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

Factors associated with psychological insulin resistance among patients with type 2 diabetes in China

Objective

The aim of this study was to understand the psychological insulin resistance status among Chinese patients with type 2 diabetes and investigate its associated factors in these patients.

Methods

A multi-stage stratified random sampling was performed to randomly select patients with type 2 diabetes from the eastern, central, and western regions in Shandong Province, China, and 660 valid questionnaires were collected. Psychological insulin resistance was assessed by the scale of My Opinion on Insulin (MOI). Factors associated with psychological insulin resistance were examined in a binary logistic model.

Results

Four-fifths of the patients with type 2 diabetes (82.1%) had psychological insulin resistance. Being female (OR = 1.770, 95% CI: 1.063-2.950, p < 0.05), having a monthly income of greater than 4,000 Renminbi (approximately $1,540) (OR = 0.444, 95% CI: 0.216-0.915, p < 0.05), living with type 2 diabetes for 11 years or more (OR = 0.387, 95% CI: 0.238-0.630, p < 0.05), self-rated poor health (OR = 1.706, 95% CI: 1.092-2.664, p < 0.05), and moderate discrimination against type 2 diabetes (OR = 1.924, 95% CI: 1.166-3.175, p < 0.05) were associated with psychological insulin resistance.

Conclusions

The prevalence of psychological insulin resistance among Chinese patients with type 2 diabetes is relatively high. Approaches are needed to address the issue of psychological insulin resistance of type 2 diabetes.

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.

Basal Insulin Initiation in Adults With Type 2 Diabetes Mellitus: A Retrospective Cohort Study Using Administrative Health Data in Alberta, Canada

OBJECTIVES

Pharmacologic treatment of type 2 diabetes mellitus (T2DM) follows a stepwise approach. Typically, metformin monotherapy is first-line treatment, followed by other noninsulin antihyperglycemic agents (NIAHAs) or progression to insulin if glycated hemoglobin (A1C) targets are not achieved. We aimed to describe real-world patterns of basal insulin initiation in people with T2DM, and A1C not at target despite treatment with at least 2 NIAHAs.

METHODS

A retrospective cohort study was conducted using administrative health data from Alberta, Canada, among adults with T2DM, indexed on the first test with 7.0% < A1C < 9.5% (April 1, 2011 to March 31, 2019), with at least 2 previous NIAHAs but no insulin. Kaplan-Meier (KM) methodology was used to analyze time to basal insulin initiation, with stratification by index A1C. Annual patient status was categorized into 5 groups: basal insulin initiation, death, NIAHA intensification, no change in therapy (subgroups of A1C <7.1% and A1C ≥7.1% [clinical inertia]), or discontinuance.

RESULTS

The cohort included 14,083 individuals. The KM cumulative probability of initiating basal insulin was 7.7% (95% confidence interval [CI] 7.3% to 8.2%) at 1 year, increasing to 43.1% (95% CI 42.1% to 44.1%) at 8 years of follow-up. Higher A1C levels were associated with greater proportions of basal insulin initiation. By year 8, proportions with NIAHA intensification and clinical inertia were 12.1% and 19.3%, respectively, relative to year 7.

CONCLUSIONS

Despite current clinical practice guidelines recommending achieving A1C targets within 6 months, less than half of the individuals with T2DM and clear indications for basal insulin initiated treatment within 8 years. Efforts to reduce delays in basal insulin initiation are needed.

Effect of Taiwan's Diabetes Shared Care Program on the risk of periprosthetic joint infection after total joint arthroplasty in patients with type 2 diabetes mellitus: an eight-year population-based study

BACKGROUND

Periprosthetic joint infection (PJI) is a significant post-arthroplasty complication for diabetic patients, with uncontrolled diabetes identified as a PJI risk factor. Taiwan's Diabetes Shared Care Program (DSCP) was established for holistic diabetes care.

AIM

To evaluate the DSCP's impact on PJI incidence and patients' medical costs.

METHODS

Data were analysed from Taiwan's National Health Insurance Research Database from 2010 to 2020, focusing on type 2 diabetes mellitus (DM) patients who had undergone arthroplasty. The study group involved DSCP participants, while a comparison group comprised non-participants with matched propensity scores for age, sex, and comorbidities. The primary outcome was the PJI incidence difference between the groups; the secondary outcome was the medical expense difference.

