure, Health Insurance Portability and Accountability Act (HIPAA)-approved server. Values were analyzed every 2-3 weeks and reports, including recommendations for insulin dose changes, were sent to a clinic nurse practitioner (NP) who modified or accepted the recommendations. A staff person contacted patients with the new doses determined by the NP.

RESULTS

Insulin regimens included basal alone (N = 11), basal/bolus (N = 14), and self-mixed/split (N = 3). Baseline HbA1 levels of 10.0% fell to 8.1% at 3 months (N = 28) and 7.6% at 6 months (N = 17) without any clinic visits for dose adjustments. There were 268 reports which allowed providers to see 268 other patients during these avoided clinic visits. The NP agreed with 82% of the recommendations. The total doses of insulin increased by 24%. No patient experienced severe hypoglycemia or visited an emergency department for hypoglycemia.

CONCLUSION

Remote glucose monitoring utilizing computerized insulin dose adjustment algorithms saved time for both providers and patients while effectively improving glycemia.

FUNDING

The Leonard M. Lipman Charitable Trust and Mellitus Health.

Predictors of Insulin Initiation in Patients with Type 2 Diabetes: An Analysis of the Look AHEAD Randomized Trial

BACKGROUND

The decision to initiate insulin in patients with type 2 diabetes is a challenging escalation of care that requires an individualized approach. However, the sociodemographic and clinical factors affecting insulin initiation are not well understood.

OBJECTIVE

We sought to identify patient factors that were independent predictors of insulin initiation among participants in the Look AHEAD (Action for Health in Diabetes) clinical trial.

DESIGN

Retrospective analysis of a randomized clinical trial.

PARTICIPANTS

Beginning in 2001, Look AHEAD enrolled ambulatory U.S. adults with type 2 diabetes who were overweight or obese and had a primary healthcare provider. Participants were randomized (1:1) to an intensive lifestyle intervention, or diabetes support and education. This study examined 3913 participants across the two trial arms who were not using insulin at baseline.

MAIN MEASURES

We used Cox proportional hazards models to estimate the association between participant characteristics and time to insulin initiation. We performed time-varying adjustment for HbA1c measured eight times over the 10-year study period, as well as for multiple clinical and socioeconomic factors.

KEY RESULTS

A total of 1087 participants (27.8%) initiated insulin during a median follow-up of 8.0 years. Age was inversely associated with insulin initiation (adjusted hazard ratio [aHR] 0.88 per 10 years, P = 0.025). The risk of insulin initiation was greater with a higher number of diabetes complications (P < 0.001 for trend); chronic kidney disease and cardiovascular disease were independently associated with insulin initiation. There was a lower risk of insulin initiation in black (aHR 0.77, P = 0.008) and Hispanic participants (aHR 0.66, P < 0.001) relative to white participants. Socioeconomic factors were not associated with insulin initiation.

CONCLUSIONS

Patient age, race/ethnicity, and diabetes complications may influence insulin initiation in type 2 diabetes, independent of glycemic control. Future work is needed to understand the drivers of racial differences in antihyperglycemic treatment, and to identify patients who benefit most from insulin.

Translation and validation of the Insulin Treatment Appraisal Scale in Hong Kong primary care patients

AIMS/INTRODUCTION

Patients with type 2 diabetes mellitus often delay the initiation or titration of insulin treatment due to psychological factors. This phenomenon is referred to as psychological insulin resistance (PIR). The Insulin Treatment Appraisal Scale (ITAS) is a 20-item instrument for assessing PIR. A previous Chinese version of the ITAS (C-ITAS) was found to be subject to problems arising from its translation. The present study aimed to translate and validate this instrument, which will facilitate research and aid in counseling in a clinical setting.

MATERIALS AND METHODS

The C-ITAS was modified to develop the Hong Kong version of the C-ITAS (C-ITAS-HK) according to published guidelines for the translation of transcultural research. A total of 328 diabetes mellitus patients who were followed-up in 10 different publically funded primary care outpatient clinics were recruited for self-administration of the C-ITAS-HK. Demographic data were recorded, and clinical data (e.g., presence of diabetes mellitus complications) were obtained from case records. The C-ITAS-HK results were subjected to psychometric analysis, including the assessment of Cronbach's alpha, factor analysis and test-retest reliability.

