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Pi L, He B, Fei D, Shi X, Zhou Z. Diabetes knowledge, attitudes and practices among Chinese primary care physicians: a cross-sectional study. BMC PRIMARY CARE 2024; 25:348. [PMID: 39342244 PMCID: PMC11438114 DOI: 10.1186/s12875-024-02600-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 09/16/2024] [Indexed: 10/01/2024]
Abstract
BACKGROUND Type 2 diabetes mellitus (T2DM) is a public health crisis that requires adequate knowledge, attitudes, and practices (KAP) by health care providers to prevent or delay the progression of the disease. This study aimed to assess the KAP regarding T2DM among primary care providers (PCPs) in Central China. METHODS This multicenter cross-sectional study was conducted among 971 PCPs using self-employed KAP questionnaires. Questionnaires were designed to evaluate KAP regarding T2DM among PCPs, and was measured with SPSS software. Descriptive statistics, the Pearson correlation coefficients and multiple regression models used to analyze the data.70%, 80% and 70% of total values were considered as the cut-off point for defining good knowledge, positive attitude and correct practice. RESULTS A total of 971 PCPs with a mean age of 44.0 ± 10.2 years were evaluated. 620 (63.9%) PCPs worked at village clinic and 605 (62.3%) PCPs have been working more than 20 years. Only 26.3% of the respondents participated in Continued Medical Education (CME) programs regarding diabetes in the past year due to Covid-19 pandemic. Overall, despite positive attitudes toward diabetes, there were substantial gaps in knowledge and practices. The PCPs scored 7.25 out of 14 points on the knowledge subscales, 7.13 out of 8 on the attitude subscales, and 4.85 out of 11 on the practice subscales. Gender, age, practice setting, professional titles, duration of practice and CME attendance were significant predictors of knowledge; Age, practice setting and duration of practice were significant predictors of attitudes; and family history of diabetes affected PCP practices. CONCLUSIONS Despite positive attitudes toward diabetes, there were substantial gaps in knowledge and practices. These findings call for action from relevant health authorities and policy makers to improve PCPs' KAP regarding diabetes in Central China.
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Affiliation(s)
- Linhua Pi
- Department of Endocrinology and Metabolism, The Second Affiliated Hospital of Guilin Medical University, Guilin, Guangxi, 541199, P.R. China
- National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology (Central South University), Department of Metabolism and Endocrinology, Ministry of Education, The Second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, China
| | - BinBin He
- National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology (Central South University), Department of Metabolism and Endocrinology, Ministry of Education, The Second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, China
| | - Dongxue Fei
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
- Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Xiajie Shi
- National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology (Central South University), Department of Metabolism and Endocrinology, Ministry of Education, The Second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, China.
| | - Zhiguang Zhou
- National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology (Central South University), Department of Metabolism and Endocrinology, Ministry of Education, The Second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, China
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Ding D, Yong H, You N, Lu W, Yang X, Ye X, Wang Y, Cai T, Zheng X, Chen H, Cui B, Zhang F, Liu X, Mao JH, Lu Y, Chang H. Prospective Study Reveals Host Microbial Determinants of Clinical Response to Fecal Microbiota Transplant Therapy in Type 2 Diabetes Patients. Front Cell Infect Microbiol 2022; 12:820367. [PMID: 35402293 PMCID: PMC8990819 DOI: 10.3389/fcimb.2022.820367] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 02/23/2022] [Indexed: 12/12/2022] Open
Abstract
Background Increasing evidence shows that alterations in gut microbiome (GM) contribute to the development of type 2 diabetes mellitus (T2DM), and fecal microbiota transplantation (FMT) successfully treats various human diseases. However, the benefits of FMT therapy to T2DM patients remain unknown. Methods We enrolled 17 patients with T2DM for nonblinded, one-armed intervention trial of FMT. A total of 20 healthy individuals were recruited as the baseline control. HbA1c% and metabolic parameter change were evaluated in 17 T2DM patients 12 weeks after they received FMT from healthy donors. The GM composition was characterized by 16S rRNA gene amplicon sequencing from fecal samples prior to and 12 weeks after FMT treatment. Results We found that the GM of T2DM patients was reconstituted by FMT. We observed a statistically significant decrease in HbA1c% (from 7.565 ± 0.148 to 7.190 ± 0.210, p<0.01), blood glucose (from 8.483 ± 0.497 to 7.286 ± 0.454 mmol/L, p<0.01), and uric acid (from 309.4 ± 21.5 to 259.1 ± 15.8 µmol/L, p<0.01) while a significant increase in postprandial C-peptide (from 4.503 ± 0.600 to 5.471 ± 0.728 ng/ml, p<0.01) at 12 weeks after FMT. Closely evaluating the changes in these assays, we found individual variability in response to FMT treatment. Out of 17 T2DM patients, 11 were found to significantly improve T2DM symptoms. The FMT responders have significantly higher levels of the family Rikenellaceae and the genus Anaerotruncus (family Ruminococcaceae) in their pretreated fecal in comparison to nonresponders, which could predict the clinical response with an area under the curve of 0.83. Conclusion Our findings suggest that certain T2DM patients can potentially benefit from FMT, and the pretreated abundance of Rikenellaceae and Anaerotruncus in the fecal of patients may serve as potential biomarkers for selecting T2DM patients to receive FMT.
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Affiliation(s)
- Dafa Ding
- Department of Endocrinology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Huijuan Yong
- Department of Endocrinology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Na You
- Department of Endocrinology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wei Lu
- Department of Endocrinology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xu Yang
- Key Laboratory of Modern Toxicology of Ministry of Education, School of Public Health, Nanjing Medical University, Nanjing, China.,Biological Systems and Engineering Division, Lawrence Berkeley National Laboratory, Berkeley, CA, United States.,Biomedical Data Science Center, Lawrence Berkeley National Laboratory, Berkeley, CA, United States
| | - Xiaolong Ye
- Department of Endocrinology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yayun Wang
- Department of Endocrinology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Tingting Cai
- Department of Endocrinology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaoling Zheng
- Department of Endocrinology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hui Chen
- Department of Endocrinology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Bota Cui
- Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Faming Zhang
- Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xingyin Liu
- Department of Pathogen Biology-Microbiology Division, Key Laboratory of Pathogen of Jiangsu Province, Nanjing Medical University, Nanjing, China
| | - Jian-Hua Mao
- Biological Systems and Engineering Division, Lawrence Berkeley National Laboratory, Berkeley, CA, United States.,Biomedical Data Science Center, Lawrence Berkeley National Laboratory, Berkeley, CA, United States
| | - Yibing Lu
- Department of Endocrinology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hang Chang
- Biological Systems and Engineering Division, Lawrence Berkeley National Laboratory, Berkeley, CA, United States.,Biomedical Data Science Center, Lawrence Berkeley National Laboratory, Berkeley, CA, United States
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Forst T, Choudhary P, Schneider D, Linetzky B, Pozzilli P. A practical approach to the clinical challenges in initiation of basal insulin therapy in people with type 2 diabetes. Diabetes Metab Res Rev 2021; 37:e3418. [PMID: 33098260 PMCID: PMC8519070 DOI: 10.1002/dmrr.3418] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 07/17/2020] [Accepted: 08/09/2020] [Indexed: 12/18/2022]
Abstract
Initiating insulin therapy with a basal insulin analogue has become a standard of care in the treatment of type 2 diabetes mellitus (T2DM). Despite increasing choices in pharmacological approaches, intensified glucose monitoring and improvements in quality of care, many patients do not achieve the desired level of glycaemic control. Although insulin therapy, when optimized, can help patients reach their glycaemic goals, there are barriers to treatment initiation on both the side of the patient and provider. Providers experience barriers based on their perceptions of patients' capabilities and concerns. They may lack the confidence to solve the practical problems of insulin therapy and avoid decisions they perceive as risky for their patients. In this study, we review recommendations for basal insulin initiation, focussing on glycaemic targets, titration, monitoring, and combination therapy with non-insulin anti-hyperglycaemic medications. We provide practical advice on how to address some of the key problems encountered in everyday clinical practice and give recommendations where there are gaps in knowledge or guidelines. We also discuss common challenges faced by people with T2DM, such as weight gain and hypoglycaemia, and how providers can address and overcome them.
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Affiliation(s)
- Thomas Forst
- Department of Endocrinology and Metabolic DiseasesUniversitatsmedizin der Johannes GutenbergMainzGermany
- Clinical Research ServicesManhheimGermany
| | - Pratik Choudhary
- Department of Diabetes and Nutritional SciencesKing's CollegeLondonUK
| | | | | | - Paolo Pozzilli
- Department of Endocrinology and Metabolic DiseasesUniversità Campus Bio‐MedicoRomeItaly
- Centre of ImmunobiologyBarts and the London School of MedicineQueen Mary University of LondonUK
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King AB. Mean basal insulin dose is 0.2 U/kg/d at near normal glycaemia for type 1 or 2 diabetes on continuous subcutaneous insulin infusion or once-nightly basal insulin. Diabetes Obes Metab 2021; 23:866-869. [PMID: 33245184 DOI: 10.1111/dom.14265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 11/05/2020] [Accepted: 11/22/2020] [Indexed: 01/21/2023]
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Peters A, Cohen N, Calhoun P, Ruedy KJ, Beck RW, Martens TW, Bao S, Njeru NM, Beck SE, Price DA. Glycaemic profiles of diverse patients with type 2 diabetes using basal insulin: MOBILE study baseline data. Diabetes Obes Metab 2021; 23:631-636. [PMID: 33118309 PMCID: PMC7839741 DOI: 10.1111/dom.14238] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/01/2020] [Accepted: 10/25/2020] [Indexed: 02/07/2023]
Abstract
Basal insulin is often prescribed to patients with suboptimally controlled type 2 diabetes (T2D); however, its therapeutic efficacy is inadequate in many. During the MOBILE study's baseline phase, we evaluated 173 participants' continuous glucose monitoring (CGM) data (mean ± SD age 57 ± 9 years; 50% female; HbA1c 9.1% [range 7.1%-11.6%]; 40% using sulphonylureas; 19% using NPH; reported self-monitored blood glucose [SMBG] frequency median 1.0 checks/day) who were using basal, but not prandial insulin. Blinded CGM data were recorded for 10 days prior to randomization. The mean glucose value was 208 ± 47 mg/dL and it was lowest in the early morning. Mean time in the 70-180 mg/dL range was 9.6 ± 6.1 hours/day (40% ± 25%). Hyperglycaemia was extensive with medians of 14.7 (61%) and 5.0 (20.9%) hours/day with glucose greater than 180 and 250 mg/dL, respectively. Hypoglycaemia was infrequent (median [IQR] 0 [0, 4.3] minutes/day [0.0% {0.0%, 0.3%}] with glucose less than 70 mg/dL). Blinded CGM highlights the limitations of infrequent SMBG in basal insulin users with T2D and allows characterization of hyperglycaemia and hypoglycaemia in basal insulin users with suboptimal control. The MOBILE study randomized phase will define the benefits of using real-time CGM compared with SMBG in this population.