FINDINGS

The study group consisted of 11,908 type 2 DM patients who had arthroplasty and joined the DSCP; PJI occurred in 128 patients. Among non-participants, 184 patients had PJI. The PJI incidence difference between the groups was statistically significant (1.07% vs 1.55%). The study group's medical costs were notably lower, regardless of PJI incidence. Multivariate regression showed higher PJI risk in patients in comparison group, aged >70 years, male, or who had obesity, anaemia.

CONCLUSION

The study indicates that DSCP involvement reduces PJI risks and decreases annual medical costs for diabetic patients after arthroplasty. Consequently, the DSCP is a recommendable option for such patients who are preparing for total joint arthroplasty.

Therapeutic Inertia and Delays in Insulin Intensification in Type 2 Diabetes: A Literature Review

Background

Therapeutic inertia leading to delays in insulin initiation or intensification is a major contributor to lack of optimal diabetes care. This report reviews the literature summarizing data on therapeutic inertia and delays in insulin intensification in the management of type 2 diabetes.

Methods

A literature search was conducted of the Allied & Complementary Medicine, BIOSIS Previews, Embase, EMCare, International Pharmaceutical Abstracts, MEDLINE, and ToxFile databases for clinical studies, observational research, and meta-analyses from 2012 to 2022 using search terms for type 2 diabetes and delay in initiating/intensifying insulin. Twenty-two studies met inclusion criteria.

Results

Time until insulin initiation among patients on two to three antihyperglycemic agents was at least 5 years, and mean A1C ranged from 8.7 to 9.8%. Early insulin intensification was linked with reduced A1C by 1.4%, reduction of severe hypoglycemic events from 4 to <1 per 100 person-years, and diminution in risk of heart failure (HF) by 18%, myocardial infarction (MI) by 23%, and stroke by 28%. In contrast, delayed insulin intensification was associated with increased risk of HF (64%), MI (67%), and stroke (51%) and a higher incidence of diabetic retinopathy. In the views of both patients and providers, hypoglycemia was identified as a primary driver of therapeutic inertia; 75.5% of physicians reported that they would treat more aggressively if not for concerns about hypoglycemia.

Conclusion

Long delays before insulin initiation and intensification in clinically eligible patients are largely driven by concerns over hypoglycemia. New diabetes technology that provides continuous glucose monitoring may reduce occurrences of hypoglycemia and help overcome therapeutic inertia associated with insulin initiation and intensification.

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.

Barriers and Attitudes of Primary Healthcare Physicians to Insulin Initiation and Intensification in Saudi Arabia

Saudi Arabia is a country with high prevalence of diabetes, uncontrolled diabetes, and diabetes-related complications. Poor glycemic control is multifactorial and could be explained in part by physician and patient reluctance toward insulin or insulin inertia. This study aimed to address physician barriers toward insulin therapy in primary care settings. It included 288 physicians from 168 primary healthcare centers (PHC) in the Jazan region of Saudi Arabia. Participants responded to questionnaire investigating physicians' attitude and barriers to insulin initiation and intensification in PHCs. In physician opinion, the most common barriers among their patients were fear of injection, lack of patient education, fear of hypoglycemia, and difficult administration. Physicians were reluctant to initiate insulin for T2D patients mostly due to patient non-adherence to blood sugar measurement, non-adherence to appointment or treatment, elderly patients, or due to patient refusal. Physicians' fear of hypoglycemia, lack of staff for patient education, and lack of updated knowledge were the primary clinician-related barriers. Exaggerated fears of insulin side effects, patient non-adherence, limited staff for patient's education, patient refusal, and inadequate consultation time were the main barriers to insulin acceptance and prescription.

The Absorption of Needle-Free Insulin Aspart Through Jet Injector in Different Body Parts of Healthy Individuals