RESULTS

Factor analysis supported a two-factor structure with good internal consistency (whole scale 0.846, negative subscale 0.882, positive subscale 0.619). The test-retest reliability correlation coefficients for all items were positive, at 0.871, 0.782, and 0.692 for the whole scale, negative subscale and positive subscale, respectively. The ITAS scores differed significantly between participants with PIR and those without in the expected direction, suggesting good discriminant validity.

CONCLUSIONS

The C-ITAS-HK is a valid tool for measuring and assessing PIR in the Hong Kong primary care diabetes mellitus population.

Identification of barriers to insulin therapy and approaches to overcoming them

Poor glycaemic control in type 2 diabetes (T2D) is a global problem despite the availability of numerous glucose-lowering therapies and clear guidelines for T2D management. Tackling clinical or therapeutic inertia, where the person with diabetes and/or their healthcare providers do not intensify treatment regimens despite this being appropriate, is key to improving patients' long-term outcomes. This gap between best practice and current level of care is most pronounced when considering insulin regimens, with studies showing that insulin initiation/intensification is frequently and inappropriately delayed for several years. Patient- and physician-related factors both contribute to this resistance at the stages of insulin initiation, titration and intensification, impeding achievement of optimal glycaemic control. The present review evaluates the evidence and reasons for this delay, together with available methods for facilitation of insulin initiation or intensification.

Canagliflozin, dapagliflozin and empagliflozin monotherapy for treating type 2 diabetes: systematic review and economic evaluation

BACKGROUND

Most people with type 2 diabetes are overweight, so initial treatment is aimed at reducing weight and increasing physical activity. Even modest weight loss can improve control of blood glucose. If drug treatment is necessary, the drug of first choice is metformin. However, some people cannot tolerate metformin, which causes diarrhoea in about 10%, and it cannot be used in people with renal impairment. This review appraises three of the newest class of drugs for monotherapy when metformin cannot be used, the sodium-glucose co-transporter 2 (SGLT2) inhibitors.

OBJECTIVE

To review the clinical effectiveness and cost-effectiveness of dapagliflozin (Farxiga, Bristol-Myers Squibb, Luton, UK), canagliflozin (Invokana, Janssen, High Wycombe, UK) and empagliflozin (Jardiance, Merck & Co., Darmstadt, Germany), in monotherapy in people who cannot take metformin.

SOURCES

MEDLINE (1946 to February 2015) and EMBASE (1974 to February 2015) for randomised controlled trials lasting 24 weeks or more. For adverse events, a wider range of studies was used. Three manufacturers provided submissions.

METHODS

Systematic review and economic evaluation. A network meta-analysis was carried out involving the three SGLT2 inhibitors and key comparators. Critical appraisal of submissions from three manufacturers.

RESULTS

We included three trials of dapagliflozin and two each for canagliflozin and empagliflozin. The trials were of good quality. The canagliflozin and dapagliflozin trials compared them with placebo, but the two empagliflozin trials included active comparators. All three drugs were shown to be effective in improving glycaemic control, promoting weight loss and lowering blood pressure (BP).

LIMITATIONS

There were no head-to-head trials of the different flozins, and no long-term data on cardiovascular outcomes in this group of patients. Most trials were against placebo. The trials were done in patient groups that were not always comparable, for example in baseline glycated haemoglobin or body mass index. Data on elderly patients were lacking.

CONCLUSIONS

Dapagliflozin, canagliflozin and empagliflozin are effective in improving glycaemic control, with added benefits of some reductions in BP and weight. Adverse effects are urinary and genital tract infections in a small proportion of users. In monotherapy, the three drugs do not appear cost-effective compared with gliclazide or pioglitazone, but may be competitive against sitagliptin (Januvia, Boehringer Ingelheim, Bracknell, UK).

