Technology in the management of type 2 diabetes: Present status and future prospects

The growing incidence of type 2 diabetes (T2D) is a significant health concern, representing 90% of diabetes cases worldwide. As the disease progresses, resultant insulin deficiency and hyperglycaemia necessitates insulin therapy in many cases. It has been recognized that a significant number of people who have a clinical requirement for insulin therapy, as well as their healthcare professionals, are reluctant to intensify treatment with insulin due to fear of hypoglycaemia, poor understanding of treatment regimens or lack of engagement, and are therefore at higher risk of developing complications from poor glycaemic control. Over the past decade, the rise of diabetes technologies, including dosing advisors, continuous glucose monitoring systems, insulin pumps and automated insulin delivery systems, has led to great improvements in the therapies available, particularly to those requiring insulin. Although the focus has largely been on delivering these therapies to the type 1 diabetes population, it is becoming increasingly recognized that people with T2D face similar challenges to achieve recommended glycaemic standards and also have the potential to benefit from these advances. In this review, we discuss diabetes technologies that are currently available for people with T2D and the evidence supporting their use, as well as future prospects. We conclude that there is a clinical need to extend the use of these technologies to the T2D population to curb the consequences of suboptimal disease management in this group.

Cost-Effectiveness of Continuous Subcutaneous Insulin Infusion Versus Multiple Daily Injections in Patients with Poorly Controlled Type 2 Diabetes in Finland

INTRODUCTION

Although primarily utilized in type 1 diabetes, continuous subcutaneous insulin infusion (CSII) represents a useful treatment alternative for patients with type 2 diabetes who are unable to achieve good glycemic control despite optimization of multiple daily injections (MDI). The aim of the analysis reported here was to investigate the long-term cost-effectiveness of CSII versus MDI in type 2 diabetes patients with poor glycemic control in Finland.

METHODS

The IQVIA CORE Diabetes Model was used to make long-term projections of the clinical and economic outcomes associated with CSII use in type 2 diabetes, based on clinical input data from the OpT2mise trial, which showed that CSII was associated with a 1.1% decrease in glycated hemoglobin (HbA1c) in patients with poor glycemic control at baseline. The analysis was performed from a societal perspective and the time horizon was that of patient lifetimes. Future costs and clinical outcomes were discounted at 3% per annum.

RESULTS

Continuous subcutaneous insulin infusion was associated with a gain in quality-adjusted life expectancy of 0.32 quality-adjusted life-years (QALYs) compared with MDI (8.15 vs. 7.83 QALYs, respectively), as well as higher mean lifetime costs, resulting in an incremental cost-effectiveness ratio of Euro (EUR) 47,834 per QALY gained for CSII versus MDI. The higher treatment costs in the CSII group were partly mitigated by a 15% reduction in diabetes-related complication costs. Sensitivity analyses demonstrated that CSII was most cost-effective in patients with the highest baseline HbA1c values.

CONCLUSION

In Finland, CSII is likely to represent a cost-effective treatment alternative for patients with type 2 diabetes with poor glycemic control despite optimization of MDI. In such patients, CSII is associated with improved clinical outcomes relative to MDI, with the higher acquisition costs partly offset by a lower lifetime incidence and cost of diabetes-related complications.

FUNDING

Medtronic International Sàrl.

A qualitative study exploring patients' experiences regarding insulin pump use

BACKGROUND

Diabetes is a threat to peoples' lives around the world, particularly in the Middle East. Medicine misuse and poor glycaemic control are prevalent among patients with type 2 diabetes, especially insulin-dependent patients (Alsairafi et al., 2016). With advances in medical technology, insulin pumps became a treatment option for patients with type 1 diabetes and those with insulin-dependent type 2 diabetes. However, use of these devices is still lacking in Kuwait, particularly in patients with type 2 diabetes. Information on how patients manage these devices and their efficacy and safety from the perspectives of patients is also lacking (Alsaleh et al., 2016).

OBJECTIVE

To examine the views and experiences of adults with type 2 diabetes regarding the use of insulin pumps compared to their previous insulin delivery methods, in terms of glycaemic control, quality of life, preference, convenience and adherence to doses.

SETTING

The main five secondary-care hospitals in Kuwait: Mobarak Al-Kabeer, Al Amiri, Al Adan, Al Farwaniya and Al Jahra.

METHOD

All adults with type 2 diabetes who used an insulin pump were invited to participate. Data were collected through semi-structured interviews. Data analysis was performed using MAXQDA-11.

RESULTS

A total of eight patients were interviewed. Interviews with patients revealed that using an insulin pump improved patients' glycaemic control and quality of life as a consequence of improved satisfaction and adherence to doses.