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Affiliation(s)
- Anne Peters
- Keck School of Medicine of the University of Southern CaliforniaLos AngelesCalifornia
| | | | | | | | | | - Thomas W. Martens
- International Diabetes Center, Park Nicollet ClinicBrooklyn CenterMinnesota
| | - Shichun Bao
- Vanderbilt University Medical CenterNashvilleTennessee
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El Fathi A, Fabris C, Breton MD. Titration of Long-Acting Insulin Using Continuous Glucose Monitoring and Smart Insulin Pens in Type 1 Diabetes: A Model-Based Carbohydrate-Free Approach. Front Endocrinol (Lausanne) 2021; 12:795895. [PMID: 35082757 PMCID: PMC8785345 DOI: 10.3389/fendo.2021.795895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 12/06/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Multiple daily injections (MDI) therapy is the most common treatment for type 1 diabetes (T1D), consisting of long-acting insulin to cover fasting conditions and rapid-acting insulin to cover meals. Titration of long-acting insulin is needed to achieve satisfactory glycemia but is challenging due to inter-and intra-individual metabolic variability. In this work, a novel titration algorithm for long-acting insulin leveraging continuous glucose monitoring (CGM) and smart insulin pens (SIP) data is proposed. METHODS The algorithm is based on a glucoregulatory model that describes insulin and meal effects on blood glucose fluctuations. The model is individualized on patient's data and used to extract the theoretical glucose curve in fasting conditions; the individualization step does not require any carbohydrate records. A cost function is employed to search for the optimal long-acting insulin dose to achieve the desired glycemic target in the fasting state. The algorithm was tested in two virtual studies performed within a validated T1D simulation platform, deploying different levels of metabolic variability (nominal and variance). The performance of the method was compared to that achieved with two published titration algorithms based on self-measured blood glucose (SMBG) records. The sensitivity of the algorithm to carbohydrate records was also analyzed. RESULTS The proposed method outperformed SMBG-based methods in terms of reduction of exposure to hypoglycemia, especially during the night period (0 am-6 am). In the variance scenario, during the night, an improvement in the time in the target glycemic range (70-180 mg/dL) from 69.0% to 86.4% and a decrease in the time in hypoglycemia (<70 mg/dL) from 10.7% to 2.6% was observed. Robustness analysis showed that the method performance is non-sensitive to carbohydrate records. CONCLUSION The use of CGM and SIP in people with T1D using MDI therapy has the potential to inform smart insulin titration algorithms that improve glycemic control. Clinical studies in real-world settings are warranted to further test the proposed titration algorithm. SIGNIFICANCE This algorithm is a step towards a decision support system that improves glycemic control and potentially the quality of life, in a population of individuals with T1D who cannot benefit from the artificial pancreas system.
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Ji L, Wan H, Wen B, Wang X, Wang J, Bian R, Pang W, Tian J, Wang Y, Bian F, Gao Z, Condoleon A, Feng W, Zhang X, Cui N. Higher versus standard starting dose of insulin glargine 100 U/mL in overweight or obese Chinese patients with type 2 diabetes: Results of a multicentre, open-label, randomized controlled trial (BEYOND VII). Diabetes Obes Metab 2020; 22:838-846. [PMID: 31944546 PMCID: PMC7187195 DOI: 10.1111/dom.13967] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 01/10/2020] [Accepted: 01/13/2020] [Indexed: 12/29/2022]
Abstract
AIM To determine the safety of a higher starting dose of basal insulin in overweight/obese patients with type 2 diabetes (T2D). MATERIALS AND METHODS This 16-week, randomized, multicentre, open-label trial enrolled adults with T2D (body mass index 25-40 kg/m2 ) and suboptimal glycaemic control (glycated haemoglobin [HbA1c] 7.5-11.0% [58-97 mmol/mol] and fasting plasma glucose [FPG] >9.0 mmol/L) with two to three oral anti-hyperglycaemic drugs at 51 centres in China. Patients were randomized (1:1) to a higher (0.3 U/kg) or standard (0.2 U/kg) starting dose of insulin glargine 100 U/mL, which was then titrated to achieve a self-monitored fasting blood glucose (FBG) of 4.4 to 5.6 mmol/L. The primary endpoint was the percentage of patients with ≥1 episode of overall confirmed hypoglycaemia (≤3.9 mmol/L or severe). RESULTS At the end of study (n = 866), 11.0% patients treated with the 0.3 U/kg starting insulin dose experienced overall confirmed hypoglycaemia versus 8.6% of patients treated with 0.2 U/kg (estimated difference 2.1%, 95% confidence interval - 1.68, 5.89). The proportions of patients with symptomatic (9.8% vs 7.0%; P = 0.128) and nocturnal hypoglycaemia (2.7% vs 1.2%; P = 0.102) were similar in the two groups. There were no events of severe hypoglycaemia or FBG <3.0 mmol/L during the 16-week treatment, and achievement of HbA1c <7.0% (53 mmol/mol) (37.1% vs 37.1%) or FPG <5.6 mmol/L (15.9% vs 16.3%), <6.1 mmol/L (27.6% vs 26.1%), or < 7.0 mmol/L (48.8% vs 48.3%) without hypoglycaemia were comparable in the two groups. Moreover, the mean time was shorter (4.53, 3.95 and 2.74 weeks vs 5.51, 5.21 and 3.64 weeks) and number of titrations was lower (3.5, 3.0 and 2.0 vs 4.3, 4.0 and 2.8) to achieve self-monitored FBG targets of <5.6, <6.1 and <7.0 mmol/L in the higher versus the standard insulin dose group (all P < 0.01). CONCLUSIONS Among overweight/obese patients with T2D, a higher insulin starting dose was as safe as the standard starting dose, and self-monitored FBG targets were achieved earlier with the higher versus the standard dose.
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Affiliation(s)
- Linong Ji
- Department of Endocrinology and MetabolismPeking University People's HospitalBeijingChina
| | - Hailong Wan
- Department of Endocrinology, Panjin Central HospitalPanjinChina
| | - Binhong Wen
- Department of Endocrinology, People's Hospital of Liaoning ProvinceLiaoningChina
| | - Xueying Wang
- Department of Endocrinology, Jinzhou Central HospitalJinzhouChina
| | - Junfen Wang
- Department of Endocrinology, Second Hospital of ShijiazhuangShijiazhuangChina
| | - Rongwen Bian
- Department of Endocrinology and MetabolismJiangsu Province Institute of GeriatricsNanjingJiangsuChina
| | - Wuyan Pang
- Department of Endocrinology and MetabolismHuaihe Hospital of Henan UniversityKaifengHenanChina
| | - Jian Tian
- Department of Endocrinology and MetabolismCentral Hospital Affiliated to Shenyang Medical CollegeShenyangChina
| | - Yan Wang
- Department of Endocrinology, Second Hospital of Chaoyang CityChaoyang CityChina
| | - Fang Bian
- Department of Endocrinology, Cangzhou People's HospitalCangzhouChina
| | - Zhengnan Gao
- Department of Endocrinology and MetabolismDalian Municipal Central Hospital Affiliated of Dalian Medical UniversityDalianLiaoningChina
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Pscherer S, Anderten H, Pfohl M, Fritsche A, Borck A, Pegelow K, Bramlage P, Seufert J. Titration of insulin glargine 100 U/mL when added to oral antidiabetic drugs in patients with type 2 diabetes: results of the TOP-1 real-world study. Acta Diabetol 2020; 57:89-99. [PMID: 31342163 DOI: 10.1007/s00592-019-01383-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 06/21/2019] [Indexed: 10/26/2022]
Abstract
AIMS Adequate insulin titration is crucial for optimal glycaemic control in type 2 diabetes (T2D). We aimed to explore the factors and outcomes associated with titration of glargine 100 U/mL (Gla-100) in patients uncontrolled on oral antidiabetic drugs (OAD) and initiating insulin therapy. METHODS Patients from the Titration and Optimization (TOP)-1 registry were stratified by the magnitude of Gla-100 up-titration during the first month (no [< 1 Units (U)/day (d)], minimal [≥ 1 and < 5 U/d], moderate [≥ 5 and ≤ 8 U/d] and strong [> 8 U/d]). The primary endpoint was a fasting blood glucose (FBG) ≤ 110 mg/dL on ≥ 2 occasions and/or individual HbA1c target by 12 months. RESULTS Of 2308 patients, 905, 715, 409 and 279 underwent no, minimal, moderate and strong titration, respectively. Age decreased across increasing titration groups (p = 0.02) while body mass index (BMI) (p < 0.0001), FBG (p < 0.0001), and HbA1c (p < 0.0001) increased. At 12 months, the proportions of patients achieving the primary endpoint were comparable across groups (66.1% overall), though a smaller proportion of no titration patients met both their individual HbA1c target and FBG ≤ 110 mg/dL compared to moderate and strong titration patients (20.1% vs. 27.2% and 26.2%, p = 0.033 and 0.023, respectively). HbA1c was also comparable, though FBG was higher in the no titration group (126.2 vs. 122.6, 121.5 and 120.9 mg/dL, p < 0.02). A similar, small reduction in body weight occurred in all groups; hypoglycaemia rates were comparable across groups. CONCLUSIONS In real-world, titration of Gla-100 during the first month appears to coincide with a number of baseline factors. Insulin dose to meet HbA1c and FBG targets remains suboptimal in the majority of T2D patients.