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Therapeutic inertia in the treatment of hyperglycaemia in patients with type 2 diabetes: A systematic review

AIMS

Therapeutic inertia, defined as the failure to initiate or intensify therapy in a timely manner according to evidence-based clinical guidelines, is a key reason for uncontrolled hyperglycaemia in patients with type 2 diabetes. The aims of this systematic review were to identify how therapeutic inertia in the management of hyperglycaemia was measured and to assess its extent over the past decade.

MATERIALS AND METHODS

Systematic searches for articles published from January 1, 2004 to August 1, 2016 were conducted in MEDLINE and Embase. Two researchers independently screened all of the titles and abstracts, and the full texts of publications deemed relevant. Data were extracted by a single researcher using a standardized data extraction form.

RESULTS

The final selection for the review included 53 articles. Measurements used to assess therapeutic inertia varied across studies, making comparisons difficult. Data from low- to middle-income countries were scarce. In most studies, the median time to treatment intensification after a glycated haemoglobin (HbA1c) measurement above target was more than 1 year (range 0.3 to >7.2 years). Therapeutic inertia increased as the number of antidiabetic drugs rose and decreased with increasing HbA1c levels. Data were mainly available from Western countries. Diversity of inertia measures precluded meta-analysis.

CONCLUSIONS

Therapeutic inertia in the management of hyperglycaemia in patients with type 2 diabetes is a major concern. This is well documented in Western countries, but corresponding data are urgently needed in low- and middle-income countries, in view of their high prevalence of type 2 diabetes.

Prediabetes

The burden of diabetes is expected to rise from 415 million individuals in 2015 to 642 million individuals by 2040. Most individuals pass through a phase of prediabetes before developing full-blown diabetes. Insulin resistance, impaired incretin action, and insulin hypersecretion are central to the pathophysiology of prediabetes. Individuals older than 40 years of age and other high-risk individuals should be screened for diabetes with fasting plasma glucose and/or hemoglobin A1c. For those diagnosed with prediabetes, the goal of treatment should be restoring euglycemia, because there are data showing that restoring normoglycemia during prediabetes and early diabetes can produce lasting remission. The preferred approach for this is intensive lifestyle intervention, which besides reducing progression to diabetes, has also been shown to reduce all-cause mortality in a long-term follow-up study. The best evidence for a pharmacological approach is with metformin. Other drugs that have shown efficacy include thiazolidinediones, alpha-glucosidase inhibitors, orlistat, basal insulin, and valsartan. However, except for metformin, none of these drugs are currently recommended for this purpose. Newer agents such as glucagon-like peptide-1 agonists and dipeptidyl peptidase 4 (DPP-4) inhibitors also have considerable promise in this area. Bariatric surgery can be offered to patients with metabolic syndrome and body mass index of 30-35.

Baseline factors associated with better response to insulin lispro low mixture or insulin glargine: A post hoc analysis of the DURABLE study

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.

Comparison of Insulin Dose Adjustments by Primary Care Physicians and Endocrinologists

IN BRIEF Insulin dose adjustment decisions in 20 simulated patients by nine primary care physicians (PCPs) and nine endocrinologists were compared to the algorithms used in a diabetes program in a large safety-net clinic. The number of dose changes was similar in the PCP and endocrinologist groups; however, the amounts of the dose changes in the PCP group were significantly closer to the diabetes program algorithms than the amounts in the endocrinologist group. Time constraints, rather than lack of ability, seem to be the major barrier to PCPs treating patients with insulin.

Therapeutic inertia in patients treated with two or more antidiabetics in primary care: Factors predicting intensification of treatment

AIMS

To determine the patterns and predictors of treatment intensification in patients with type 2 diabetes on ≥2 non-insulin antidiabetic drugs (NIADs) and inadequate glycaemic control in primary care in Catalonia, Spain.

MATERIAL AND METHODS

This was a retrospective analysis using electronic medical records from patients with HbA1c ≥ 7% and a first prescription for a new NIAD or insulin recorded from January 2010 to December 2014. Therapeutic inertia was defined as no intensification if HbA1c was ≥8% at baseline or during follow-up. Time to first intensification was evaluated by time-to-event analysis, and factors predicting intensification through a competing-risk regression model.

