A new look at established therapies: practical tools for optimizing insulin use

Development and Psychometric Evaluation of the Hypoglycemia Perspectives Questionnaire in Patients with Type 2 Diabetes Mellitus

AIMS

The aim of this study was to evaluate the factor structure and psychometric characteristics of the Hypoglycemia Perspectives Questionnaire (HPQ) assessing experience and perceptions of hypoglycemia in patients with type 2 diabetes mellitus (T2DM).

METHODS

HPQ was administered to adults with T2DM in a clinical sample from Cyprus (HYPO-Cyprus, n = 500) and a community sample in the United States (US, n = 1257) from the 2011 US National Health and Wellness Survey. Demographic and clinical data were collected. Analysis of HPQ data from two convenience samples examined item performance, factor structure, and HPQ measurement properties (reliability, convergent validity, known-groups validity).

RESULTS

Analyses supported three HPQ domains: symptom concern (six items), compensatory behavior (five items), and worry (five items). Internal consistency was high for all three domains (all ≥0.75), supporting reliability. Convergent validity was supported by moderate Spearman correlations between HPQ domain scores and the Audit of Diabetes-Dependent Quality of Life (ADDQoL-19) total score. Patients with recent hypoglycemia events had significantly higher HPQ scores, supporting known-group validity.

CONCLUSIONS

HPQ may be a valid and reliable measure capturing the experience and impact of hypoglycemia and useful in clinical trials and community-based settings.

U-500 concentrated regular insulin: practical application in the outpatient setting

Administering large insulin doses to patients with severely insulin-resistant diabetes is often ineffective, expensive, and painful. U-500 regular insulin is absorbed better, less painful, and more cost-effective due to the reduced volume. This article describes the most recent guidelines for U-500 insulin in the clinical setting.

An exploration of barriers to insulin initiation for physicians in Japan: findings from the Diabetes Attitudes, Wishes And Needs (DAWN) JAPAN study

OBJECTIVE

Insulin is recommended as an appropriate treatment in type 2 diabetes patients with suboptimal glycemic control; however, its initiation is often delayed. We therefore conducted the DAWN (Diabetes Attitudes, Wishes and Needs) JAPAN study in an attempt to identify specific patient- and physician-related factors which contribute to delay of insulin initiation among Japanese patients with diabetes. In this report, we explored barriers for physicians which prevent timely insulin initiation.

METHODS

The DAWN JAPAN study is a multicenter, questionnaire-based survey, conducted between 2004 and 2005. Participating physicians were categorized as follows based on their expertise: Japan Diabetes Society (JDS) certified specialists (n = 77), JDS-affiliated physicians (n = 30), and non-JDS-affiliated physicians (n = 27). To assess physician barriers to insulin initiation, we have used a newly developed 27- item questionnaire.

RESULTS

The mean age of patients (n = 11,656) treated by participating physicians was 64.1 years. The mean duration of diabetes was 121.6 months, and their mean HbA1c was 7.5%. Insulin was used in 27.4% of total patients. With regard to physician barriers to insulin initiation, the biggest differences in concerns expressed by JDS-certified specialists and non-JDS-affiliated physicians were observed in the following items with statistical significance: "I do not have staff (nurse, pharmacists) who can assist with explanations" (1.3% vs 55.5%, respectively), "I have concerns about the use of insulin therapy in elderly patients" (38.1% vs 81.5%), and "It is difficult to provide guidance and education on insulin injection to patients" (16.9% vs 55.5%). The mean HbA1c at which physicians responded they would recommend insulin to their patients was 8.7%; however, they would reduce this level to 8.2% if they themselves required insulin.

CONCLUSIONS

Our results demonstrated that physicians have concerns about insulin use, and suggested that their concerns can lead to delay of insulin initiation.

Basal insulin: physiology, pharmacology, and clinical implications

Primary goals in the treatment of type 2 diabetes mellitus (T2DM) include lowering blood glucose levels sufficiently to prevent micro- and macrovascular complications while limiting side effects, such as hypoglycemia and excessive weight gain. Patients with T2DM are typically treated initially with oral antidiabetes agents; however, as the disease progresses, most will require insulin to maintain glycemic control. Often insulin therapy is initiated with basal insulin, and the objective of this article is to present the conceptual aspects of basal insulin therapy and use these concepts to illustrate important clinical aspects. This will be accomplished within a broader contextual discussion of the normal physiologic patterns of insulin secretion, which consist of sustained levels of basal insulin production throughout the day, superimposed with bursts of insulin secretion following a meal (termed bolus or prandial insulin secretion) that slowly decay over 1 to 3 hours. Long-acting basal insulin analogs form a key component of basal-bolus therapy and provide basal support for patients with T2DM. Insulin therapy is often initiated with basal insulin, and newer long-acting analogs, such as insulin glargine and insulin detemir, provide steady, reliable basal insulin coverage in addition to significant advantages over traditional long-acting insulins. This article will integrate conceptual aspects of basal insulin therapy in the context of physiology, molecular pharmacology, and clinical implications of modern basal insulin analogs to provide a foundational understanding of basal insulin biology and physiology.