The absorption of needle-free fast-acting insulin injected into different body parts of healthy male subjects was studied in an attempt to provide clinical guidance for diabetic patients who take needle-free insulin injections in terms of providing reference in the clinical guidance regarding the correct use of needle-free insulin injections among diabetic patients. This randomized, open-label, cross-over trial was conducted on eight healthy adult male volunteers, in which the skin thickness at three injection sites (abdomen, upper arm, and thigh), the time to peak, peak rate, and area under the glucose infusion rate (GIR) curve of plasma insulin were measured through the hyperinsulin-normal glucose clamp test after the injection of insulin aspart with a needle-free syringe at three different sites to analyze the correlation between insulin absorption index at different injection sites and skin thickness. The values of the skin thickness of the abdomen, upper arm, and thigh measured by ultrasonic wave were 2.45 ± 0.34 mm, 2.18 ± 0.50 mm, and 1.93 ± 0.55 mm, respectively. There was a significant difference in the skin thickness of the abdomen and thigh (P = 0.014). The hyperinsulin-normal glucose clamp model was successfully established for each subject. Approximately 0-2 h after injection of insulin aspart with needle-free syringes, the area under the GIR-time curve of the abdomen, upper arm, and thigh was 29,400.75 ± 2,645.00 ml, 30,230.50 ± 4,937.87 ml, and 30,179.63 ± 6,188.57 ml, respectively. There was no significant difference in the area under the GIR curve between any two injection sites (P >0.05). The time to peak of GIR at different injection sites was 38.68 ± 13.57 min in the abdomen, 40.86 ± 12.70 min in the upper arm, and 37.03 ± 13.29 min in the thigh, respectively, in which no significant difference was found between each of them (P >0.05). The GIR curve after injection at the three different sites was consistent with each other. There was no significant difference in insulin absorption after the injection of insulin aspartate into the abdomen, upper arm, and thigh with a needleless syringe in healthy male adult volunteers, and there was no correlation between skin thickness at the injection site and insulin absorption. Injection sites did not affect the absorption of insulin in needle-free injections.

Barriers of Doctors and Patients in Starting Insulin for Type 2 Diabetes Mellitus

Background Management of patients with type 2 diabetes mellitus (T2DM) may involve insulin therapy. However, this treatment may be avoided or delayed by physicians or patients due to the presence of certain barriers. This study aimed to evaluate the barriers to initiating insulin therapy for both physicians and patients with T2DM.  Method This was a cross-sectional, questionnaire-based study. Data related to the physicians' personal and professional experience were collected, and 15 barriers to initiating insulin therapy were scored by each physician on a four-point Likert scale. Also, the patients' general data were collected, including previous insulin experience, discontinuation reason, and willingness to start insulin therapy if indicated. Twenty-one other barriers were examined with yes/no questions as well. Results For physicians, the patient's treatment compliance, motive, dependence on others for insulin therapy, hypoglycemia, socioeconomic status, occupation, and lack of follow-up were the most highly ranked barriers to initiating insulin therapy. A history of insulin use was reported in 42 (20.7%) patients, 31 of whom had decided to discontinue insulin therapy themselves (73.8%). The three most common reasons for discontinuing insulin therapy among patients were deterioration of T2DM and causing complications, hypoglycemia, and needle injections. Based on the findings, 99 (48.8%) patients were willing to start insulin therapy, if indicated. The family history of insulin therapy was positively correlated with the patient's willingness to start insulin. On the other hand, it was negatively correlated with a low educational level and some barriers to insulin therapy, such as fear of death, dependence on others, the difficulty of carrying insulin while traveling, follow-up challenges, the difficulty of dosing accuracy, the difficulty of keeping insulin, inconveniences in daily life, considering insulin as the last resort, the deterioration of T2DM with insulin, and social stigma. Conclusion The physicians believed that the barriers to initiating insulin therapy were mainly related to the patient's attitudes and thoughts about this therapy. While hypoglycemia and weight gain are well-known side effects of insulin therapy, the most important patient-related barriers to insulin therapy were related to its impact on the patient's social life and misperceptions about the side effects of insulin.

Efficacy and Safety of Treatment with Quadruple Oral Hypoglycemic Agents in Uncontrolled Type 2 Diabetes Mellitus: A Multi-Center, Retrospective, Observational Study

BACKGROUND

Only few studies have shown the efficacy and safety of glucose-control strategies using the quadruple drug combination. Therefore, the aim of the present study was to investigate the usefulness of the quadruple combination therapy with oral hypoglycemic agents (OHAs) in patients with uncontrolled type 2 diabetes mellitus (T2DM).

METHODS

From March 2014 to December 2018, data of patients with T2DM, who were treated with quadruple hypoglycemic medications for over 12 months in 11 hospitals in South Korea, were reviewed retrospectively. We compared glycosylated hemoglobin (HbA1c) levels before and 12 months after quadruple treatment with OHAs. The safety, maintenance rate, and therapeutic patterns after failure of the quadruple therapy were also evaluated.