CONCLUSION

From the perspective of adults with type 2 diabetes, there are lots of benefits of using insulin pumps over other insulin delivery methods, mainly seen by the improvement of quality of life and patients' adherence to doses. Policy-makers and healthcare professionals (HCPs) must be aware of such benefits and should support the wider implementation of this technology in the country by including patients with type 2 diabetes. Results of this study will help to inform healthcare provision and guideline modifications and to provide guidance for new patients using this therapy.

The role of insulin pump therapy for type 2 diabetes mellitus

Many patients with type 2 diabetes fail to achieve adequate glucose control despite escalation of treatment and combinations of multiple therapies including insulin. Patients with long-standing type 2 diabetes often suffer from the combination of severe insulin deficiency in addition to insulin resistance, thereby requiring high doses of insulin delivered in multiple injections to attain adequate glycemic control. Insulin-pump therapy was first introduced in the 1970s as an approach to mimic physiological insulin delivery and attain normal glucose in patients with type 1 diabetes. The recent years have seen an increase in the use of this technology for patients with type 2 diabetes. This article summarizes the clinical studies evaluating insulin pump use in patients with type 2 diabetes and discusses the benefits and shortcomings of pump therapy in this population. Copyright © 2016 John Wiley & Sons, Ltd.

Incidence, prevalence, and trend analysis of the use of insulin delivery systems in the United States (2005 to 2011)

OBJECTIVE

Estimate the incidence and prevalence rates and assess overall trends among patients with diabetes using insulin vial/syringe and pens over time.

METHODS

A retrospective study was conducted using the Truven MarketScan database from 1 July 2004 to 31 December 2011. The database contained medical and pharmacy claims of >20 million US residents insured by commercial health plans. Patients with diabetes who utilized vial/syringe and pens were included. Incidence rate was defined as the proportion of patients initiating a new insulin type for the first time with vial/syringe and pens within each year from 2005 to 2011 among the total number of patients initiating that particular insulin type for the first time. Prevalence rate was defined as the proportion of patients using vial/syringe or pens among patients with diabetes using that insulin type within each year from 2005 to 2011. A linear trend over time was assessed by Cochran-Armitage Trend tests and Generalized Estimating Equations.

RESULTS

Incidence of patients initiating vial/syringe decreased from 2005 to 2011 (basal analog [90.5% to 31.3%]; mealtime analog [67.6% to 37.1%]), while patients initiating pens increased (basal analog [9.5% to 68.7%]; mealtime analog [32.4% to 62.9%]). There was a significant trend over time indicating increased usage of pens relative to vial/syringe; the number of pen users increased (all p < 0.0001 except mealtime human). Prevalence of patients using vial/syringe decreased from 2005 to 2011 (basal analog [93.8% to 41.2%]; mealtime analog [71.0% to 50.6%]), while patients using pens increased (basal analog [6.2% to 58.8%]; mealtime analog [29.0% to 49.4%]). From 2005 to 2011, patients were more likely to use pens than vial/syringe (all p < 0.0001 except for human mixtures and mealtime human).

CONCLUSIONS

The incidence and prevalence of patients using the traditional vial/syringe decreased over time, while the use of pens increased. Some patient populations may be under-represented, limiting generalizability of results.

Impact of clinical pharmacist collaboration in patients beginning insulin pump therapy: a retrospective and cross-sectional analysis

Objective

To measure clinical and qualitative outcomes in patients with diabetes mellitus transitioning from intensive insulin therapy using multiple daily injections (MDI) to continuous subcutaneous insulin infusion (CSII) initiated and managed by clinical pharmacists under a collaborative practice agreement in a primary care setting without an endocrinologist.

Research design and methods

This study was a retrospective and cross-sectional analysis of data from an electronic medical record (EMR) and patient survey at a large primary care private practice. Patients with type 1 or type 2 diabetes who were ≥18 years old, started on CSII between 2007 and 2010, and had at least one follow-up visit post-CSII were analyzed. Mean HbA1c results were stratified across 3-month intervals post-CSII initiation and compared to pre-CSII levels. Body mass index (BMI), the number of diabetes-related clinic visits with the primary care physician (PCP), and non-insulin diabetes medication use was compared pre- and post-CSII initiation. Paper-based questionnaires were used to assess patient satisfaction with CSII vs MDI and pharmacist-led services.

