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Simonson GD, Criego AB, Battelino T, Carlson AL, Choudhary P, Franc S, Gershenoff D, Grunberger G, Hirsch IB, Isaacs D, Johnson ML, Kerr D, Kruger DF, Mathieu C, Martens TW, Nimri R, Oser SM, Peters AL, Weinstock RS, Wright EE, Wysham CH, Bergenstal RM. Expert Panel Recommendations for a Standardized Ambulatory Glucose Profile Report for Connected Insulin Pens. Diabetes Technol Ther 2024. [PMID: 38758213 DOI: 10.1089/dia.2024.0107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
Background: Connected insulin pens capture data on insulin dosing/timing and can integrate with continuous glucose monitoring (CGM) devices with essential insulin and glucose metrics combined into a single platform. Standardization of connected insulin pen reports is desirable to enhance clinical utility with a single report. Methods: An international expert panel was convened to develop a standardized connected insulin pen report incorporating insulin and glucose metrics into a single report containing clinically useful information. An extensive literature review and identification of examples of current connected insulin pen reports were performed serving as the basis for creation of a draft of a standardized connected insulin pen report. The expert panel participated in three virtual standardization meetings and online surveys. Results: The Ambulatory Glucose Profile (AGP) Report: Connected Insulin Pen brings all clinically relevant CGM-derived glucose and connected insulin pen metrics into a single simplified two-page report. The first page contains the time in ranges bar, summary of key insulin and glucose metrics, the AGP curve, and detailed basal (long-acting) insulin assessment. The second page contains the bolus (mealtime and correction) insulin assessment periods with information on meal timing, insulin-to-carbohydrate ratio, average bolus insulin dose, and number of days with bolus doses recorded. The report's second page contains daily glucose profiles with an overlay of the timing and amount of basal and bolus insulin administered. Conclusion: The AGP Report: Connected Insulin Pen is a standardized clinically useful report that should be considered by companies developing connected pen technology as part of their system reporting/output.
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Affiliation(s)
- Gregg D Simonson
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Amy B Criego
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Tadej Battelino
- University Medical Center Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Anders L Carlson
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Pratik Choudhary
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
| | - Sylvia Franc
- Diabetes and Metabolic Diseases Department, Sud Francilien Hospital, Corbeil-Essonnes, France
| | | | - George Grunberger
- Grunberger Diabetes & Endocrinology, Bloomfield Hills, Michigan, USA
| | - Irl B Hirsch
- University of Washington School of Medicine, Seattle, Washington, USA
| | | | - Mary L Johnson
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - David Kerr
- Center for Health Systems Research, Sutter Health, Santa Barbara, California, USA
| | - Davida F Kruger
- Division of Endocrinology, Diabetes, Bone and Mineral Disease, Henry Ford Health System, Detroit, Michigan, USA
| | - Chantal Mathieu
- Department of Endocrinology, UZ Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Thomas W Martens
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Revital Nimri
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Faculty of Medical and Health Sciences, Tel-Aviv University, Tel-Aviv, Israel
| | - Sean M Oser
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Anne L Peters
- USC Keck School of Medicine, Los Angeles, California, USA
| | | | - Eugene E Wright
- South Piedmont Area Health Education Center, Charlotte, North Carolina, USA
| | | | - Richard M Bergenstal
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
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2
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Samson SL, Vellanki P, Blonde L, Christofides EA, Galindo RJ, Hirsch IB, Isaacs SD, Izuora KE, Low Wang CC, Twining CL, Umpierrez GE, Valencia WM. American Association of Clinical Endocrinology Consensus Statement: Comprehensive Type 2 Diabetes Management Algorithm - 2023 Update. Endocr Pract 2023; 29:305-340. [PMID: 37150579 DOI: 10.1016/j.eprac.2023.02.001] [Citation(s) in RCA: 76] [Impact Index Per Article: 76.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/31/2023] [Accepted: 02/06/2023] [Indexed: 05/09/2023]
Abstract