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Affiliation(s)
- Stefan Pscherer
- Klinik für Innere Medizin III, Sophien-und Hufeland-Klinikum, Henry-van-de-Velde-Straße 2, Weimar, Germany.
| | - Helmut Anderten
- Gemeinschaftspraxis Anderten-Krok & Partner, Hildesheim, Germany
| | - Martin Pfohl
- Medizinische Klinik I, Evang. Bethesda-Krankenhaus, Duisburg, Germany
| | - Andreas Fritsche
- Klinik für Innere Medizin IV, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Anja Borck
- Sanofi-Aventis Deutschland GmbH, Berlin, Germany
| | | | - Peter Bramlage
- Institut für Pharmakologie und Präventive Medizin, Mahlow, Germany
| | - Jochen Seufert
- Klinik für Innere Medizin II, Universitätsklinikum Freiburg, Freiburg, Germany
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Frier BM, Ratzki‐Leewing A, Harris SB. Reporting of hypoglycaemia in clinical trials of basal insulins: A need for consensus. Diabetes Obes Metab 2019; 21:1529-1542. [PMID: 30924567 PMCID: PMC6767397 DOI: 10.1111/dom.13732] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 03/13/2019] [Accepted: 03/26/2019] [Indexed: 12/31/2022]
Abstract
Hypoglycaemia is a common side-effect of diabetes therapies, particularly insulin, and imposes a substantial burden on individuals and healthcare systems. Consequently, regulatory approval of newer basal insulin (BI) therapies has relied on demonstration of a balance between achievement of good glycaemic control and less hypoglycaemia. Randomized controlled trials (RCTs) are the gold standard for assessing efficacy and safety, including hypoglycaemia risk, of BIs and are invaluable for obtaining regulatory approval. However, their highly selected patient populations and their conditions lead to results that may not be representative of real-life situations. Real-world evidence (RWE) studies are more representative of clinical practice, but they also have limitations. As such, data both from RCTs and RWE studies provide a fuller picture of the hypoglycaemia risk with BI therapies. However, substantial differences exist in the way hypoglycaemia is reported across these studies, which confounds comparisons of hypoglycaemia frequency among different BIs. This problem is ongoing and persists in recent trials of second-generation BI analogues. Although they provide a lower risk of hypoglycaemia when compared with earlier BIs, they do not eliminate it. This review describes differences in the way hypoglycaemia is reported across RCTs and RWE studies of second-generation BI analogues and examines potential reasons for these differences. For studies of BIs, there is a need to standardize aspects of design, analysis and methods of reporting to better enable interpretation of the efficacy and safety of such insulins among studies; such aspects include length of follow-up, glycaemic targets, hypoglycaemia definitions and time intervals for determining nocturnal events.
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Affiliation(s)
- Brian M. Frier
- British Heart Foundation Centre for Cardiovascular ScienceThe Queen's Medical Research Institute, University of EdinburghEdinburghUK
| | - Alexandria Ratzki‐Leewing
- Department of Epidemiology and BiostatisticsSchulich School of Medicine and Dentistry, Western UniversityLondonOntario, Canada
| | - Stewart B. Harris
- Department of Family MedicineSchulich School of Medicine and Dentistry, Western UniversityLondonOntario, Canada
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Umpierrez GE, Skolnik N, Dex T, Traylor L, Chao J, Shaefer C. When basal insulin is not enough: A dose-response relationship between insulin glargine 100 units/mL and glycaemic control. Diabetes Obes Metab 2019; 21:1305-1310. [PMID: 30724009 PMCID: PMC6594069 DOI: 10.1111/dom.13653] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 01/31/2019] [Accepted: 02/04/2019] [Indexed: 12/20/2022]
Abstract
AIMS A post-hoc analysis to assess the impact in people with type 2 diabetes, of increasing doses of basal insulin on glycaemic measures, body weight and hypoglycaemia. RESEARCH DESIGN AND METHODS We included data from prospective, randomized controlled treat-to-target trials of ≥24 weeks' duration in people with type 2 diabetes, uncontrolled on metformin and sulphonylureas, and treated with insulin glargine 100 units/mL (U100), who had at least six fasting plasma glucose (FPG) measurements. The impact of insulin dose on glycated haemoglobin (HbA1c) values, FPG, hypoglycaemia incidence (<3.9 mmol/L [70 mg/dL]), and body weight was analysed. A total of 458 participants from three eligible trials were included. RESULTS The observed relationship between higher basal insulin doses and glycaemic control was non-linear, with increasing insulin dose leading to smaller reductions in FPG and HbA1c for doses >0.3 IU/kg/d, with a plateauing effect at 0.5 IU/kg/d. Total daily dose of insulin >0.5 IU/kg/d resulted in greater weight gain, but without higher rates of hypoglycaemia, compared with insulin doses ≤0.5 IU/kg/d. CONCLUSIONS This analysis indicates that basal insulin doses >0.5 IU/kg/d have diminishing additional impact on improving glycaemic measures, with the disadvantage of additional weight gain. Clinicians should consider anti-hyperglycaemic treatment intensification at doses approaching 0.5 IU/kg/d.
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Affiliation(s)
| | - Neil Skolnik
- Abington Family MedicineJefferson Health, JenkintownPennsylvania
| | - Terry Dex
- Sanofi US, Inc.BridgewaterNew Jersey
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Brož J, Janíčková Ždárská D, Štěpánová R, Kvapil M. Addition of Basal Insulin to Oral Antidiabetic Agents in Patients with Inadequately Controlled Type 2 Diabetes Leads to Improved HbA1c Levels: Metabolic Control, Frequency of Hypoglycemia, and Insulin Titration Analysis as Results of a Prospective Observational Study (BALI Study). Diabetes Ther 2019; 10:663-672. [PMID: 30788806 PMCID: PMC6437250 DOI: 10.1007/s13300-019-0584-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Despite the continuously growing number of therapeutic options for patients with type 2 diabetes mellitus (T2DM), a large percentage of these individuals fail to achieve their glycated hemoglobin (HbA1c) target. The aim of this study was to determine the change in metabolic control in insulin-naïve T2DM patients inadequately controlled with oral antidiabetic drugs (OADs) at 6 months after initiating basal insulin treatment as add-on to existing OADs. METHODS This was a non-interventional prospective study conducted from June 2013 to December 2014 in 137 centers in the Czech Republic under routine clinical practice conditions. Adult patients whose diabetes was uncontrolled on their current OAD treatment (HbA1c ≥ 53 mmol/mol; Diabetes Control and Complications Trial [DCCT]-HbA1c 7%) and whose physician had decided to initiate treatment on a basal insulin regimen were documented over a 6-month period beginning from the time of initiation of basal insulin treatment. RESULTS Overall, 1426 T2DM patients were included in the study, of whom 53% were male. The mean age of the study population was 63.8 ± 10.1 years, mean body mass index was 31.5 ± 5.3 kg/m2, and mean duration of diabetes was 10.2 ± 5.3 years. At the 6-month follow-up, the target HbA1c level of 53 mmol/mol (DCCT < 7%) was achieved by 18% of patients. The mean HbA1c overall had decreased from 77.2 ± 15.1 mmol/mol (DCCT 9.21 ± 1.38%) at baseline to 63.2 ± 12.5 mmol/mol (DCCT 7.93 ± 1.14 %) at the 6-month follow-up. This difference was significant at p < 0.001. The largest mean reduction in HbA1c, i.e., 20.9 mmol/mol (DCCT 2.4 %) was observed in the group of patients with a baseline HbA1c of ≥ 9%. The mean daily basal insulin dose at 6 months was 18.8 ± 8.9 units. Symptomatic hypoglycemia was reported in 12.3% of patients, of those only one patient (0.1%) suffered from severe hypoglycemia. CONCLUSION The addition of basal insulin to the therapeutic regimen of insulin-naïve T2DM on OAD treatment resulted in an improved metabolic control of diabetes after 6 months of treatment. However, most patients did not achieve their HbA1c target, probably also due to inadequate titration of basal insulin. FUNDING Sanofi, Czech Republic.
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Affiliation(s)
- Jan Brož
- Department of Internal Medicine, Second Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Denisa Janíčková Ždárská
- Department of Internal Medicine, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | | | - Milan Kvapil
- Department of Internal Medicine, Second Faculty of Medicine, Charles University, Prague, Czech Republic
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Lakhani OJ, Kumar S, Tripathi S, Desai MA, Seth C. Correlation between Basal Insulin Glargine Dose Required in Achieving Target Fasting Blood Glucose and Various Clinical and Laboratory Parameters in Hospitalized Noncritical Patients. Indian J Endocrinol Metab 2018; 22:469-472. [PMID: 30148091 PMCID: PMC6085955 DOI: 10.4103/ijem.ijem_297_17] [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] [Indexed: 12/04/2022] Open
Abstract
AIMS The primary objective was to study the interrelationship between the basal insulin glargine dose and baseline clinical and laboratory parameters in noncritically ill hospitalized patients who have achieved the stable fasting blood glucose in the target range of 100-140 mg/dl. PATIENTS AND METHODS This was retrospective, cross-sectional, observational study. Consenting, nonpregnant, adult patients on basal-bolus insulin who had fasting capillary blood glucose in the range of 100-140 mg/dl as measured by glucometer for 3 consecutive days were included in this study. Patient receiving any basal insulin other than insulin glargine were excluded from this study. The data collected for these patients included age, sex, glycated hemoglobin (HBA1c) at the time of admission, timing of basal insulin, basal insulin dose (BID), BID/kg, weight, and serum creatinine. BID/kg was correlated with other parameters using regression analysis (Pearson's). Comparison of BID/kg in various subgroups was analyzed using Student's t- test. Parametric data of more than three groups were compared using ANOVA. The P < 0.05 was considered as statistically significant. RESULTS A total of 180 patients were included in the study. On correlating the BID/kg with various parameters, we found statistically significant correlation between BID/kg and glycated hemoglobin (HbA1c) at the time of admission (P = 0.044). Patients with HbA1c ≥8.0% had higher BID/kg compared to those with HbA1c <8.0% (P = 0.004). The mean BID in patients with renal failure was significantly higher compared to those without renal failure. CONCLUSION HbA1c at the time of admission is the most important parameter for determining the appropriate BID in hospitalized patients. Patients with renal failure may require a higher dose of basal insulin than those not having renal failure.
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Affiliation(s)
- Om J. Lakhani
- Department of Endocrinology and Metabolism, Sir Ganga Ram Hospital, New Delhi, India
| | - Surender Kumar
- Department of Endocrinology and Metabolism, Sir Ganga Ram Hospital, New Delhi, India
| | - Sudhir Tripathi
- Department of Endocrinology and Metabolism, Sir Ganga Ram Hospital, New Delhi, India
| | - Mitali A. Desai
- Department of Endocrinology and Metabolism, Sir Ganga Ram Hospital, New Delhi, India
| | - Chandani Seth
- Department of Endocrinology and Metabolism, Sir Ganga Ram Hospital, New Delhi, India
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Hodish I. Insulin therapy for type 2 diabetes - are we there yet? The d-Nav® story. Clin Diabetes Endocrinol 2018; 4:8. [PMID: 29682315 PMCID: PMC5894229 DOI: 10.1186/s40842-018-0056-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 02/20/2018] [Indexed: 12/26/2022] Open
Abstract
Insulin replacement therapy is mostly used by patients with type 2 diabetes who become insulin deficient and have failed other therapeutic options. They comprise about a quarter of those with diabetes, endures the majority of the complications and consumes the majority of the resources. Adequate insulin replacement therapy can prevent complications and reduce expenses, as long as therapy goals are achieved and maintained. Sadly, these therapy goals are seldom achieved and outcomes have not improved for decades despite advances in pharmacotherapy and technology. There is a growing recognition that the low success rate of insulin therapy results from intra-individual and inter-individual variations in insulin requirements. Total insulin requirements per day vary considerably between patients and constantly change without achieving a steady state. Thus, the key element in effective insulin therapy is unremitting and frequent dosage adjustments that can overcome those dynamics. In practice, insulin adjustments are done sporadically during outpatient clinic. Due to time constraints, providers are not able to deliver appropriate insulin dosage optimization. The d-Nav® Insulin Guidance Service has been developed to provide appropriate insulinization in insulin users without increasing the burden on healthcare systems. It relies on dedicated clinicians and a spectrum of technological solutions. Patients are provided with a handheld device called d-Nav® which advises them what dose of insulin to administer during each injection and automatically adjust insulin dosage when needed. The d-Nav care specialists periodically follow-up with users through telephone calls and in-person consultations to bestow user confidence, correct usage errors, triage, and identify uncharacteristic clinical courses. The following review provide details about the service and its clinical outcomes.