RESULTS

In total, 357 patients were enrolled for quadruple OHA therapy, and the baseline HbA1c level was 9.0%±1.3% (74.9±14.1 mmol/mol). After 12 months, 270 patients (75.6%) adhered to the quadruple therapy and HbA1c was significantly reduced from 8.9%±1.2% to 7.8%±1.3% (mean change, -1.1%±1.2%; P<0.001). The number of patients with HbA1c <7% increased significantly from 5 to 68 (P<0.005). In addition, lipid profiles and liver enzyme levels were also improved whereas no changes in body weight. There was no significant safety issue in patients treated with quadruple OHA therapy.

CONCLUSION

This study shows the therapeutic efficacy of the quadruple OHA regimen T2DM and demonstrates that it can be an option for the management of T2DM patients who cannot use insulin or reject injectable therapy.

The insulin sharps disposal study: Evaluation of a structured patient education initiative in an urban community health centre in India

Context:

India has witnessed an increase in people suffering from diabetes mellitus and also those on insulin. The issue of handling used sharps in the community is an area of concern.

Aims:

Our study aimed to assess the change in knowledge and practise concerning the disposal of used insulin sharps in patients with diabetes, pre- and post-evaluation, a structured, health provider-initiated, patient-centred insulin-use health education (PIHE)

Settings and Design:

A pre- and post-evaluation study of PIHE set in an urban health centre in south India

Methods and Materials:

A pre-evaluation study was done on a cross-sectional sample of type II diabetes patients, who visited the urban health centre and were on insulin for at least 1 year. A semi-structured pilot-tested questionnaire was used for the study. For 18 months, PIHE was provided to all insulin users at outpatient contact, after which a post-evaluation study among another cross-sectional sample of patients in the same centre, was done to assess change in knowledge and practise.

Statistical Analysis Used:

Univariate analysis followed by logistic regression.

Results:

The participants in the pre- and post-evaluation studies had a mean (SD) age of 54.9 (11.33) years and 57.2 (11.01) years, respectively. The baseline characteristics of gender, socioeconomic status and diabetes duration were similar. There was a statistically significant (P < 0.001) difference in knowledge (19 [19%] to 81 [81%]) and practise (7 [7%] to 73 [73%]) of participants regarding the correct disposal method of used insulin syringes and sharps before and after PIHE.

Conclusions:

PIHE over an 18-month period for diabetic patients on insulin significantly improved knowledge and practises relating to insulin use and correct disposal of syringes and sharps.

The Unmet Medical Needs of Current Injectable Antidiabetic Therapies in China: Patient and Health Care Professional Perspectives

PURPOSE

Patients with diabetes and health care professionals (HCPs) play important roles in effective application of injectable antidiabetic therapies (IATs). However, their concerns and opinions on IATs are rarely investigated in China. This study aims to assess unmet medical needs of IATs regarding patient concerns, patient satisfaction, aspects that need improvement, and training burden from patient and HCP perspectives.

METHODS

This cross-sectional survey was conducted in 12 representative Chinese cities from December 2018 to January 2019. Patients with adult type 2 diabetes who were receiving IAT currently and had received IAT continuously for at least 1 month before the survey, endocrinologists with ≥5 years of experience and prescribing IAT in the past 1 month, and nurses with ≥3 years of experience and providing IAT training in the past 1 month were eligible participants. The patient survey assessed concerns of initiating IAT, satisfaction with IAT, aspects of IAT that need improvement, and IAT training received. The HCP survey evaluated patient concern of initiating IAT, aspects of IAT that need improvement, experience of providing IAT training, and self-reported burden of training. Descriptive statistical analysis was performed.

FINDINGS

In total, 500 patients, 200 endocrinologists, and 100 nurses were surveyed. The mean (SD) age of patients was 55.1 (11.8) years, with a disease duration of 7.6 (6.4) years. Of all patients, 391 (78.2%) were insulin users and 109 (21.8%) were glucagon-like peptide 1 receptor agonist users. Of the top 4 concerns about initiating IAT, both patients and endocrinologists reported inconvenience of daily injection (58.0% of patients and 68.5% of endocrinologists), worries about insulin dependence (42.6% of patients and 62.5% of endocrinologists), and fear of injection (37.0% of patients and 66.5% of endocrinologists). Medical expenses, convenience of drug portability and storage, and injection site reactions were the top 3 aspects that need improvement according to both patients and HCPs. High injection frequency was also one of the most urgent aspects for improvement (mean urgency score, 3.8 for physicians and 4.0 for nurses). A typical IAT training session took a mean (SD) of 14.1 (9.7) minutes. Both patients and HCPs considered injection operation after dose is set and symptoms and treatment for adverse effects as the 2 most time-consuming training contents. In addition, 97.1% of endocrinologists who provided training and 97.0% of nurses thought a more user-friendly IAT would reduce their training burden.