RESULTS

Among 23 678 patients with HbA1c ≥ 7%, 26.2% were censored without treatment intensification after a median follow up of 4.2 years. Among the 12 730 patients in the subgroup with HbA1c ≥ 8% at baseline or during follow-up, therapeutic inertia was present in 18.1% of cases. In the overall cohort, mean HbA1c at initiation of insulin and NIAD were 9.4% ± 1.5% and 8.7% ± 1.3%, respectively. Median time to first intensification was 17.1 months in patients with HbA1c 8.0% to 9.9%, and 10.1 months in those with HbA1c > 10%. Variables strongly associated with intensification were HbA1c values 8.0% to 9.9% (subhazard ratio [SHR], 1.7; 95% CI, 1.65-1.78) and >10% (SHR, 2.5; 95% CI, 2.37-2.68); diabetes duration ≥20 years (SHR, 1.25; 95% CI, 1.11-1.41) and, to a lesser extent, female gender, presence of comorbidities, chronic kidney disease and microvascular complications.

CONCLUSIONS

Intensification was not undertaken in 1 in 5 patients. Both HbA1c thresholds and time until therapy intensification exceeded current recommendations.

Slow Titration and Delayed Intensification of Basal Insulin Among Patients with Type 2 Diabetes

BACKGROUND

Clinical inertia in type 2 diabetes mellitus (T2DM) refers to the failure of clinicians to intensify therapy when indicated. Many T2DM patients remain suboptimally controlled after initiating basal insulin.

OBJECTIVE

To examine the prevalence of patients treated with basal insulin but in poor glycemic control (hemoglobin A1c [A1c] ≥ 7%) after initiation and subsequent treatment intensification patterns and glycemic outcomes in a real-world setting.

METHODS

Adults diagnosed with T2DM newly initiating a basal insulin analog (insulin glargine or detemir) from January 2010 to September 2014 were identified in the QuintilesIMS Real-World Data Adjudicated Claims linked to the QuintilesIMS Real-World Data Electronic Medical Records. Patients were previously naive to insulin and glucagon-like peptide-1 receptor agonists (GLP-1 RAs), were persistent on therapy for ≥ 6 months, and had ≥ 12 months of continuous health plan enrollment after initiation. First treatment intensification (increase in basal insulin dose [of ≥ 10%], addition of bolus insulin, GLP-1 RA, or a new oral antidiabetic drug [OAD]) was assessed among patients in poor glycemic control at 6 months after initiation over the available (minimum ≥ 12-month) follow-up. Subsequent glycemic outcomes and treatment intensification were assessed. Kaplan-Meier (KM) analysis evaluated time-to-treatment intensification and time to A1c goal.

RESULTS

Of 427 eligible patients with A1c available at 6 months, 59.3% were male; mean age was 53.9 years; mean follow-up was 29.4 months; and mean dose of the initiated prescription was 29.6 insulin units (U) (median 24U). Six months after initiating basal insulin, 81.0% of patients (n = 346) remained in poor glycemic control, and mean basal insulin dose was 31.0U (median 25U). Most (88.4%; n = 306) of these uncontrolled patients subsequently intensified treatment over the available follow-up. Using KM analysis, these patients intensified treatment in a median of 58 days (range: 17.5 days [GLP-1 RA addition] to 52 days [increase in basal insulin dose]) from the first elevated A1c measurement taken after 6 months, and 72.5% (GLP-1 RA addition) to 91.1% (OAD addition) of patients continued to remain in poor glycemic control at 12 months after intensification. Most patients (66.8%; n = 231/346) first intensified treatment by increasing their basal insulin dose, and mean dose increased to 61.7U (median 38U) at intensification. Six months following basal insulin increase, almost all patients remained on basal insulin therapy and among those with available A1c, 92.1% (140 of 152) were in poor glycemic control. In the subsequent 12 months, only a third (34%) of uncontrolled patients added another antihyperglycemic agent.