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Affiliation(s)
- I Hodish
- 1Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical Center, 1000 Wall St, Ann Arbor, MI 48105 USA.,Hygieia, Inc, Livonia, MI USA
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14
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Berard L, Bonnemaire M, Mical M, Edelman S. Insights into optimal basal insulin titration in type 2 diabetes: Results of a quantitative survey. Diabetes Obes Metab 2018; 20:301-308. [PMID: 28719066 PMCID: PMC5811840 DOI: 10.1111/dom.13064] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 07/04/2017] [Accepted: 07/10/2017] [Indexed: 01/15/2023]
Abstract
AIMS Basal insulin (BI) treatment initiation and dose titration in type 2 diabetes (T2DM) are often delayed. Such "clinical inertia" results in poor glycaemic control and high risk of long-term complications. This survey aimed to determine healthcare professional (HCP) and patient attitudes to BI initiation and titration. METHODS An online survey (July-August 2015) including HCPs and patients with T2DM in the USA, France and Germany. Patients were ≥18 years old and had been on BI for 6 to 36 months, or discontinued BI within the previous 12 months. RESULTS Participants comprised 386 HCPs and 318 people with T2DM. While >75% of HCPs reported discussing titration at the initiation visit, only 16% to 28% of patients remembered such discussions, many (32%-42%) were unaware of the need to titrate BI, and only 28% to 39% recalled mention of the time needed to reach glycaemic goals. Most HCPs and patients agreed that more effective support tools to assist BI initiation/titration are needed; patients indicated that provision of such tools would increase confidence in self-titration. HCPs identified fear of hypoglycaemia, failure to titrate in the absence of symptoms, and low patient motivation as important titration barriers. In contrast, patients identified weight gain, the perception that titration meant worsening disease, frustration over the time to reach HbA1c goals and fear of hypoglycaemia as major factors. CONCLUSION A disconnect exists between HCP- and patient-perceived barriers to effective BI titration. To optimize titration, strategies should be targeted to improve HCP-patient communication, and provide support and educational tools.
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Affiliation(s)
- Lori Berard
- Winnipeg Regional Health Authority Health Sciences CentreWinnipegManitobaCanada
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15
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Zhang T, Zhao Y, Du T, Zhang X, Li X, Liu R, Wang Y, Chen B, He L, Li W. Lack of coordination between partners: investigation of Physician-Preferred and Patient-Preferred (4P) basal insulin titration algorithms in the real world. Patient Prefer Adherence 2018; 12:1253-1259. [PMID: 30050287 PMCID: PMC6055906 DOI: 10.2147/ppa.s169000] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Patient-centered care is respectful to a patient's preference. All prior clinical trials on patient self-titration algorithms for basal insulin were decided by physicians. We hypothesized that patients and physicians have different preferences. PATIENTS AND METHODS Physicians and diabetes patients were asked to choose their preferred insulin glargine self-titration algorithm among 5 algorithms. Algorithm 1, 1 U increase once daily; algorithm 2, 2 U increase every 3 days; algorithm 3, 3 U increase every 3 days; algorithm 4, titration every 3 days according to fasting blood glucose, and algorithm 5, weekly titration 2-8 U based on 3-day mean fasting blood glucose levels. RESULTS Eleven (5.2%) out of 210 physicians and 180 (90.9%) out of 198 patients preferred algorithm 1 (χ2=300.4, p=0.000). In contrast, 195 (92.9%) physicians and 18 (9.1%) patients preferred algorithm 2 (χ2=286.6, p=0.000). In addition, 4 (1.9%) physicians but no patients preferred algorithm 3 (χ2=2.099, p=0.124). Neither physicians nor patients chose algorithms 4 or 5. Most physicians preferred algorithm 2 since it is recommended by guidelines, but most patients preferred algorithm 1 for its simplicity. CONCLUSION Patients had different preferences compared with physicians. Attention should be given to patients' preferences to increase adherence and improve glycemic control.
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Affiliation(s)
- Tong Zhang
- Department of Endocrinology, The Third Affiliated Hospital, Southern Medical University, Guangzhou 510630, People's Republic of China
| | - Yunjuan Zhao
- Department of Endocrinology, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou 510260, People's Republic of China,
| | - Tao Du
- Department of Endocrinology, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou 510260, People's Republic of China,
| | - Xiaodan Zhang
- Department of Endocrinology, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou 510260, People's Republic of China,
| | - Xiaowei Li
- Department of Endocrinology, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou 510260, People's Republic of China,
| | - Ruike Liu
- Department of Endocrinology, The Third People's Hospital of Dongguan, Dongguan 523326, People's Republic of China
| | - Yunlin Wang
- Department of Endocrinology, Foshan Hospital, Southern Medical University, Foshan 528000, People's Republic of China
| | - Bo Chen
- Department of Endocrinology, Guangdong Second Provincial General Hospital, Guangzhou 510317, People's Republic of China
| | - Ling He
- Department of Endocrinology, Guangzhou First People's Hospital, Guangzhou 510180, People's Republic of China
| | - Wangen Li
- Department of Endocrinology, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou 510260, People's Republic of China,
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Herrera-Gómez F, Asensio-González M, González-López A, Álvarez FJ. Effects of Intensive Control of Glycemia on Clinical Kidney Outcomes in Type 2 Diabetes Patients Compared with Standard Control: A Meta-Analysis. Front Pharmacol 2017; 8:845. [PMID: 29209216 PMCID: PMC5702491 DOI: 10.3389/fphar.2017.00845] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 11/06/2017] [Indexed: 12/15/2022] Open
Abstract
Background: Association between poor control of glycemia and the onset of microvascular complications in type 2 diabetes mellitus (T2DM) patients is a hard issue. However, it seems that the impact of pharmacological treatment is important only in early stages of diabetic nephropathy. We sought to examine whether intensive glycemic control is associated with improvement of clinical Chronic Kidney Disease (CKD) outcomes compared to standard glycemic control. Methods: Meta-analysis of published and unpublished randomized controlled trials (RCT) and post-hoc analysis of RCTs comparing anti-diabetic drugs and/or insulin (intensive control) vs. dietary measures (standard control) for relevant outcomes related to progression of CKD clinically manifest was undertaken. Summary estimates obtained by random effects model and funnel plots for assessing reporting bias are presented. Results: Our analysis was based on four RCTs representing 27,391 adult T2DM patients with CKD from around the world. The pooled OR for the outcomes of doubling of serum creatinine and need of dialysis were, respectively, of 0.98 with 95% confidence interval (95% CI) 0.81-1.19, and 0.84 with 95% CI 0.69-1.02. The pooled OR for the outcome of death from kidney failure was 0.62 with 95% CI 0.39-0.98. Clinical differences between studies were not translated in statistical heterogeneity. Reporting bias may be present. Conclusions: Intensive glycemic control has an effect on death from kidney failure compared to standard glycemic control. Better comprehension of glycemic control effects on both T2DM patients with and without CKD is important for individualization of these two treatment modalities.
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Affiliation(s)
- Francisco Herrera-Gómez
- Pharmacology and Therapeutics, Faculty of Medicine, University of Valladolid, Valladolid, Spain
- Nephrology, Complejo Asistencial de Zamora, Zamora, Spain
| | - María Asensio-González
- Pharmacology and Therapeutics, Faculty of Medicine, University of Valladolid, Valladolid, Spain
| | | | - F. Javier Álvarez
- Pharmacology and Therapeutics, Faculty of Medicine, University of Valladolid, Valladolid, Spain
- CEIC/CEIm Área de Salud Valladolid Este, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
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McBain H, Begum S, Rahman S, Mulligan K. Barriers to and enablers of insulin self-titration in adults with Type 2 diabetes: a qualitative study. Diabet Med 2017; 34:253-261. [PMID: 27505306 DOI: 10.1111/dme.13196] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/08/2016] [Indexed: 12/20/2022]
Abstract
AIMS To identify the barriers to and enablers of effective insulin self-titration in people with Type 2 diabetes. METHODS A qualitative semi-structured interview approach was used. Questions were structured according to the Theoretical Domains Framework, which outlines 14 domains that can act as barriers to and enablers of changing behaviour. Interviews were audio-recorded and transcribed verbatim. The data were coded according to the 14 domains, belief statements were created within each domain, and a frequency count of the most reported barriers and enablers was then carried out. Analyses were conducted by two researchers, and discrepancies agreed with a third researcher. RESULTS A total of 18 adults with Type 2 diabetes took part in an interview. The majority were of South-Asian ethnicity (n = 8) and were men (n = 12). Their mean age was 61 years old. The mean duration of diabetes was 16 years and time on insulin 9 years. Inter-rater reliability for each of the domains varied (29-100%). The most frequently reported domains were Social Influence and Beliefs about Consequences; the least frequently reported were Optimism and Reinforcement. Interviewees reported receiving support to self-titrate from a range of sources. Self-titrating was perceived to have a range of both positive and negative consequences, as was not titrating. CONCLUSIONS The findings highlight that those interviewed experienced a range of barriers and enablers when attempting to self-titrate. Improved education and training when initiating insulin treatment among adults with Type 2 diabetes, and throughout their journey on insulin therapy could help identify and address these barriers in order to optimize self-titration.