OBJECTIVE This consensus statement provides (1) visual guidance in concise graphic algorithms to assist with clinical decision-making of health care professionals in the management of persons with type 2 diabetes mellitus to improve patient care and (2) a summary of details to support the visual guidance found in each algorithm. METHODS The American Association of Clinical Endocrinology (AACE) selected a task force of medical experts who updated the 2020 AACE Comprehensive Type 2 Diabetes Management Algorithm based on the 2022 AACE Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan and consensus of task force authors. RESULTS This algorithm for management of persons with type 2 diabetes includes 11 distinct sections: (1) Principles for the Management of Type 2 Diabetes; (2) Complications-Centric Model for the Care of Persons with Overweight/Obesity; (3) Prediabetes Algorithm; (4) Atherosclerotic Cardiovascular Disease Risk Reduction Algorithm: Dyslipidemia; (5) Atherosclerotic Cardiovascular Disease Risk Reduction Algorithm: Hypertension; (6) Complications-Centric Algorithm for Glycemic Control; (7) Glucose-Centric Algorithm for Glycemic Control; (8) Algorithm for Adding/Intensifying Insulin; (9) Profiles of Antihyperglycemic Medications; (10) Profiles of Weight-Loss Medications (new); and (11) Vaccine Recommendations for Persons with Diabetes Mellitus (new), which summarizes recommendations from the Advisory Committee on Immunization Practices of the U.S. Centers for Disease Control and Prevention. CONCLUSIONS Aligning with the 2022 AACE diabetes guideline update, this 2023 diabetes algorithm update emphasizes lifestyle modification and treatment of overweight/obesity as key pillars in the management of prediabetes and diabetes mellitus and highlights the importance of appropriate management of atherosclerotic risk factors of dyslipidemia and hypertension. One notable new theme is an emphasis on a complication-centric approach, beyond glucose levels, to frame decisions regarding first-line pharmacologic choices for the treatment of persons with diabetes. The algorithm also includes access/cost of medications as factors related to health equity to consider in clinical decision-making.
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Affiliation(s)
- Susan L Samson
- Chair of Task Force; Chair of the Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Mayo Clinic, Jacksonville, Florida
| | - Priyathama Vellanki
- Vice Chair of Task Force; Associate Professor of Medicine, Department of Medicine, Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Emory University; Section Chief, Endocrinology, Grady Memorial Hospital, Atlanta, Georgia
| | - Lawrence Blonde
- Director, Ochsner Diabetes Clinical Research Unit, Frank Riddick Diabetes Institute, Department of Endocrinology, Ochsner Health, New Orleans, Louisiana
| | | | - Rodolfo J Galindo
- Associate Professor of Medicine, University of Miami Miller School of Medicine; Director, Comprehensive Diabetes Center, Lennar Medical Center, UMiami Health System; Director, Diabetes Management, Jackson Memorial Health System, Miami, Florida
| | - Irl B Hirsch
- Professor of Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Scott D Isaacs
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Kenneth E Izuora
- Associate Professor, Department of Internal Medicine, Endocrinology, Kirk Kerkorian School of Medicine, University of Nevada Las Vegas, Las Vegas, Nevada
| | - Cecilia C Low Wang
- Professor of Medicine, Department of Medicine, Division of Endocrinology, Metabolism, and Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Christine L Twining
- Endocrinology, Diabetes and Metabolism, Maine Medical Center, Maine Health, Scarborough, Maine
| | - Guillermo E Umpierrez
- Professor of Medicine, Emory University School of Medicine, Division of Endocrinology, Metabolism; Chief of Diabetes and Endocrinology, Grady Health Systems, Atlanta, Georgia
| | - Willy Marcos Valencia
- Endocrinology and Metabolism Institute, Center for Geriatric Medicine, Cleveland Clinic, Cleveland, Ohio
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3
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Szmuilowicz ED, Aleppo G. Stepwise approach to continuous glucose monitoring interpretation for internists and family physicians. Postgrad Med 2022; 134:743-751. [PMID: 35930313 DOI: 10.1080/00325481.2022.2110507] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Continuous glucose monitoring (CGM) use has expanded rapidly in recent years among people with both type 1 and type 2 diabetes. In concert with the globally increasing prevalence of type 2 diabetes, the majority of whom receive diabetes care from internists or family physicians rather than specialists, it is becoming increasingly incumbent upon physicians within internal medicine and family practice to interpret and utilize CGM data in real-world clinical practice. It is therefore of paramount importance that internists and family physicians have access to the tools which will enable them to (1) interpret CGM data, and (2) utilize CGM data to guide therapeutic modifications for their patients with type 2 diabetes. Given the limited amount of time available to internists and family physicians to address multiple complex topics in a typical office visit, a pragmatic, simple, and systematic approach to CGM interpretation is crucial. This article aims to provide internists and family physicians with a simplified and systematic approach to CGM interpretation that can be easily and efficiently implemented in a brief office visit.