IMPLICATIONS

Study results indicate that the IATs with more convenient drug portability and storage, fewer injection site reactions and adverse events, less injection frequency, more user-friendly design, and fewer steps for injection might help improve patient experience with self-injection and reduce HCPs' training burden.

A pragmatic study of mid-mixture insulin and basal insulin treatment in patients with type 2 diabetes uncontrolled with oral antihyperglycaemic medications: A lesson from real-world experience

BACKGROUND

Chinese guidelines for the treatment of type 2 diabetes (T2D) recommend basal or premixed insulins as insulin starters after failed oral antihyperglycaemic medication (OAM). This pragmatic study compared effectiveness and safety of add-on basal insulin analog (BI) and mid-mixture insulin analog (MMI; 50:50 premixed insulin) as starter insulin regimens in Chinese patients with T2D in a real-world setting.

MATERIALS AND METHODS

This was a multicentre, open-label, randomized, parallel, pragmatic trial. Patients receiving OAMs were randomized 1:1 to BI (n = 410) or MMI (n = 404) for 24 weeks. Insulin titration and OAM adjustment were determined by investigators following usual standard-of-care. The primary outcome was change in glycated haemoglobin (HbA1c) from baseline.

RESULTS

Least-squares mean changes in HbA1c from baseline to week 24 were -2.00% and -2.15% for BI and MMI groups, respectively (P = .13). The MMI group demonstrated a greater reduction in concomitant OAM therapies used than BI group (53.8% vs. 35.3%, respectively; P < .001). Very limited daily insulin dose increments were observed from baseline to week 24 in both BI and MMI groups (2.5 U/day and 1.8 U/day, respectively). Although both insulin analogs were well-tolerated without severe hypoglycaemia, small weight gains were seen with both treatments. Higher total hypoglycaemia rates were noticed with the MMI group, while nocturnal hypoglycaemia events were comparable.

CONCLUSIONS

In real-world settings, BI and MMI provided similar improvement in glucose control without conceding hypoglycaemia. The BI group received a greater number of OAMs in real-world settings. Limited insulin dose titration was observed, while more adjustments occurred with OAM usage.

Obesity, clinical, and genetic predictors for glycemic progression in Chinese patients with type 2 diabetes: A cohort study using the Hong Kong Diabetes Register and Hong Kong Diabetes Biobank

BACKGROUND

Type 2 diabetes (T2D) is a progressive disease whereby there is often deterioration in glucose control despite escalation in treatment. There is significant heterogeneity to this progression of glycemia after onset of diabetes, yet the factors that influence glycemic progression are not well understood. Given the tremendous burden of diabetes in the Chinese population, and limited knowledge on factors that influence glycemia, we aim to identify the clinical and genetic predictors for glycemic progression in Chinese patients with T2D.

METHODS AND FINDINGS

In 1995-2007, 7,091 insulin-naïve Chinese patients (mean age 56.8 ± 13.3 [SD] years; mean age of T2D onset 51.1 ± 12.7 years; 47% men; 28.4% current or ex-smokers; median duration of diabetes 4 [IQR: 1-9] years; mean HbA1c 7.4% ± 1.7%; mean body mass index [BMI] 25.3 ± 4.0 kg/m2) were followed prospectively in the Hong Kong Diabetes Register. We examined associations of BMI and other clinical and genetic factors with glycemic progression defined as requirement of continuous insulin treatment, or 2 consecutive HbA1c ≥8.5% while on ≥2 oral glucose-lowering drugs (OGLDs), with validation in another multicenter cohort of Hong Kong Diabetes Biobank. During a median follow-up period of 8.8 (IQR: 4.8-13.3) years, incidence of glycemic progression was 48.0 (95% confidence interval [CI] 46.3-49.8) per 1,000 person-years with 2,519 patients started on insulin. Among the latter, 33.2% had a lag period of 1.3 years before insulin was initiated. Risk of progression was associated with extremes of BMI and high HbA1c. On multivariate Cox analysis, early age at diagnosis, microvascular complications, high triglyceride levels, and tobacco use were additional independent predictors for glycemic progression. A polygenic risk score (PRS) including 123 known risk variants for T2D also predicted rapid progression to insulin therapy (hazard ratio [HR]: 1.07 [95% CI 1.03-1.12] per SD; P = 0.001), with validation in the replication cohort (HR: 1.24 [95% CI 1.06-1.46] per SD; P = 0.008). A PRS using 63 BMI-related variants predicted BMI (beta [SE] = 0.312 [0.057] per SD; P = 5.84 × 10-8) but not glycemic progression (HR: 1.01 [95% CI 0.96-1.05] per SD; P = 0.747). Limitations of this study include potential misdiagnosis of T2D and lack of detailed data of drug use during follow-up in the replication cohort.