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Affiliation(s)
- H McBain
- School of Health Sciences, City University London, London, UK
- East London Foundation NHS Foundation Trust, London, UK
| | - S Begum
- School of Social Sciences, City University, London, UK
| | - S Rahman
- East London Foundation NHS Foundation Trust, London, UK
| | - K Mulligan
- School of Health Sciences, City University London, London, UK
- East London Foundation NHS Foundation Trust, London, UK
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18
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Bajaj HS, Venn K, Ye C, Aronson R. Randomized Trial of Long-Acting Insulin Glargine Titration Web Tool (LTHome) Versus Enhanced Usual Therapy of Glargine Titration (INNOVATE Trial). Diabetes Technol Ther 2016; 18:610-615. [PMID: 27652718 DOI: 10.1089/dia.2016.0182] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Basal insulin titration in the real world is often unsuccessful. LTHome, a web tool, applies a rules engine-based algorithm providing insulin titration advice directly to the patient. METHODS This pilot, randomized trial evaluates basal insulin glargine titration by LTHome compared to enhanced usual therapy ([EUT]-diabetes education program) over 12 weeks. Important inclusion criteria: 18-75 years, type 2 diabetes, computer literacy, and HbA1c >7.0%. Trial protocol was approved by ethics board. RESULTS We randomized 139 subjects. The achievement of primary composite outcome (four out of seven fasting plasma glucose [FPG] within 5-7.2 mmol/L + mean for three consecutive FPG within 5-7.2 mmol/L + no severe hypoglycemia) was 15% in LTHome versus 41% in EUT (noninferiority not met, P-value = 0.92). Other outcomes were similar between the LTHome and EUT arms: alternate composite outcome achievement (last five FPG mean within the range of 5-7.2 mmol/L + no hypoglycemia, 47% and 51%, P = 0.73); A1c reduction (-1.0% and -1.1%, P = 0.66); proportion achieving A1c ≤7% (14% and 20%, P = 0.36); and hypoglycemia incidence (31% and 37%, P = 0.4), respectively. Patient satisfaction score improvements were greater in LTHome versus EUT (change in fear of hypoglycemia score P = 0.04 and change in diabetes distress score P = 0.04). The mean number of additional healthcare provider visits was 0.13 for LTHome and 1.22 for EUT (P < 0.01). CONCLUSION INNOVATE trial suggests clinical utility of LTHome compared to EUT in real-life settings. Further research is needed to evaluate the efficacy and safety of automated insulin titration algorithms.
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Affiliation(s)
- Harpreet S Bajaj
- 1 LMC Diabetes & Endocrinology , Toronto, Canada
- 2 Leadership Sinai Centre for Diabetes, Mount Sinai Hospital , Toronto, Canada
| | - Karri Venn
- 1 LMC Diabetes & Endocrinology , Toronto, Canada
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19
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Harper R, Donnelly R, Bi Y, Bashan E, Minhas R, Hodish I. Dynamics in insulin requirements and treatment safety. J Diabetes Complications 2016; 30:1333-8. [PMID: 27288203 DOI: 10.1016/j.jdiacomp.2016.05.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 05/17/2016] [Accepted: 05/17/2016] [Indexed: 11/22/2022]
Abstract
AIMS The majority of insulin users have elevated HbA1c. There is growing recognition that the low success rates are due to variations in insulin requirements. Thus, frequent dosage adjustments are needed. In practice, adjustments occur sporadically due to limited provider availability. We investigated intra-individual dynamics of insulin requirements using data from a service evaluation of the d-Nav® Insulin Guidance Service. This service facilitates automated insulin dosage adjustments, as often as needed, to achieve and maintain optimal glycemic balance. METHODS Data were collected from subjects who have been using the service for more than a year. Events of considerable and persistent decrease in insulin requirements were identified by drops in total daily insulin ≥25%. RESULTS Overall, 62 patients were studied over an average period of 2.1±0.5 (mean±standard deviation) years. Stability in HbA1c was attained after ~3 quarters at 7.4%±0.2% (57.4mmol/mol±1mmol/mol). Events were identified in 56.5% of the patients. On average, each affected patient had 0.8±0.4 events per year, lasting 9.7±6.6weeks, while total daily insulin dosage decreased by 41.4±13.4%. CONCLUSIONS Our findings may call attention to a major contributing factor to hypoglycemia among insulin users. In reality, insulin dosage is seldom adjusted and thus transient periods of decrease in insulin requirements and overtreatment are usually overlooked.
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Affiliation(s)
- R Harper
- Diabetes Center, Ulster Hospital, South East and Social Care Trust, Belfast, Northern Ireland
| | - R Donnelly
- Diabetes Center, Ulster Hospital, South East and Social Care Trust, Belfast, Northern Ireland
| | - Yixi Bi
- Queen's University, Belfast, Northern Ireland
| | - E Bashan
- Hygieia, Inc., Ann Arbor, Michigan
| | - R Minhas
- Hygieia, Inc., Ann Arbor, Michigan
| | - I Hodish
- Hygieia, Inc., Ann Arbor, Michigan; Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical Center, Ann Arbor, Michigan.
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20
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King AB, Clark D. Omitting late-night eating may cause hypoglycemia in "well controlled" basal insulin-treated type 2 diabetes. Endocr Pract 2016; 21:280-5. [PMID: 25370327 DOI: 10.4158/ep14334.or] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To assess hypoglycemia caused by eating the last meal of the day earlier or its omission in "well controlled" type 2 diabetes mellitus patients treated with once-nightly basal insulin. METHODS Previously basal insulin-titrated subjects (n = 20) (fasting plasma glucose, FPG, <110 mg/dL and no self-reported hypoglycemia) underwent continuous glucose monitoring (CGM) during 3 consecutive eating conditions of 3 days each; (1) usual eating, (2) the last meal restricted to 18:00, and (3) 1 sequential meal omitted/day thereby creating a fasting day after transposing the 4-hour period after a meal with that when the meal was omitted. One 24-hour (00:00 to 00:00) period within each eating condition was selected for comparison. RESULTS The mean duration in all hypoglycemic ranges doubled (P = .0584 or greater) when the last meal was omitted or eaten at 18:09 ± 0:39 instead of 19:43 ± 1:01, the usual time for the subjects' undisturbed eating. The mean duration of hypoglycemia was greatest between 00:00 to 06:00 compared to the 3 other 6-hour periods of the day. CONCLUSIONS Increased hypoglycemia occurs when the subject's last meal is eaten earlier or omitted and may not be recognized because it occurs predominately during sleep. When titrating basal insulin from the morning FPG, considerations should be given to the effect of the last meal of the day and possible hypoglycemia between 00:00 and 06:00 to avoid excessive basal insulin treatment.
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Affiliation(s)
| | - Dawn Clark
- Diabetes Care Center, Salinas, California
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21
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Zisman A, Morales F, Stewart J, Stuhr A, Vlajnic A, Zhou R. BeAM value: an indicator of the need to initiate and intensify prandial therapy in patients with type 2 diabetes mellitus receiving basal insulin. BMJ Open Diabetes Res Care 2016; 4:e000171. [PMID: 27110368 PMCID: PMC4838666 DOI: 10.1136/bmjdrc-2015-000171] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 03/03/2016] [Accepted: 03/04/2016] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION In patients with type 2 diabetes mellitus (T2DM) with uncontrolled glycemia despite ongoing upward titration of basal insulin, targeting postprandial hyperglycemia may be required. Nevertheless, the point at which basal insulin is fully optimized and postprandial glucose (PPG) should be targeted with additional treatment remains unclear. We report here on the BeAM value (difference between bedtime and morning blood glucose values) as an indicator of the need to target PPG. METHODS This study had 3 stages: exploratory, main, and proof-of-concept analyses. For the exploratory and main analyses, data were pooled from phase 3 trials in adults with T2DM adding basal insulin to oral antidiabetic drugs (OADs). The main analysis included only patients who did not reach A1C ≤7.0% (53 mmol/mol) at week 24. The proof-of-concept analysis used pooled data from phase 3 trials in adults with T2DM adding insulin glargine and a single insulin glulisine injection to OADs. RESULTS In patients undergoing basal insulin titration, BeAM value increased over 24 weeks (27.8-61.7 mg/dL, n=1188; 32.6-71.2 mg/dL, n=553; exploratory and main analyses, respectively). There were significant correlations between week 24 BeAM value and postprandial contribution to hyperglycemia (Pearson's correlation coefficient (r)=0.375, p<0.001; r=0.396, p<0.001; exploratory and main analyses, respectively). When PPG was targeted (proof-of-concept analysis), the BeAM value reduced from 77.0 to 40.4 mg/dL (n=299). CONCLUSIONS The BeAM value described in this study is a simple, easy-to-calculate value that may identify patients with T2DM using basal insulin that need targeting of postprandial control rather than advancing basal insulin dose.
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Affiliation(s)
- Ariel Zisman
- The Endocrine Center of Aventura, Aventura, Florida, USA
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22
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Shaefer CF, Anderson J. The importance of postprandial glycemic control: optimizing add-on therapy to basal insulin. Postgrad Med 2015; 128:137-44. [DOI: 10.1080/00325481.2016.1103640] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Bashan E, Harper R, Bi Y, Hodish I. A novel approach to optimise glycaemic control in insulin users. BMJ Case Rep 2015; 2015:bcr-2015-209356. [PMID: 26231186 DOI: 10.1136/bcr-2015-209356] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Insulin therapy has been available for almost a century. However, its success rate is still disappointing where the majority of users sustain harmfully elevated glycated haemoglobin (HbA1c) levels. The key element essential for effective and safe insulin therapy is frequent dosage titration to overcome constant variations in insulin requirements. In reality, dosage titration is done sporadically during clinic visits. A scalable solution to this problem is being reviewed. A diabetes nurses service improves glycaemic control without overburdening the health system. The service relies on a handheld device, which provides patients with an insulin dose recommendation for each injection while using the device to monitor glucose. Similar to the approach providers use during clinical encounters, the device analyses stored glucose trends and constantly titrates insulin dosage without care providers' supervision. In this report, we describe the logic behind the technology by providing examples from users.
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Affiliation(s)
| | - Roy Harper
- Diabetes Center, Ulster Hospital, South East and Social Care Trust, Belfast, Northern Ireland, UK
| | - Yixi Bi
- Queen's University, Belfast, Northern Ireland, UK
| | - Israel Hodish
- Hygieia Inc, Ann Arbor, Michigan, USA Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical Center, Ann Arbor, Michigan, USA
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Abstract
Because of its ease and simplicity of its measurement, the morning fasting plasma glucose (FPG), has been as used a surrogate marker for the entire basal day when titrating once-nightly basal insulin. Common in obese insulin-treated patients with type 2 diabetes, late and large evening meals elevate the FPG. This has led to dosing of basal insulin well beyond the basal requirements and contributes to hypoglycemia and weight gain seen with this therapy. It is recommended that during basal insulin titration, the evening meal be limited and hypoglycemia be monitored early in the morning, that bewitching time when the "peakless" basal insulin's action is peaking and the predawn phenomenon insulin sensitivity is higher.