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Affiliation(s)
- Emily D Szmuilowicz
- Division of Endocrinology, Metabolism and Molecular Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine
| | - Grazia Aleppo
- Division of Endocrinology, Metabolism and Molecular Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine
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5
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Kress S, Borck A, Zisman A, Bramlage P, Siegmund T. A Difference Between Bedtime and Pre-Breakfast Plasma Glucose Levels Indicates the Need for Prandial Insulin in Basal Insulin-Treated Type 2 Diabetic Patients with Normal Fasting Glucose. Diabetes Metab Syndr Obes 2021; 14:1215-1222. [PMID: 33776458 PMCID: PMC7987255 DOI: 10.2147/dmso.s267882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/04/2021] [Indexed: 11/23/2022] Open
Abstract
AIM In the present analysis, we characterised the efficacy and safety of adding a single daily injection of insulin glulisine to optimised basal-supported oral therapy (BOT) in patients with a high BeAM value, defined as a more than 50 mg/dl difference between bedtime and pre-breakfast blood glucose. METHODS The BeAM value was retrospectively calculated for patients pooled from two clinical trials that supplemented BOT with glulisine. Data regarding changes in HbA1c, fasting plasma glucose (FPG), and postprandial glucose (PPG) levels from observation periods of 3 to 6 months were assessed. RESULTS Out of 358 patients that received BOT/glulisine, 182 had a high BeAM value. Patients with a high BeAM value were older and had a longer diabetes duration than patients with a medium BeAM value. Significant reductions in HbA1c (7.5% to 7.2% [59 to 55 mmol/mol], p<0.0001) and PPG (202 to 143 mg/dl, p<0.0001) levels were documented. The proportion of patients with a high BeAM value achieving an HbA1c <7% [53 mmol/mol], alone or in combination with no hypoglycaemia, was lower than that of patients with a medium BeAM value. CONCLUSION The analysis indicates that the supplementation of BOT with a single daily injection of prandial insulin is safe and effective for reducing HbA1c and PPG levels in patients with a high BeAM value (more than 50 mg/dl). However, patients with a medium BeAM value also responded well, which suggests that they should also be considered candidates for this change in therapy.
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Affiliation(s)
- Stephan Kress
- Diabeteszentrum, Vinzentius-Krankenhaus, Landau, Germany
- Correspondence: Stephan Kress Diabeteszentrum, Vinzentius Krankenhaus, Cornichonstr. 4, Landau, 76829, GermanyTel +49 6341 172208 Email
| | - Anja Borck
- Medical Department, Sanofi, Berlin, Germany
| | - Ariel Zisman
- The Endocrine Center of Aventura, Aventura, FL, USA
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
- Department for Angiology, Brandenburg Medical School, Campus Brandenburg/Havel, Brandenburg, Germany
| | - Thorsten Siegmund
- Diabetes- Hormon- Und Stoffwechselzentrum Am Isar Klinikum München, München, Germany
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Cowart K. Overbasalization: Addressing Hesitancy in Treatment Intensification Beyond Basal Insulin. Clin Diabetes 2020; 38:304-310. [PMID: 32699482 PMCID: PMC7364465 DOI: 10.2337/cd19-0061] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Kevin Cowart
- Department of Pharmacotherapeutics & Clinical Research, Taneja College of Pharmacy and Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL
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Kumar A, Sharma S, Gupta A, Dasgupta A, Asirvatham A, Talwalkar P, Das A, Mohan V. Indian reality of managing type 2 diabetes: an expert review of global and national guidelines for optimum insulin use. JOURNAL OF DIABETOLOGY 2020. [DOI: 10.4103/jod.jod_59_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Warren M, Steel D. Clinical Use of IDegLira: Initiation to Titration After Basal Insulin. Clin Diabetes 2020; 38:62-70. [PMID: 31975753 PMCID: PMC6969665 DOI: 10.2337/cd19-0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Delayed treatment intensification is common in U.S. patients with type 2 diabetes uncontrolled on basal insulin. Concerns about weight gain, hypoglycemia, increased