CONCLUSIONS

The vast majority of patients remained uncontrolled in the 6 months following basal insulin initiation. Basal insulin up-titration was slow and insufficient in the 6 months after initiation, indicating treatment inertia. Subsequently, most patients failed to achieve glycemic targets despite intensification with basal insulin. This finding suggests a substantial unmet need for effective treatment intensification among T2DM patients treated with basal insulin who remain uncontrolled. Improved provider education and guidelines on appropriate intensification are warranted.

DISCLOSURES

This study was funded by Novo Nordisk. Mocarski, Guerrero, Langer, and Thorsted are employees and shareholders of Novo Nordisk. Yeaw, Divino, and DeKoven are employed by QuintilesIMS, which received remuneration from Novo Nordisk for work on this study. Study concept and design were contributed by Mocarski, DeKoven, Langer, and Thorsted. Yeaw took the lead in data collection, along with Divino and DeKoven. Data interpretation was performed by Yeaw, Divino, DeKoven, and Guerrero. The manuscript was written by Mocarski and Divino and revised by Guerrero, Langer, and Thorsted, along with Yeaw and DeKoven. Some of the data from this study were presented via poster at the AMCP Annual Meeting in March 2017 and at the 53rd EASD Annual Meeting in September 2017.

Decline of insulin therapy and delays in insulin initiation in people with uncontrolled diabetes mellitus

AIMS

To design and validate a natural language processing algorithm to identify insulin therapy decline from the text of physician notes, and to determine the prevalence of insulin therapy decline and its impact on insulin initiation.

METHODS

We designed the algorithm using the publicly available natural language processing platform Canary. We evaluated the accuracy of the algorithm on 1501 randomly selected primary care physicians' notes from the electronic medical record system of a large academic medical centre. Using the validated language model, we then studied the prevalence of insulin therapy decline between 2000 and 2014.

RESULTS

The algorithm identified documentation of insulin therapy decline with a sensitivity of 100% (95% CI 82.4-100), a positive predictive value of 95% (95% CI 74.4-99.9), and a specificity of 99.9% (95% CI 99.6-100.0). We identified 3295 insulin-naïve adults with Type 2 diabetes who were recommended insulin therapy; 984 of them (29.9%) initially declined insulin. People with HbA_1c ≥ 75 mmol/mol (9.0%) were more likely [766/2239 (34.2%)] to have declined insulin than people with HbA_1c 53-63 mmol/mol (7.0-7.9%) and 64-74 mmol/mol (8.0-8.9%; P < 0.0001). Among the people who initially declined but ultimately started insulin [374/984 (38.0%)], mean time to insulin initiation was 790 days.

CONCLUSIONS

Insulin therapy decline is common, potentially leading to progression of hyperglycaemia and a delay in achievement of glycaemic control. Further investigation is needed to determine the reasons, risk factors and long-term outcomes of this important clinical phenomenon.

Canary: An NLP Platform for Clinicians and Researchers

Information Extraction methods can help discover critical knowledge buried in the vast repositories of unstructured clinical data. However, these methods are underutilized in clinical research, potentially due to the absence of free software geared towards clinicians with little technical expertise. The skills required for developing/using such software constitute a major barrier for medical researchers wishing to employ these methods. To address this, we have developed Canary, a free and open-source solution designed for users without natural language processing (NLP) or software engineering experience. It was designed to be fast and work out of the box via a user-friendly graphical interface.

Citation: Malmasi S, Sandor NL, Hosomura N, Goldberg M, Skentzos S, Turchin A. Canary: an NLP platform for clinicians and researchers. Appl Clin Inform 2017; 8: 447–453 https://doi.org/10.4338/ACI-2017-01-IE-0018

Delay of insulin initiation in patients with type 2 diabetes mellitus inadequately controlled with oral hypoglycemic agents (analysis of patient- and physician-related factors): A prospective observational DIPP-FACTOR study in Korea

Aims/Introduction

To assess the time to initiation of insulin therapy, and concurrently investigate both patient‐ and physician‐related factors associated with delaying insulin therapy in Korean patients with type 2 diabetes uncontrolled by oral hypoglycemic agents (OHAs).