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Katalenich B, Shi L, Liu S, Shao H, McDuffie R, Carpio G, Thethi T, Fonseca V. Evaluation of a Remote Monitoring System for Diabetes Control. Clin Ther 2015; 37:1216-25. [PMID: 25869625 DOI: 10.1016/j.clinthera.2015.03.022] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 03/23/2015] [Accepted: 03/23/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE The use of technology to implement cost-effective health care management on a large scale may be an alternative for diabetes management but needs to be evaluated in controlled trials. This study assessed the utility and cost-effectiveness of an automated Diabetes Remote Monitoring and Management System (DRMS) in glycemic control versus usual care. METHODS In this randomized, controlled study, patients with uncontrolled diabetes on insulin were randomized to use of the DRMS or usual care. Participants in both groups were followed up for 6 months and had 3 clinic visits at 0, 3, and 6 months. The DRMS used text messages or phone calls to remind patients to test their blood glucose and to report results via an automated system, with no human interaction unless a patient had severely high or low blood glucose. The DRMS made adjustments to insulin dose(s) based on validated algorithms. Participants reported medication adherence through the Morisky Medication Adherence Scale-8, and diabetes-specific quality of life through the diabetes Daily Quality of Life questionnaire. A cost-effectiveness analysis was conducted based on the estimated overall costs of DRMS and usual care. FINDINGS A total of 98 patients were enrolled (59 [60%] female; mean age, 59 years); 87 participants (89%) completed follow-up. HbA1c was similar between the DRMS and control groups at 3 months (7.60% vs 8.10%) and at 6 months (8.10% vs 7.90%). Changes from baseline to 6 months were not statistically significant for self-reported medication adherence and diabetes-specific quality of life, with the exception of the Daily Quality of Life-Social/Vocational Concerns subscale score (P = 0.04). IMPLICATIONS An automated system like the DRMS may improve glycemic control to the same degree as usual clinic care and may significantly improve the social/vocational aspects of quality of life. Cost-effectiveness analysis found DRMS to be cost-effective when compared to usual care and suggests DRMS has a good scale of economy for program scale up. Further research is needed to determine how to sustain the benefits seen with the automated system over longer periods.
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Affiliation(s)
- Bonnie Katalenich
- Tulane University Health Sciences Center, New Orleans, Louisiana; Southeast Louisiana Veterans Health Care Systems, New Orleans, Louisiana.
| | - Lizheng Shi
- Tulane University Health Sciences Center, New Orleans, Louisiana
| | - Shuqian Liu
- Tulane University Health Sciences Center, New Orleans, Louisiana
| | - Hui Shao
- Tulane University Health Sciences Center, New Orleans, Louisiana
| | - Roberta McDuffie
- Tulane University Health Sciences Center, New Orleans, Louisiana; Southeast Louisiana Veterans Health Care Systems, New Orleans, Louisiana
| | - Gandahari Carpio
- Tulane University Health Sciences Center, New Orleans, Louisiana; Southeast Louisiana Veterans Health Care Systems, New Orleans, Louisiana
| | - Tina Thethi
- Tulane University Health Sciences Center, New Orleans, Louisiana; Southeast Louisiana Veterans Health Care Systems, New Orleans, Louisiana
| | - Vivian Fonseca
- Tulane University Health Sciences Center, New Orleans, Louisiana; Southeast Louisiana Veterans Health Care Systems, New Orleans, Louisiana
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Tran L, Zielinski A, Roach AH, Jende JA, Householder AM, Cole EE, Atway SA, Amornyard M, Accursi ML, Shieh SW, Thompson EE. Pharmacologic Treatment of Type 2 Diabetes. Ann Pharmacother 2015; 49:700-14. [DOI: 10.1177/1060028015573010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objective: To review the oral and injectable pharmacologic treatment options for type 2 diabetes. Data Sources: A literature search was conducted using PubMed electronic database for studies published in English between 1993 and September 2014. Search terms included diabetes mellitus, type 2 diabetes, and the individual name for each antidiabetic medication reviewed. In addition, manual searches were performed for cross-references from publications. Package inserts, United States Food and Drug Administration (FDA) Web site, Institute for Safe Medication Practices Web site, American Diabetes Association Web site and scientific session poster presentations, and individual drug company Web pages were also reviewed. Study Selection and Data Extraction: This review focused on information elucidated over the past 10 years to assist prescribers in choosing optimal therapy based on individual patient characteristics. Studies leading to the approval of or raising safety concerns for the antidiabetic medications reviewed in this article were included. Data Synthesis: In the past 10 years, there have been 4 novel oral antidiabetic medication classes and 10 new injectable agents and insulin products approved by the FDA for the treatment of type 2 diabetes as well as new information regarding the safety and use of several older antidiabetic medication classes. The distinctions were reviewed for each individual agent, and a comparison was completed if there was more than one agent in a particular therapeutic class. Using current information available, select investigational agents in phase III trials or with a pending new drug application were highlighted. Conclusion: There are now 9 distinct oral pharmacologic classes and a variety of insulin and noninsulin injectable medications available for the treatment of type 2 diabetes. Metformin remains the first-line treatment option for most patients. When considering options for alternative or additional treatment, prescribers must weigh the benefits and risks using individual patient characteristics.
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Affiliation(s)
- Linda Tran
- Chalmers P. Wylie Veterans Affairs Ambulatory Care Center, Columbus, OH, USA
| | - Angela Zielinski
- Chalmers P. Wylie Veterans Affairs Ambulatory Care Center, Columbus, OH, USA
| | - Arpi H. Roach
- Chalmers P. Wylie Veterans Affairs Ambulatory Care Center, Columbus, OH, USA
| | - Jennifer A. Jende
- Chalmers P. Wylie Veterans Affairs Ambulatory Care Center, Columbus, OH, USA
| | | | - Emily E. Cole
- Chalmers P. Wylie Veterans Affairs Ambulatory Care Center, Columbus, OH, USA
| | - Shuruq A. Atway
- Chalmers P. Wylie Veterans Affairs Ambulatory Care Center, Columbus, OH, USA
| | - Melinda Amornyard
- Chalmers P. Wylie Veterans Affairs Ambulatory Care Center, Columbus, OH, USA
| | - Mallory L. Accursi
- Chalmers P. Wylie Veterans Affairs Ambulatory Care Center, Columbus, OH, USA
| | - Suzanna W. Shieh
- Chalmers P. Wylie Veterans Affairs Ambulatory Care Center, Columbus, OH, USA
| | - Erin E. Thompson
- Chalmers P. Wylie Veterans Affairs Ambulatory Care Center, Columbus, OH, USA
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Simon ACR, Schopman JE, Hoekstra JBL, Abu-Hanna A, Gerdes VEA, Peek N, Holleman F. Factors that drive insulin-dosing decisions of diabetes care providers: a vignette-based study in the Netherlands. Diabet Med 2015; 32:69-77. [PMID: 25204362 DOI: 10.1111/dme.12586] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 07/09/2014] [Accepted: 09/04/2014] [Indexed: 01/09/2023]
Abstract
AIM To test how certain patient factors would influence the decision of Dutch care providers regarding insulin dose adjustments. We hypothesize that some of these decisions would diverge from recent evidence and consensus statements. METHODS We developed narrative vignettes describing clinical scenarios of patients receiving basal insulin therapy. For each vignette, the respondents were asked to indicate whether they would advise a change in insulin dose. A total of 520 paper questionnaires were distributed among physicians and nurses in primary and secondary care in the Netherlands. Multivariate linear and logistic regression analyses were performed to identify factors associated with dosing decisions. RESULTS A total of 190 (37%) questionnaires were returned. In cases of a severe rather than mild hypoglycaemic event, care providers were nearly five times more likely to decrease the dose (odds ratio 4.77, 95% CI 1.65-13.75). Care providers were six times more likely to increase the dose when the patient's current dose was low (30 units) rather than high (90 units) (odds ratio 6.38, 95% CI 3.04-13.37). The plasma glucose concentration during a hypoglycaemic event and a known history of cardiovascular disease did not influence the care providers' dosing decisions. CONCLUSION Evidence regarding the optimum insulin titration is not always translated into clinical practice. When formulating guidelines, misconceptions should be identified and addressed.
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Affiliation(s)
- A C R Simon
- Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands; Medical Informatics, Academic Medical Center, Amsterdam, The Netherlands
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Shaw P, Saleem T, Gahtan V. Correlation of hemoglobin A1C level with surgical outcomes: Can tight perioperative glucose control reduce infection and cardiac events? Semin Vasc Surg 2014; 27:156-61. [DOI: 10.1053/j.semvascsurg.2015.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Gao Y, Luquez C, Lynggaard H, Andersen H, Saboo B. The SimpleMix study with biphasic insulin aspart 30: a randomized controlled trial investigating patient-driven titration versus investigator-driven titration. Curr Med Res Opin 2014; 30:2483-92. [PMID: 25180608 DOI: 10.1185/03007995.2014.960512] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The study aimed to confirm the efficacy, through non-inferiority, of patient-driven versus investigator-driven titration of biphasic insulin aspart 30 (BIAsp 30) in terms of glycemic control assessed by HbA1c change. METHODS SimpleMix was a 20 week, open-label, randomized, two-armed, parallel-group, multicenter study in five countries (Argentina, China, India, Poland, and the UK). Patients with type 2 diabetes were randomized into either patient-driven or investigator-driven BIAsp 30 titration groups. RESULTS Non-inferiority of patient-driven vs. investigator-driven titration based on change in HbA1c from baseline to week 20 could not be demonstrated. Mean (SE) estimated change from baseline to week 20 was -0.72 (0.08)% in the patient-driven group and -0.97 (0.08)% in the investigator-driven group; estimated difference 0.25% (95% CI: 0.04; 0.46). Estimated mean change (SE) in fasting plasma glucose from baseline to week 20 was similar between groups: -0.94 (0.21) mmol/L for patient-driven and -1.07 (0.22) mmol/L for investigator-driven (difference non-significant). Both treatment arms were well tolerated, and hypoglycemic episode rates were similar between groups, with a rate ratio of 0.77 (95% CI: 0.54; 1.09; p = 0.143) for all hypoglycemic episodes and 0.78 (95% CI: 0.42; 1.43; p = 0.417) for nocturnal hypoglycemic episodes. CONCLUSIONS Non-inferiority of patient-driven versus investigator-driven titration with regard to change from baseline to end-of-treatment HbA1c could not be confirmed. It is possible that a clinic visit 12 weeks after intensification of treatment with BIAsp 30 in patients with type 2 diabetes inadequately treated with basal insulin may benefit patient-driven titration of BIAsp 30. A limitation of the study was the relatively small number of patients recruited in each country, which does not allow country-specific analyses to be performed. Overall, treatment with BIAsp 30 was well tolerated in both treatment groups.