regimen complexity, and additional copayments may lead to reluctance to initiate prandial insulin. IDegLira is a titratable, fixed-ratio coformulation that combines the advantages of insulin degludec and the glucagon-like peptide 1 receptor agonist liraglutide in a single once-daily injection and mitigates the side effects associated with each component. Clinical trials have demonstrated that IDegLira improves glycemic control without the increased risk of hypoglycemia and weight gain observed with basal insulin up-titration and the addition of prandial insulin, and this is achieved using twice-weekly titration. Clinical trials and real-world studies have also shown that IDegLira has the potential to reduce therapeutic and titration inertia. However, better outcomes could be achieved with IDegLira initiation in suitable patients with timely titration and by providers sharing their experience with this combination product. This review describes considerations for initiation, titration, and intensification of IDegLira in patients previously receiving basal insulin.
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Affiliation(s)
- Mark Warren
- Endocrinology and Metabolism, Physicians East, Greenville, NC
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9
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Peters AL, Piletič M, Ejstrud J, Salvesen‐Sykes K, Snyder J, Bowering K. Baseline nocturnal glucose change: A predictor of the treatment effect of bolus intensification in insulin-treated type 2 diabetes. Diabetes Obes Metab 2019; 21:1752-1756. [PMID: 30924578 PMCID: PMC6618272 DOI: 10.1111/dom.13729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/07/2019] [Accepted: 03/26/2019] [Indexed: 12/04/2022]
Abstract
This post hoc analysis of an 18-week randomized trial explored the utility of calculating baseline glycated haemoglobin (HbA1c), postprandial glucose (PPG) increments and nocturnal glucose change in predicting efficacy and safety outcomes in response to bolus insulin intensification in people with type 2 diabetes (T2D). Analyses were conducted on 236 participants with T2D receiving metformin: 116 received fast-acting insulin aspart (faster aspart) basal-bolus therapy and 120 received basal-only insulin. Participants were grouped according to baseline HbA1c, PPG increments and nocturnal glucose change variables; analyses were performed on the end-of-trial treatment differences between "high" and "low" baseline values. The change from baseline in end-of-trial mean HbA1c and mean PPG increments was in favour of faster aspart across all subgroups. Significantly greater treatment differences were observed in participants with high (vs. low) baseline nocturnal glucose change and PPG increments. For baseline HbA1c, significantly greater treatment differences were observed for change in end-of-trial PPG increments, but not end-of-trial HbA1c. In conclusion, both nocturnal glucose change and PPG increments may be more useful than HbA1c for identifying subgroups of people with T2D who would most benefit from bolus intensification.
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Affiliation(s)
- Anne L. Peters
- Clinical Diabetes Program, Keck School of Medicine of the University of Southern CaliforniaLos AngelesCalifornia
| | | | | | | | | | - Keith Bowering
- Division of Endocrinology and MetabolismUniversity of AlbertaEdmontonAlbertaCanada
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10
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Abstract
Insulin initiation and titration can be challenging for many primary care providers who are involved in the treatment of patients with type 2 diabetes. Despite the introduction of advanced insulin analogs and improvements in insulin delivery devices, many patients with type 2 diabetes continue to experience suboptimal glycemic control. With an increasing number of treatment options available, type 2 diabetes management is moving away from a "one-size-fits-all" approach and toward individualized treatment regimens based on particular patient needs. Given this, nurse practitioners, physician assistants, pharmacists, and certified diabetes educators are becoming increasingly valuable resources in busy primary care practices.