Materials and Methods

This prospective, observational disease registry study was carried out across 69 centers in Korea. Type 2 diabetes patients who had received two or more OHAs within the past 5 years, had a glycated hemoglobin ≥8% in the past 6 months and had not received insulin were included. Data recorded on data collection forms during a 12‐month period were analyzed.

Results

Of 2168 patients enrolled, 1959 were evaluated and classified as the insulin‐initiated or insulin‐delayed group. Insulin was prescribed for just 20% of the patients during a 1‐year follow‐up period, and less than half (44.5%) of the patients who were taking two OHAs started insulin after 6 years. Patient‐related factors for delay in insulin initiation included older age, shorter duration of diabetes and lower glycated hemoglobin. Physician‐related factors included age (~50 to <60 years), sex (women) and number (<1000) of patients consulted per month. Patient refusal (33.6%) and physicians’ concerns of patient non‐compliance (26.5%) were the major physician‐reported reasons for delaying insulin therapy. Inconvenience of insulin therapy (51.6%) and fear of injection (48.2%) were the major reasons for patient refusal.

Conclusions

Insulin initiation is delayed in patients with type 2 diabetes uncontrolled by two or more OHAs in Korea. Patient‐ and physician‐related factors associated with this delay need to be addressed for better diabetes management.

InsuOnline, an Electronic Game for Medical Education on Insulin Therapy: A Randomized Controlled Trial With Primary Care Physicians

BACKGROUND

Most patients with diabetes mellitus (DM) are followed by primary care physicians, who often lack knowledge or confidence to prescribe insulin properly. This contributes to clinical inertia and poor glycemic control. Effectiveness of traditional continuing medical education (CME) to solve that is limited, so new approaches are required. Electronic games are a good option, as they can be very effective and easily disseminated.

OBJECTIVE

The objective of our study was to assess applicability, user acceptance, and educational effectiveness of InsuOnline, an electronic serious game for medical education on insulin therapy for DM, compared with a traditional CME activity.

METHODS

Primary care physicians (PCPs) from South of Brazil were invited by phone or email to participate in an unblinded randomized controlled trial and randomly allocated to play the game InsuOnline, installed as an app in their own computers, at the time of their choice, with minimal or no external guidance, or to participate in a traditional CME session, composed by onsite lectures and cases discussion. Both interventions had the same content and duration (~4 h). Applicability was assessed by the number of subjects who completed the assigned intervention in each group. Insulin-prescribing competence (factual knowledge, problem-solving skills, and attitudes) was self-assessed through a questionnaire applied before, immediately after, and 3 months after the interventions. Acceptance of the intervention (satisfaction and perceived importance for clinical practice) was also assessed immediately after and 3 months after the interventions, respectively.

RESULTS

Subjects' characteristics were similar between groups (mean age 38, 51.4% [69/134] male). In the game group, 69 of 88 (78%) completed the intervention, compared with 65 of 73 (89%) in the control group, with no difference in applicability. Percentage of right answers in the competence subscale, which was 52% at the baseline in both groups, significantly improved immediately after both interventions to 92% in the game group and to 85% in control (P<.001). After 3 months, it remained significantly higher than that at the baseline in both groups (80% in game, and 76% in control; P<.001). Absolute increase in competence score was better with the game (40%) than with traditional CME (34%; P=.01). Insulin-related attitudes were improved both after the game (significant improvement in 4 of 9 items) and after control activity (3 of 9). Both interventions were very well accepted, with most subjects rating them as "fun or pleasant," "useful," and "practice-changing."

CONCLUSIONS

The game InsuOnline was applicable, very well accepted, and highly effective for medical education on insulin therapy. In view of its flexibility and easy dissemination, it is a valid option for large-scale CME, potentially helping to reduce clinical inertia and to improve quality of care for DM patients.

TRIAL REGISTRATION

Clinicaltrials.gov NCT001759953; https://clinicaltrials.gov/ct2/show/NCT01759953 (Archived by WebCite at http://www.webcitation.org/6oeHoTrBf).