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Affiliation(s)
- Yan Gao
- Department of Endocrinology, Peking University First Hospital , Beijing , China
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Simon AC, Gude WT, Holleman F, Hoekstra JB, Peek N. Diabetes patients' experiences with the implementation of insulin therapy and their perceptions of computer-assisted self-management systems for insulin therapy. J Med Internet Res 2014; 16:e235. [PMID: 25340869 PMCID: PMC4259961 DOI: 10.2196/jmir.3198] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Revised: 06/24/2014] [Accepted: 07/10/2014] [Indexed: 11/21/2022] Open
Abstract
Background Computer-assisted decision support is an emerging modality to assist patients with type 2 diabetes mellitus (T2DM) in insulin self-titration (ie, self-adjusting insulin dose according to daily blood glucose levels). Computer-assisted insulin self-titration systems mainly focus on helping patients overcome barriers related to the cognitive components of insulin titration. Yet other (eg, psychological or physical) barriers could still impede effective use of such systems. Objective Our primary aim was to identify experiences with and barriers to self-monitoring of blood glucose, insulin injection, and insulin titration among patients with T2DM. Our research team developed a computer-assisted insulin self-titration system, called PANDIT. The secondary aim of this study was to evaluate patients’ perceptions of computer-assisted insulin self-titration. We included patients who used PANDIT in a 4-week pilot study as well as patients who had never used such a system. Methods In-depth, semi-structured interviews were conducted individually with patients on insulin therapy who were randomly recruited from a university hospital and surrounding general practices in the Netherlands. The interviews were transcribed verbatim and analyzed qualitatively. To classify the textual remarks, we created a codebook during the analysis, in a bottom-up and iterative fashion. To support examination of the final coded data, we used three theories from the field of health psychology and the integrated model of user satisfaction and technology acceptance by Wixom and Todd. Results When starting insulin therapy, some patients feared a lifelong commitment to insulin therapy and disease progression. Also, many barriers arose when implementing insulin therapy (eg, some patients were embarrassed to inject insulin in public). Furthermore, patients had difficulties increasing the insulin dose because they fear hypoglycemia, they associate higher insulin doses with disease progression, and some were ignorant of treatment targets. Patients who never used a computer-assisted insulin self-titration system felt they had enough knowledge to know when their insulin should be adjusted, but still believed that the system advice would be useful to confirm their reasoning. Furthermore, the time and effort saved with automated insulin advice was considered an advantage. Patients who had used PANDIT found the system useful if their glycemic regulation improved. Nevertheless, for some patients, the absence of personal contact with their caregiver was a drawback. While guidelines state that adjustment of basal insulin dose based on fasting plasma glucose values is sufficient, both patients who had and those who had not used PANDIT felt that such a system should take more patient data into consideration, such as lifestyle and diet factors. Conclusions Patients encounter multiple obstacles when implementing insulin therapy. Computer-assisted insulin self-titration can increase patient awareness of treatment targets and increase their confidence in self-adjusting the insulin dose. Nevertheless, some barriers may still exist when using computer-assisted titration systems and these systems could also introduce new barriers.
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Affiliation(s)
- Airin Cr Simon
- University of Amsterdam/Academic Medical Center, Internal Medicine/Medical Informatics, Amsterdam, Netherlands.
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Stokes V, Gough SC. Recent advances with insulin degludec for the treatment of Type 2 diabetes. Expert Rev Endocrinol Metab 2014; 9:301-312. [PMID: 30763990 DOI: 10.1586/17446651.2014.917045] [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: 11/08/2022]
Abstract
Type 2 diabetes has been referred to as the global epidemic of the 21st century, and is associated with significant morbidity and premature mortality. Estimates suggest that over 50% of people with Type 2 diabetes will at some point need insulin injections to help treat their diabetes. Once daily insulin injections are being increasingly used to initiate insulin in people with Type 2 diabetes and the development of novel, safe, once daily basal insulins with low rates of hypoglycaemia are important to help achieve internationally recommended glycaemic targets for individual patients. Insulin degludec is a novel once daily basal insulin analogue that has been developed for use in people with Type 2 diabetes. A comprehensive drug development program suggests that it can achieve comparable glycaemic control to existing basal insulins but with reduced rates of hypoglycaemia.
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Affiliation(s)
- Victoria Stokes
- a Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, OX3 7LE, UK
| | - Stephen Cl Gough
- a Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, OX3 7LE, UK
- b NIHR Oxford Biomedical Research Centre, Oxford, UK
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Escalante M, Gagliardino JJ, Guzmán JR, Tschiedel B. Call-to-action: timely and appropriate treatment for people with type 2 diabetes in Latin America. Diabetes Res Clin Pract 2014; 104:343-52. [PMID: 24835577 DOI: 10.1016/j.diabres.2014.01.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 08/27/2013] [Accepted: 01/01/2014] [Indexed: 01/27/2023]
Abstract
Latin America faces a unique set of challenges in the treatment of type 2 diabetes mellitus (T2DM). This report identifies these challenges and provides a framework for implementation of the strategies, policies and education programs which are needed to optimize the management of this condition. In order to improve future diabetes care, it will be necessary to address existing problems such as limitation of resources, inadequate management of hyperglycemia, and inappropriate education of healthcare team members and people with diabetes. Achieving these goals will require collaborative efforts by many individuals, groups and organizations. These include policymakers, international organizations, healthcare providers, those responsible for setting medical school curricula, patients and society as a whole. It is anticipated that improved/continuing education of healthcare professionals, diabetes self-management education and development of a team approach for T2DM care will lead to optimization of patient-centered care. Implementation of multicentric demonstration studies and rational use of antidiabetic treatments will be necessary to demonstrate the long-term favorable impact of these strategies upon quality of care, prevention of chronic complications, mortality, healthcare costs and patient quality of life.
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Affiliation(s)
- Miguel Escalante
- Hospital de Especialidades, Centro Medico Nacional de Occidente, Mexican Institute of Social Security, Guadalajara, Mexico.
| | - Juan José Gagliardino
- CENEXA. Centro de Endocrinología Experimental y Aplicada (UNLP-CONICET La Plata), PAHO/WHO Collaborating Centre for Diabetes, Facultad de Ciencias Médicas UNLP, La Plata, Argentina
| | - Juan Rosas Guzmán
- Centro de Especialidades Medicas de Celaya, Latin University of Mexico in Celaya, Guanajuato, Mexico
| | - Balduino Tschiedel
- Institute for Children with Diabetes in Porto Alegre and the Brazilian Diabetes Society, Porto Alegre, Brazil
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King AB. When is enough, enough? The correlation between once-daily basal insulin doses to the fasting plasma glucose in type 2 diabetes. Endocr Pract 2014; 19:735-6. [PMID: 23512401 DOI: 10.4158/ep12094.lt] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
Treat-to-target is a therapeutic concept that considers well defined and specific physiologic targets as aims in controlling the pathophysiology of the disease. It has been widely used in diseases that pathophysiology includes, chronic metabolic and physiological disturbances, namely rheumatic conditions, vascular medicine and diabetes. In diabetes, the availability of "gold-standard" quantitative measures like fasting plasma glucose and glycated hemoglobin make the application of treat-to-target trials especially pertinent. Treatment modalities which have used single therapeutic agents or combinations or in combination with a variety of titration algorithms and implementation protocols have broadened our understanding of diabetes management with specific reference to insulin initiation and maintenance. Treat-to-target trials have been used to investigate a wide variety of questions including efficacy, safety, effect of treatment on comorbidities and patient satisfaction, ideal mechanisms to implement insulin initiation etc. A more generalized acceptance and implementation of treat-to-target trials may finally revolutionize diabetes management by combining aspects of individual care with standard treatment protocols.
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Affiliation(s)
| | - Bipin Sethi
- Department of Endocrinology, Care Hospital, Hyderabad, India
| | - Rakesh K. Sahay
- Department of Endocrinology, Osmania Medical College and Hospital, Hyderabad, India
| | - Mathew John
- Department of Endocrinology, Providence Endocrine and Diabetes Specialty Centre, Trivandrum, India
| | - Samit Ghosal
- Department of Diabetology, Nightingale Hospital, Kolkata, India
| | - Surendra K. Sharma
- Department of Endocrinology, Dr. SK Sharma's Diabetes Thyroid and Endocrine Centre, Jaipur, Rajasthan, India
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Garber AJ. Treat-to-target trials: uses, interpretation and review of concepts. Diabetes Obes Metab 2014; 16:193-205. [PMID: 23668598 PMCID: PMC4237121 DOI: 10.1111/dom.12129] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 02/15/2013] [Accepted: 05/06/2013] [Indexed: 01/14/2023]
Abstract
Treat-to-target trial designs compare investigational insulins with a standard insulin. Treat-to-target trials force-titrate insulin dosages to achieve a prespecified treatment goal. With comparable glycaemic control, comparisons of safety endpoints such as hypoglycaemia can be made to establish the risk-benefit profile of the new insulin. Glargine versus NPH showed comparable A1C reductions; however, A1C <7% without associated nocturnal hypoglycaemia was reached in more patients on glargine and overall hypoglycaemia was lower. Detemir versus glargine showed non-inferiority between the groups; however, with less weight gain and more injection site reactions with detemir. Detemir/aspart versus glargine/aspart showed non-inferiority between the treatments, however, with less weight gain in the detemir group but comparable risk of hypoglycaemia. Degludec in combination with aspart versus glargine/aspart showed comparable A1C reductions. However, degludec-treated patients had less overall hypoglycaemia and less nocturnal hypoglycaemia. Because insulin titrations are guided by goal attainment with each treatment, treat-to-target trials enable clinicians to determine differences in non-glycaemic treatment effects, such as rates of hypoglycaemia and weight gain, at the same level of glycaemic control.
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Affiliation(s)
- A J Garber
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA; Department of Biochemistry and Molecular Biology, Baylor College of Medicine, Houston, TX, USA; Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX, USA
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Dailey G, Aurand L, Stewart J, Ameer B, Zhou R. Comparison of three algorithms for initiation and titration of insulin glargine in insulin-naive patients with type 2 diabetes mellitus. J Diabetes 2014; 6:176-83. [PMID: 23931125 DOI: 10.1111/1753-0407.12080] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 07/18/2013] [Accepted: 08/02/2013] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Several titration algorithms can be used to adjust insulin dose and attain blood glucose targets. We compared clinical outcomes using three initiation and titration algorithms for insulin glargine in insulin-naive patients with type 2 diabetes mellitus (T2DM); focusing on those receiving both metformin and sulfonylurea (SU) at baseline. METHODS This was a pooled analysis of patient-level data from prospective, randomized, controlled 24-week trials. Patients received algorithm 1 (1 IU increase once daily, if fasting plasma glucose [FPG] > target), algorithm 2 (2 IU increase every 3 days, if FPG > target), or algorithm 3 (treat-to-target, generally 2-8 IU increase weekly based on 2-day mean FPG levels). Glycemic control, insulin dose, and hypoglycemic events were compared between algorithms. RESULTS Overall, 1380 patients were included. In patients receiving metformin and SU at baseline, there were no significant differences in glycemic control between algorithms. Weight-adjusted dose was higher for algorithm 2 vs algorithms 1 and 3 (P = 0.0037 and P < 0.0001, respectively), though results were not significantly different when adjusted for reductions in HbA1c (0.36 IU/kg, 0.43 IU/kg, and 0.31 IU/kg for algorithms 1, 2, and 3, respectively). Yearly hypoglycemic event rates (confirmed blood glucose <56 mg/dL) were higher for algorithm 3 than algorithms 1 (P = 0.0003) and 2 (P < 0.0001). CONCLUSIONS Three algorithms for initiation and titration of insulin glargine in patients with T2DM resulted in similar levels of glycemic control, with lower rates of hypoglycemia for patients treated using simpler algorithms 1 and 2.