CONCLUSIONS

Our results show that approximately 5% of patients with T2D failed OGLDs annually in this clinic-based cohort. The independent associations of modifiable and genetic risk factors allow more precise identification of high-risk patients for early intensive control of multiple risk factors to prevent glycemic progression.

Reason for refusal of insulin therapy among type 2 diabetes mellitus patients in primary care clinic in Bangalore

Background

Early initiation of insulin therapy and thereby the better control of blood sugar levels has shown reduction in complications. Although insulin therapy has been demonstrated to be efficacious, its initiation is often delayed due to multiple factors including the refusal of insulin therapy by the patients. This study aims to explore the reasons for the refusal of insulin therapy in a resource-constrained primary care setting in an urban slum in India.

Materials and Methods

We included 148 patients who required insulin therapy but refused. A semi-structured questionnaire was administered by a primary care physician. Chi-square test was done to test the association between demographic factors and the reasons for refusal. P < 0.05 was considered as significant.

Results

The mean age of the patients was 49.53 (SD+/-9.8) years. Majority (40.5%) of the patients had diabetes for 6-10 years, and most of them were living with their families (89.9%) and 77% of them were dependent on their family for their financial and physical needs. Financial constraint was the most common reason for reason (74.3%) followed by afraid of pain (68.9%) and fear of dependency (57.4). Gender, occupation, and duration of diabetes and witnessing insulin administration were significantly associated with stigma related to insulin therapy.

Conclusion

Financial constraint is one of the key factors as patients have to buy insulin out of pocket and are not covered by insurance. Government initiatives to reduce and monitor the cost of the insulin would be of great benefit to the patients in this setting.

Efficacy and Safety of Pioglitazone versus Glimepiride after Metformin and Alogliptin Combination Therapy: A Randomized, Open-Label, Multicenter, Parallel-Controlled Study

BACKGROUND

There is limited information regarding the optimal third-line therapy for managing type 2 diabetes mellitus (T2DM) that is inadequately controlled using dual combination therapy. This study assessed the efficacy and safety of pioglitazone or glimepiride when added to metformin plus alogliptin treatment for T2DM.

METHODS

This multicenter, randomized, active-controlled trial (ClinicalTrials.gov: NCT02426294) recruited 135 Korean patients with T2DM that was inadequately controlled using metformin plus alogliptin. The patients were then randomized to also receive pioglitazone (15 mg/day) or glimepiride (2 mg/day) for a 26-week period, with dose titration was permitted based on the investigator's judgement.

RESULTS

Glycosylated hemoglobin levels exhibited similar significant decreases in both groups during the treatment period (pioglitazone: -0.81%, P<0.001; glimepiride: -1.05%, P<0.001). However, the pioglitazone-treated group exhibited significantly higher high density lipoprotein cholesterol levels (P<0.001) and significantly lower homeostatic model assessment of insulin resistance values (P<0.001). Relative to pioglitazone, adding glimepiride to metformin plus alogliptin markedly increased the risk of hypoglycemia (pioglitazone: 1/69 cases [1.45%], glimepiride: 14/66 cases [21.21%]; P<0.001).

CONCLUSION

Among patients with T2DM inadequately controlled using metformin plus alogliptin, the addition of pioglitazone provided comparable glycemic control and various benefits (improvements in lipid profiles, insulin resistance, and hypoglycemia risk) relative to the addition of glimepiride.