Real-world evidence studies into treatment adherence, thresholds for intervention and disparities in treatment in people with type 2 diabetes in the UK

PURPOSE

The University of Surrey-Lilly Real World Evidence (RWE) diabetes cohort has been established to provide insights into the management of type 2 diabetes mellitus (T2DM). There are 3 areas of study due to be conducted to provide insights into T2DM management: exploration of medication adherence, thresholds for changing diabetes therapies, and ethnicity-related or socioeconomic-related disparities in management. This paper describes the identification of a cohort of people with T2DM which will be used for these analyses, through a case finding algorithm, and describes the characteristics of the identified cohort.

PARTICIPANTS

A cohort of people with T2DM was identified from the Royal College of General Practitioners Research and Surveillance Centre (RCGP RSC) data set. This data set comprises electronic patient records collected from a nationally distributed sample of 130 primary care practices across England with scope to increase the number of practices to 200.

FINDINGS TO DATE

A cohort (N=58 717) of adults with T2DM was identified from the RCGP RSC population (N=1 260 761), a crude prevalence of diabetes of 5.8% in the adult population. High data quality within the practice network and an ontological approach to classification resulted in a high level of data completeness in the T2DM cohort; ethnicity identification (82.1%), smoking status (99.3%), alcohol use (93.3%), glycated haemoglobin (HbA1c; 97.9%), body mass index (98.0%), blood pressure (99.4%), cholesterol (87.4%) and renal function (97.8%). Data completeness compares favourably to other, similarly large, observational cohorts. The cohort comprises a distribution of ages, socioeconomic and ethnic backgrounds, diabetes complications, and comorbidities, enabling the planned analyses.

FUTURE PLANS

Regular data uploads from the RCGP RSC practice network will enable this cohort to be followed prospectively. We will investigate medication adherence, explore thresholds and triggers for changing diabetes therapies, and investigate any ethnicity-related or socioeconomic-related disparities in diabetes management.

Opportunities and Challenges in Developing a Cohort of Patients with Type 2 Diabetes Mellitus Using Electronic Primary Care Data

Purpose

To develop a cohort of patients with T2DM treated with insulin using CPRD to obtain an accurate diagnosis date. This was used to analyse time from T2DM diagnosis to first ever insulin prescription between 01/01/2000 and 30/06/2012, for patients in England and Wales.

Methods

Patients aged 18 years and over at diagnosis, were included if prescribed an anti-diabetic drug and were excluded if first diagnosis-specific code was inconsistent with a T2DM diagnosis. Diagnosis codes were split into 8 categories based on whether they related to specific T2DM or non-specific diabetes codes. Patients were excluded if they had non-specific diagnosis codes and were prescribed insulin as their first-ever treatment for diabetes. Descriptive statistics for time from T2DM diagnosis to insulin initiation were calculated.

Results

Two hundred and fifty-six codes were identified which were consistent with a first-ever diagnosis of T2DM. 7 codes were considered to clearly define a diagnosis of T2DM, which were reported for 64% of patients. The final cohort comprised 11,917 patients and the median time to first insulin prescription from the date of diagnosis was 4.4 years.

Conclusions

A clear definition of cohort development is required to compare and interpret results from studies. Use of diagnosis and product codes is essential when examining use of drugs such as insulin, where competing diagnoses need to be considered separately.