Results

Twenty-five patients were included in the analysis. HbA1c decreased from 8.69 to 7.52% pre and post-CSII, respectively (p < 0.001). HbA1c also decreased across all 3-month intervals post-CSII. BMI decreased from 33.0 to 32.3 kg/m² pre- and post-CSII, respectively (p = 0.085). Fewer diabetes-related PCP visits were completed post-CSII (5.09 vs 3.78 visits/year, p = 0.009), and less non-insulin diabetes medications were prescribed post-CSII (p < 0.001). Patients felt more comfortable controlling glycemic excursions and resultant insulin adjustments with CSII compared to MDI (p < 0.001).

Conclusions

Pharmacist-led CSII services appear to improve diabetes control in patients requiring intensive insulin therapy. Patients report greater comfort using CSII and strong confidence in the abilities of the pharmacist. Physician–pharmacist collaboration in the management of intensive insulin therapy in the primary care setting should be further explored.

Adolescent build plotting on body composition chart and the type of diabetes mellitus

Although the prevalence of type 2 diabetes is increasing, there are cases difficult to categorize into certain type in pediatric diabetic patients. The aims of this study were to detect and choose a proper treatment modality for atypical cases of diabetes mellitus, using the body composition chart. We conducted a retrospective study from August 2005 to 2012 with patients who visited Konkuk University Medical Center, and were diagnosed with diabetes mellitus. The medical records were reviewed for the anthropometric data and indices of body composition. The subjects were grouped by the type of diabetes and gender. We constructed a body composition chart plotting fat free mass index and fat mass index (FMI). Body mass index and all body composition indices were higher in type 2 diabetes, in each gender in analysis with Mann-Whitney test. Significant determinant of diabetes type was revealed as FMI and contributing factors on FMI were analyzed with regression analysis. Six atypical cases were identified by a body composition chart including non-obese type 2 diabetes showing suboptimal growth with lower BMI related to relatively lower insulin secretion and type 1 diabetes with insulin resistance resulted from obesity. Body composition chart analysis might be useful in characterization of diabetes type and detection of atypical cases and early adjustment of diabetes management strategy.

Management of diabetes mellitus: is the pump mightier than the pen?

Continuous subcutaneous insulin infusion (CSII, or insulin pump therapy) reduces HbA1c levels and hypoglycaemia in patients with type 1 diabetes mellitus (T1DM) compared with multiple daily insulin injections (MDI). The greatest reduction in HbA(1c) levels with CSII occurs in patients with the worst glycaemic control; therefore, the most appropriate and cost-effective use of CSII in adults with T1DM is in those who have continued, elevated HbA(1c) levels or disabling hypoglycaemic episodes with MDI (including the use of long-acting insulin analogues and structured patient education). The disadvantages of CSII include higher costs than MDI and the risk of ketosis in the event of pump failure. In children with T1DM, CSII may be used when MDI is considered impractical or inappropriate. Pumps are not generally recommended for patients with type 2 diabetes mellitus but may improve control in some subgroups. A new generation of smaller insulin infusion pumps with an integrated cannula, called patch pumps, could improve uptake of CSII in general. The important clinical question is not whether CSII is more efficacious than MDI in general adult T1DM, but whether CSII further improves glycaemic control when this control continues to be poor with MDI, and evidence exists that in most cases it does.

Novel methodology to determine the accuracy of the OmniPod insulin pump: a key component of the artificial pancreas system

BACKGROUND

This article describes two novel and easy approaches for assessing the accuracy of insulin pumps as implemented within the artificial pancreas system. The approaches are illustrated by data testing the OmniPod Insulin Management System at its lowest delivery volume (0.05 U) and at doses of 0.1, 0.2, 1, and 6U.

METHOD

In method 1, a pipette, digital microscope, and imaging software were used to measure average bolus delivery on a linear scale for multiple volumes. In method 2, a digital microscope and imaging software were used to measure the volume of a spherical bolus of 0.05 U of insulin.

RESULTS

Bench testing results using the two novel methods demonstrated that the OmniPod is extremely accurate, with a relative error ranging from -0.90% to +0.96% for all measured doses (0.05, 0.1, 0.2, 1, and 6 U). In method 1, at target bolus dose of 0.05 U, the mean delivered dose (± standard deviation) was 0.0497 ± 0.003 U, 0.099 ± 0.005 U at 0.1 U, 0.2 ± <1e-5 U at 0.2 U, 1.001 ± 0.018 U at 1 U, and 6.03 ± 0.04 U at 6 U. In method 2, at target bolus dose of 0.5 ml, the mean delivered dose for both OmniPods was 0.505 ± 0.014.

CONCLUSIONS

Both methods confirmed a high degree of accuracy for the OmniPod insulin pump. These techniques can be used to estimate delivery volume in other infusion pumps as well.