Nationwide Trends in Pancreatitis and Pancreatic Cancer Risk Among Patients With Newly Diagnosed Type 2 Diabetes Receiving Dipeptidyl Peptidase 4 Inhibitors

OBJECTIVE

Dipeptidyl peptidase 4 inhibitors (DPP-4i) are useful incretin-based antidiabetes drugs. However, there is a concern that DPP-4i may adversely impact the exocrine pancreas, owing to their pleiotropic effects. In this study, we investigated whether DPP-4i are associated with pancreatitis and pancreatic cancer using a nationwide population-based cohort study.

RESEARCH DESIGN AND METHODS

We included patients newly diagnosed with type 2 diabetes who were treated with antidiabetes drugs (n = 33,208) from 2007 to 2013. The data were obtained from the Korean National Health Insurance Service-Health Screening Cohort database (n = 514,866). Risk was estimated using a Cox proportional hazards model with time-dependent covariates. A 6-month lag time was used to account for a possible latency time. The risk across various time segments since the first prescription of DPP-4i was also analyzed.

RESULTS

Out of 33,208 subjects, 10,218 were new users of DPP-4i and 22,990 were new users of other antidiabetes drugs. DPP-4i significantly increased the risks of pancreatitis (adjusted hazard ratio [aHR] 1.24, 95% CI 1.01-1.52; P = 0.037) and pancreatic cancer (aHR 1.81, 95% CI 1.16-2.82; P = 0.009) with a 6-month drug use lag period. The risk of pancreatitis and pancreatic cancer was generally consistent in the first 12 months and 1 year after the initial prescription without showing an increasing trend according to exposure duration.

CONCLUSIONS

DPP-4i use is associated with increased risks of pancreatitis and pancreatic cancer in patients with newly diagnosed type 2 diabetes. However, the absence of increasing trend according to exposure duration suggests the chances of reverse causality, and long-term pancreatic safety of DPP-4i has to be further investigated.

Study of type 2 diabetes management among patients in a Macau primary care setting

Background

In the primary care setting in Macau, type 2 diabetes mellitus (T2DM) is the seventh most common reason for consultation. Inadequate glycaemic control constitutes a major public health problem and is associated with premature death and disability and decreased quality of life. Moreover, this condition substantially increases healthcare expenditures.

Objective

The primary objective was to assess the successful glycaemic control rates, blood pressure (BP) and cholesterol control rates in patients with T2DM in a Macau primary care setting. The secondary objective of this study was to assess the delay of insulin initiation in the Sao Lourence Health Center.

Methods

Patients were stratified according to age (<65 years vs ≥65 years) and sex. Successful glycaemic control was defined as glycated haemoglobin (HbA1c) <7%. Successful cholesterol control was defined as a low-density lipoprotein cholesterol (LDL-C) level <2.6 mmol/L, and BP control was defined as BP <140/90 mm Hg.

Results

Among the 2157 participants included in this study, 1046 (48.5%) patients had HbA1c <7%, 1209 (56.1%) patients had BP <140/90 mm Hg and 1244 (57.7%) patients had LDL-C <2.6 mmol/L. In conclusion, only 403 (18.7%) patients met the targets for all three measures. Of the 235 patients who were on insulin therapy, the mean (±SD) duration from T2DM diagnosis to insulin initiation was 7.47±6.52 years, the mean (±SD) duration from HbA1c not meeting the target (HbA1c ≥7% over 1 year and persistently) to insulin initiation was 3.34±3.66 years and the mean baseline HbA1c was 9.13%. Compared with patients with a longer duration (≥5 years) of HbA1c not meeting the target before insulin initiation, those who started insulin within 1 year of HbA1c not meeting the target had a better glycaemic control rate (40.7% vs 13%).

Conclusions

Nearly half of the patients at Sao Lourence Health Center, a primary care centre in Macau, met the glycaemic control target, but less than one-fifth of patients met all three targets for T2DM control. Moreover, there was a delay in insulin initiation for people with T2DM.

Individualised targets for insulin initiation in type 2 diabetes mellitus-the influence of physician and practice: a cross-sectional study in eight European countries

OBJECTIVES

To determine at what glycated haemoglobin (HbA1c) level physicians from eight European countries would initiate insulin in type 2 diabetes, which physician or practice related factors influenced this level and whether physicians would differentiate between a younger uncomplicated patient and an older patient with comorbidities.

DESIGN

Cross-sectional study with data from the Guideline Adherence to Enhance Care study.