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Affiliation(s)
- Ji Chun
- OptumCare Medical Group, Laguna Niguel, CA
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11
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Siegmund T, Borck A, Zisman A, Bramlage P, Kress S. A higher blood glucose level pre-breakfast in comparison to bedtime is a contraindication for intensification of prandial insulin therapy in patients with type 2 diabetes - The impact of a negative BeAM value. J Clin Transl Endocrinol 2018; 14:34-38. [PMID: 30416973 PMCID: PMC6214867 DOI: 10.1016/j.jcte.2018.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 09/27/2018] [Accepted: 10/22/2018] [Indexed: 01/21/2023] Open
Abstract
Aims The BeAM value refers to the difference between a patient’s blood glucose level at bedtime (Be) and the following morning before breakfast (AM). The clinical impact of a negative BeAM value (AM blood glucose reading compared to that taken at bedtime) is unknown. Methods T2DM patients of the OPAL and POC trials were pooled and their BeAM values calculated. Results From a total of 358 patients, 31 were calculated as having a negative BeAM value at baseline, while 182 had a high value. Patients in the negative BeAM group were younger, had shorter diabetes duration, and lower HbA1c levels. Fasting blood glucose levels were higher in the negative BeAM group, and these increased to a greater extent during the trial periods. No significant differences in hypoglycaemia occurrence were observed. Multivariate adjusted analysis indicated no association between a negative BeAM value and achievement of HbA1c < 7%, or composite endpoints that additionally included no hypoglycaemia and no weight gain. Conclusions Supplementation of BOT with prandial insulin is not beneficial for patients who have a higher blood glucose reading before breakfast in comparison to before bedtime. Further investigation into the cause of the high morning reading in these patients is indicated.
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Affiliation(s)
- Thorsten Siegmund
- Städt. Klinikum München GmbH, Klinikum Bogenhausen, Germany
- Corresponding author at: Klinik für Endokrinologie, Diabetologie und Angiologie, Klinikum München Bogenhausen, Städt. Klinikum München GmbH, Englschalkinger Straße 77, 81925 München, Germany.
| | - Anja Borck
- Sanofi-Aventis Deutschland GmbH, Berlin, Germany
| | - Ariel Zisman
- The Endocrine Center of Aventura, Aventura, FL, USA
| | - Peter Bramlage
- Institut für Pharmakologie und Präventive Medizin, Cloppenburg, Germany
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12
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Zisman A, Dex T, Roberts M, Saremi A, Chao J, Aroda VR. Bedtime-to-Morning Glucose Difference and iGlarLixi in Type 2 Diabetes: Post Hoc Analysis of LixiLan-L. Diabetes Ther 2018; 9:2155-2162. [PMID: 30218434 PMCID: PMC6167304 DOI: 10.1007/s13300-018-0507-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Indexed: 11/02/2022] Open
Abstract
INTRODUCTION A difference of ≥ 50-55 mg/dL between bedtime and morning glucose (BeAM) values in patients with type 2 diabetes (T2D) on basal insulin is an indicator of poor postprandial glucose control. This analysis compared the effect of treatment with a fixed-ratio combination of insulin glargine/lixisenatide (iGlarLixi) vs insulin glargine (iGlar) on BeAM values, and evaluated the impact of BeAM values on glycemic and safety endpoints. METHODS In this post hoc analysis of 517 participants from the LixiLan-L trial, change in BeAM values and composite efficacy and safety endpoints stratified by BeAM value < 55 mg/dL or ≥ 55 mg/dL were evaluated in patients with T2D uncontrolled on basal insulin randomized to iGlarLixi or iGlar over 30 weeks (LixiLan-L). RESULTS Greater reductions in BeAM values were seen with iGlarLixi vs iGlar, and a higher proportion of patients reached a BeAM value < 55 mg/dL in the iGlarLixi arm. A BeAM value < 55 mg/dL was associated with improved glycemic control, lower risk of hypoglycemia, and a greater proportion of patients achieving glycemic targets without hypoglycemia or weight gain. Greater reductions in BeAM values were seen with iGlarLixi vs iGlar, irrespective of stratification by glycated hemoglobin A1c or glycemic endpoints. CONCLUSIONS Greater reductions in bedtime-to-morning glucose differential, or BeAM, were observed with iGlarLixi vs iGlar in patients with T2D uncontrolled on basal insulin, reflecting better overall control of both fasting and prandial glucose and more appropriate matching of therapy to physiologic needs. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT02058160. FUNDING Sanofi US, Inc.