New Insulin Delivery Recommendations

Many primary care professionals manage injection or infusion therapies in patients with diabetes. Few published guidelines have been available to help such professionals and their patients manage these therapies. Herein, we present new, practical, and comprehensive recommendations for diabetes injections and infusions. These recommendations were informed by a large international survey of current practice and were written and vetted by 183 diabetes experts from 54 countries at the Forum for Injection Technique and Therapy: Expert Recommendations (FITTER) workshop held in Rome, Italy, in 2015. Recommendations are organized around the themes of anatomy, physiology, pathology, psychology, and technology. Key among the recommendations are that the shortest needles (currently the 4-mm pen and 6-mm syringe needles) are safe, effective, and less painful and should be the first-line choice in all patient categories; intramuscular injections should be avoided, especially with long-acting insulins, because severe hypoglycemia may result; lipohypertrophy is a frequent complication of therapy that distorts insulin absorption, and, therefore, injections and infusions should not be given into these lesions and correct site rotation will help prevent them; effective long-term therapy with insulin is critically dependent on addressing psychological hurdles upstream, even before insulin has been started; inappropriate disposal of used sharps poses a risk of infection with blood-borne pathogens; and mitigation is possible with proper training, effective disposal strategies, and the use of safety devices. Adherence to these new recommendations should lead to more effective therapies, improved outcomes, and lower costs for patients with diabetes.

Time to insulin initiation and long-term effects of initiating insulin in people with type 2 diabetes mellitus: the Hoorn Diabetes Care System Cohort Study

OBJECTIVE

The aim of this study was to assess the time to insulin initiation in type 2 diabetes mellitus (T2DM) patients treated with oral glucose-lowering agents and to determine the baseline characteristics associated with time to insulin initiation. This was evaluated in T2DM patients with HbA1c levels consistently ≥7.0% during total follow up and in those with fluctuating HbA1c levels around 7.0%.

DESIGN AND METHODS

Prospective, observational study was performed, comprising 2418 persons with T2DM aged ≥40 years who entered the Diabetes Care System between 1998 and 2012 with a minimum follow up of at least 3 years, following the first HbA1c level ≥7.0%. Cox regression analyses were performed to assess the determinants of time to insulin initiation. Data related to long-term effects of insulin initiation were studied at baseline and at the end of follow up using descriptive summary statistics.

RESULTS

Two-thirds of the patients initiated insulin during follow up. The time to insulin varied from 1.2 years (range 0.3-3.1) in patients with HbA1c levels consistently ≥7.0% to 5.4 years (range 3.0-7.5) in patients with fluctuating HbA1c levels around 7.0%. Longer diabetes duration (hazard ratio (HR) 1.04 95% CI 1.03-1.05) and lower age (HR 1.00 95% CI 0.99-1.00) at baseline were associated with a shorter time to initiation. More insulin initiators had retinopathy compared with patients that remained on oral glucose-lowering agents during follow up.

CONCLUSION

The time to insulin initiation was short, and most of the patients with HbA1c levels consistently ≥7.0% were initiating insulin. Longer diabetes duration and younger age shortened the time to insulin.

Clinical inertia with regard to intensifying therapy in people with type 2 diabetes treated with basal insulin

AIM

To investigate whether clinical inertia, the failure to intensify treatment regimens when required, exists in people with type 2 diabetes treated with basal insulin.

METHODS

This was a retrospective cohort study involving patients with type 2 diabetes in the UK Clinical Practice Research Datalink database between January 2004 and December 2011, with follow-up until December 2013.

RESULTS

A total of 11 696 patients were included in the analysis. Among all patients, 36.5% had their treatment intensified during the study period; of these, the treatment of 50.0, 42.5 and 7.4% was intensified with bolus or premix insulin or glucagon-like peptide-1 receptor agonists, respectively. The median time from initiation of basal insulin to treatment intensification was 4.3 years [95% confidence interval (CI) 4.1, 4.6]. Among patients clinically eligible for treatment intensification [glycated haemoglobin (HbA1c) ≥7.5% (58 mmol/mol)], 30.9% had their treatment regimen intensified. The median time to intensification in this group was 3.7 years (95% CI 3.4, 4.0). Increasing age, duration of diabetes, oral antihyperglycaemic agent usage and Charlson comorbidity index score were associated with a significant delay in the time to intensification (p < 0.05). Among patients with HbA1c ≥7.5% (58 mmol/mol), 32.1% stopped basal insulin therapy.

CONCLUSIONS

Strategies should be developed to increase the number of patients undergoing therapy intensification and to reduce the delay in intensifying therapy for suitable patients on basal insulin. Initiatives to support patients continuing on insulin are also required.

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

Background

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

Method

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

Results

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

Conclusion

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