SETTING AND PARTICIPANTS

410 physicians from both primary and secondary care from Belgium, France, Germany, Italy, Ireland, Sweden, the Netherlands and the UK.

OUTCOME MEASURES

Physicians were asked at which HbA1c level they would initiate insulin for a young, uncomplicated patient (vignette 1) and for an older, complicated patient (vignette 2). We evaluated differences in HbA1c levels between physicians from different countries using analysis of variance. To identify physician and practice related factors associated with HbA1c level at initiation of insulin, we performed multivariable linear regression. Multiple imputation was used to deal with missing data.

RESULTS

In Germany, Ireland, Sweden, the Netherlands and the UK, the HbA1c levels for initiating insulin in vignette 2 (range: 60.0 to 66.0 mmol/mol; 7.6% to 8.2%) were higher than for vignette 1 (range: 57.2 to 64.2 mmol/mol; 7.4% to 8.0%). In multivariable analysis, the HbA1c level at which insulin was initiated only differed between countries (vignette 1): Dutch physicians initiated insulin at a lower HbA1c level compared with Belgium, France and the UK. No physician or practice factors were independently associated with HbA1c level at insulin initiation.

CONCLUSIONS

When deciding on individualised HbA1c targets for insulin initiation, physicians from five countries took patient's age and comorbidity into account. The HbA1c level at which physicians would initiate insulin therapy differed between countries.

The perceived barriers to insulin therapy among type 2 diabetic patients

BACKGROUND

Problems may arise with insulin treatment, due to patients' perspective towards it leading to refusal.

OBJECTIVES

To evaluate diabetic patients' refusal towards insulin therapy, and to assess patients' perception and perceived barriers towards insulin.

METHODS

A cross-sectionalstudy, where type 2 diabetics participated in the study during a period, February through March 2017. They were interviewed in person by a questionnaire including three sections; socio-demography, medical history and a health belief model, comprising barriers to use insulin. Five points Likert scale was used to measure patients' perception and barriers towards insulin therapy.

RESULTS

One fourth (24.4%) of the diabetic patients refused insulin. Among the controlled group, 34.4% refused insulin, while 21% refused insulin among the uncontrolled group. The study showed different barriers towards insulin therapy, including fear of injection, pain, insulin injection needs help from others, fear of hypoglycaemia and embarrassment.

CONCLUSION

Diabetics showed a negative attitude towards insulin therapy due to social and psychological factors. The results necessitate the development of a strategy to address problems related with a reluctance to initiate insulin and put a strategy to implement education and better interaction with diabetic team to the stigma from phobia from insulin use.

Probability of Achieving Glycemic Control with Basal Insulin in Patients with Type 2 Diabetes in Real-World Practice in the USA

INTRODUCTION

Basal insulin (BI) plays an important role in treating type 2 diabetes (T2D), especially when oral antidiabetic (OAD) medications are insufficient for glycemic control. We conducted a retrospective, observational study using electronic medical records (EMR) data from the IBM^® Explorys database to evaluate the probability of achieving glycemic control over 24 months after BI initiation in patients with T2D in the USA.

METHODS

A cohort of 6597 patients with T2D who started BI following OAD(s) and had at least one valid glycated hemoglobin (HbA1c) result recorded both within 90 days before and 720 days after BI initiation were selected. We estimated the changes from baseline in HbA1c every 6 months, the quarterly conditional probabilities of reaching HbA1c < 7% if a patient had not achieved glycemic control prior to each quarter (Q), and the cumulative probability of reaching glycemic control over 24 months.

RESULTS

Our cohort was representative of patients with T2D who initiated BI from OADs in the USA. The average HbA1c was 9.1% at BI initiation, and decreased robustly (1.5%) in the first 6 months after initiation with no further reductions thereafter. The conditional probability of reaching glycemic control decreased rapidly in the first year (26.6% in Q2; 17.6% in Q3; 8.6% in Q4), and then remained low (≤ 6.1%) for each quarter in the second year. Cumulatively, about 38% of patients reached HbA1c < 7% in the first year; only approximately 8% more did so in the second year.

CONCLUSION

Our study of real-world data from a large US EMR database suggested that among patients with T2D who initiated BI after OADs, the likelihood of reaching glycemic control diminished over time, and remained low from 12 months onwards. Additional treatment options should be considered if patients do not reach glycemic control within 12 months of BI initiation.

FUNDING

Sanofi Corporation.

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.