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Affiliation(s)
| | - Terry Dex
- Sanofi US, Inc, Bridgewater, NJ, USA
| | | | | | | | - Vanita R Aroda
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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13
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Umpierrez GE, Bailey TS, Carcia D, Shaefer C, Shubrook JH, Skolnik N. Improving postprandial hyperglycemia in patients with type 2 diabetes already on basal insulin therapy: Review of current strategies. J Diabetes 2018; 10:94-111. [PMID: 28581207 DOI: 10.1111/1753-0407.12576] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 05/02/2017] [Accepted: 05/21/2017] [Indexed: 11/28/2022] Open
Abstract
A large number of patients with type 2 diabetes (T2D) on basal insulin do not reach their HbA1c goals and require additional therapy to address postprandial hyperglycemia. Guidelines from expert bodies have outlined several approaches to accomplish postprandial glucose (PPG) control, and recent literature suggests several more. This article provides strategies for primary care physicians caring for patients with T2D who do not achieve glycemic control with basal insulin alone. Current treatment guidelines and strategies for improving PPG control are reviewed, including the efficacy, safety, and cost-effectiveness of rapid-acting insulin (RAI) analogs, premixed insulin, glucagon-like peptide-1 (GLP-1) receptor agonists (RAs), dipeptidyl peptidase 4 inhibitors, sodium-glucose cotransporter 2 inhibitors, and α-glucosidase inhibitors. Other approaches, such as combinations of newer basal insulin plus RAI and a fixed-ratio combination of basal insulin and a GLP-1 RA, are also described.
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Affiliation(s)
| | | | - Danielle Carcia
- Abington Hospital Jefferson Health, Abington, Pennsylvania, USA
| | | | | | - Neil Skolnik
- Abington Hospital Jefferson Health, Abington, Pennsylvania, USA
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Valentine V, Goldman J, Shubrook JH. Rationale for, Initiation and Titration of the Basal Insulin/GLP-1RA Fixed-Ratio Combination Products, IDegLira and IGlarLixi, for the Management of Type 2 Diabetes. Diabetes Ther 2017; 8:739-752. [PMID: 28721686 PMCID: PMC5544623 DOI: 10.1007/s13300-017-0287-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Indexed: 12/11/2022] Open
Abstract
Type 2 diabetes (T2D) is a progressive disease affecting glucose regulation and a major cause of morbidity and mortality globally. Many patients are not escalated up the treatment ladder appropriately despite failing to achieve glycemic control, with barriers such as fear of hypoglycemia, weight gain, and treatment burden recognized as factors. Exogenous basal insulin is titrated to address control of fasting plasma glucose and may preserve residual β-cell function, thus promoting a greater endogenous prandial insulin response. Native glucagon-like peptide-1 (GLP-1) is a peptide hormone secreted by the gut in response to nutrient ingestion; it increases insulin secretion, inhibits glucagon secretion, and prolongs gastric emptying, thereby lowering overall food intake. As its glucose-lowering action is glucose dependent, a GLP-1 receptor agonist (GLP-1RA) achieves these benefits with a lower risk of hypoglycemia compared with other diabetes therapies. Two products, an insulin degludec/liraglutide combination (IDegLira) and an insulin glargine/lixisenatide combination (IGlarLixi), were approved for use in adults with T2D by the US Food and Drug Administration in 2016. The efficacy and safety of these two basal insulin/GLP-1RA combination products were studied in the DUAL program (NCTs 01336023, 01392573, 01676116, 01618162, 01952145, and 02298192) and the LixiLan program (NCTs 02058160 and 02058147). Compared with basal insulin, insulin/GLP-1RA fixed-ratio combinations are superior at reducing HbA1c with weight neutrality or weight loss rather than weight gain, as well as reduced hypoglycemia rates, and reduced insulin-dose requirement with IDegLira. A combination of different medications may often be required to achieve glycemic control, and fixed-ratio combination products allow such therapies to be given in simple regimens. Clinical trial data for these products highlight the great potential of these agents, not merely their efficacy and safety but also their ease of use and decreased injection burden for patients.
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