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Al Hamarneh YN, Charrois T, Lewanczuk R, Tsuyuki RT. Pharmacist intervention for glycaemic control in the community (the RxING study). BMJ Open 2013; 3:e003154. [PMID: 24068762 PMCID: PMC3787489 DOI: 10.1136/bmjopen-2013-003154] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 08/12/2013] [Accepted: 08/13/2013] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To determine the effect of a community pharmacist prescribing intervention on glycaemic control in patients with poorly controlled type 2 diabetes. DESIGN Pragmatic, before-after design. SETTING 12 community pharmacies in Alberta, Canada. PARTICIPANTS Type 2 diabetes receiving oral hypoglycaemic medications and with glycated haemoglobin (HbA1c) of 7.5-11%. INTERVENTION Pharmacists systematically identified potential candidates by inviting patients with type 2 diabetes to test their HbA1c using validated point-of-care technology. Pharmacists prescribed 10 units of insulin glargine at bedtime, adjusted by increments of 1 unit daily to achieve a morning fasting glucose of ≤5.5 mmol/L. The patients were followed up at 2, 4, 8, 14, 20 and 26 weeks. PRIMARY OUTCOME Change in HbA1c from baseline to week 26. SECONDARY OUTCOMES Proportion of patients achieving target HbA1c, changes in oral hypoglycaemic agents, quality of life and patient satisfaction, persistence on insulin glargine, number of insulin dosage adjustments per patient and number of hypoglycaemic episodes. RESULTS We screened 365 patients of whom 111 were eligible. Of those, 100 (90%) were enrolled in the study; all 11 patients who did not consent refused to use insulin. Average age was 64 years (SD 10.4), while average diabetes duration was 10.2 years (SD 7). HbA1c was reduced from 9.1% (SD 1) at baseline to 7.3% (SD 0.9); a change of 1.8% (95% CI 1.4 to 2, p<0.001). Fasting plasma glucose was reduced from 11 (SD 3.3) to 6.9 mmol/L (SD 1.8); a change of 4.1 mmol/L (95% CI of 3.3 to 5, p=0.007). Fifty-one per cent of the patients achieved the target HbA1c of ≤7% at the end of the study. CONCLUSIONS This is the first completed study of independent prescribing by pharmacists. Our results showed similar improvements in glycaemic control as previous physician-led studies. RxING provides further evidence for the benefit of pharmacist care in diabetes. TRIAL REGISTRATION clinicaltrials.gov; Identifier: NCT01335763.
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Affiliation(s)
- Yazid N Al Hamarneh
- Division of Cardiology, Department of Medicine, EPICORE Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Theresa Charrois
- School of Pharmacy, Curtin University, Perth, Western Australia, Australia
| | - Richard Lewanczuk
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ross T Tsuyuki
- Division of Cardiology, Department of Medicine, EPICORE Centre, University of Alberta, Edmonton, Alberta, Canada
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Onishi Y, Ono Y, Rabøl R, Endahl L, Nakamura S. Superior glycaemic control with once-daily insulin degludec/insulin aspart versus insulin glargine in Japanese adults with type 2 diabetes inadequately controlled with oral drugs: a randomized, controlled phase 3 trial. Diabetes Obes Metab 2013; 15:826-32. [PMID: 23557077 DOI: 10.1111/dom.12097] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 12/15/2012] [Accepted: 03/07/2013] [Indexed: 11/27/2022]
Abstract
AIMS This phase 3, 26-week, open-label, treat-to-target trial investigated the efficacy and safety of insulin degludec/insulin aspart (IDegAsp) in insulin-naïve Japanese adults with type 2 diabetes. METHODS Subjects were randomized to once-daily injections of IDegAsp (n = 147) or insulin glargine (IGlar) (n = 149), both ±≤2 oral antidiabetic treatments. IDegAsp was given before the largest meal at the discretion of each subject (and maintained throughout the trial); IGlar was dosed according to label. Both insulins were titrated to a target prebreakfast self-measured plasma glucose of 3.9 to <5.0 mmol/l. RESULTS After 26 weeks, mean HbA1c was 7% with IDegAsp and 7.3% with IGlar; superiority of IDegAsp to IGlar was shown (estimated treatment difference, ETD; IDegAsp-IGlar: -0.28% points [-0.46; -0.10](95% CI), p < 0.01). At end-of-trial, mean fasting plasma glucose (FPG) was similar for IDegAsp and IGlar (5.7 vs. 5.6 mmol/l; ETD IDegAsp-IGlar: 0.15 mmol/l [-0.29; 0.60](95% CI), p = NS). IDegAsp was associated with numerically lower rates of overall confirmed (27%) and nocturnal confirmed hypoglycaemia (25%) versus IGlar (estimated rate ratio IDegAsp/IGlar: 0.73 [0.50; 1.08](95% CI), p = NS, and 0.75 [0.34; 1.64](95% CI), p = NS, respectively). Mean daily insulin doses were similar between groups at end-of-trial (both: 0.41 U/kg) as were the increases in body weight from baseline (both: 0.7 kg). Adverse event profiles were similar between groups. CONCLUSIONS IDegAsp provided superior long-term glycaemic control compared to IGlar, with similar FPG and doses and numerically lower rates of overall and nocturnal hypoglycaemia (p = NS).
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Affiliation(s)
- Y Onishi
- The Institute for Adult Diseases, Asahi Life Foundation, Tokyo, Japan
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Khunti K, Davies MJ, Kalra S. Self-titration of insulin in the management of people with type 2 diabetes: a practical solution to improve management in primary care. Diabetes Obes Metab 2013; 15:690-700. [PMID: 23253563 DOI: 10.1111/dom.12053] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Revised: 10/22/2012] [Accepted: 12/11/2012] [Indexed: 01/03/2023]
Abstract
Good glycaemic control in type 2 diabetes (T2DM) is associated with a reduced risk of diabetes complications; however, achieving and maintaining glycaemic control represents a major challenge to physicians, and despite the availability of a range of antidiabetic therapies, many patients with T2DM will eventually require insulin supplementation to reach target glycaemic levels. Insulin initiation, adjustment of the insulin dose and the need for frequent assessment of blood glucose levels are often complicated by patient and physician misconceptions and concerns regarding its use. For most patients requiring insulin therapy, dose titration is carried out by physicians; however, evidence suggests that this process may not provide optimal glycaemic management for patients. Self-monitoring of blood glucose and self-adjustment of insulin dose (insulin self-titration) is well established in type 1 diabetes, suggesting that similar therapeutic self-management may be beneficial when applied to patients with T2DM. This article reviews the rationale and clinical evidence for insulin self-titration in patients with T2DM with the aim of highlighting the importance of educating patients about insulin therapy and empowering them to manage their diabetes through self-titration of insulin.
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Affiliation(s)
- K Khunti
- Diabetes Research Unit, University of Leicester, Leicester, UK.
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Abstract
Type 2 diabetes mellitus has become a worldwide major health problem, and the number of people affected is steadily increasing. Thus, not all patients suffering from the disease can be treated by specialized diabetes centers or outpatient clinics, but by primary care physicians. The latter, however, might have time constraints and have to deal with many kinds of diseases or with multimorbid patients, so their focus is not so much on lowering high blood glucose values. Thus, the physicians, as well as the patients themselves, are often reluctant to initiate and adjust insulin therapy, although basal insulin therapy is considered the appropriate strategy after oral antidiabetic drug failure, according to the latest international guidelines. A substantial number of clinical studies have shown that insulin initiation and optimization can be managed successfully by using titration algorithms-even in cases where patients themselves are the drivers of insulin titration. Nevertheless, tools and strategies are needed to facilitate this process in the daily life of both primary health care professionals and patients with diabetes.
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Affiliation(s)
- Sabine Arnolds
- Profil, Neuss, Germany, Hellersbergstrasse 9, Neuss, Germany.
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Papa G, Baratta R, Calì V, Degano C, Iurato MP, Licciardello C, Maiorana R, Finocchiaro C. Factors that influence basal insulin requirement in type 2 diabetes. Acta Diabetol 2012; 49:387-93. [PMID: 22274553 DOI: 10.1007/s00592-012-0372-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Accepted: 01/16/2012] [Indexed: 01/17/2023]
Abstract
In clinical practice, basal insulin dosage (BID) for the treatment for type 2 diabetes given as slow-acting analogues or NPH insulin varies widely when adjusted for body weight (UI/kg). In this study, we investigated the interrelationship between BID and anthropometric, laboratory and clinical parameters. A total of 681 type 2 diabetic patients, treated with bedtime insulin in association with other antidiabetic drugs (preprandial insulin and/or oral agents), were studied. Anthropometric, clinical and biochemical parameters, as well as micro- and macrovascular complications, were evaluated. Non-alcoholic fatty liver disease (NAFLD) was assessed by liver ultrasound. BID was titrated to achieve a fasting blood glucose target of ≤6.7 mmol/L (120 mg/dL). In the multivariate analysis, BID was significantly associated with waist circumference (p = 0.04) and the insulin treatment duration (p = 0.004) as the type of insulin treatment ("basal-bolus" regimen vs. basal insulin only, p < 0.0001), the use of lipid-lowering drugs (p = 0.0003) and insulin sensitizers (p = 0.005). Several glycometabolic parameters were strongly associated with BID (HbA1c p = 0.01, FPG p < 0.0001, HDL p = 0.02, triglycerides p = 0.03). Moreover, the presence of severe NAFLD resulted in a higher BID (p = 0.03). We concluded that when starting and titrating the basal insulin in type 2 diabetes, certain anthropometric, laboratory and clinical factors can be useful to find optimal BID more quickly and appropriately.
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Affiliation(s)
- Giuseppe Papa
- Unit of Metabolic and Endocrine Diseases, "Centro Catanese di Medicina e Chirurgia" Clinic, Catania, Italy.
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Abstract
Hypoglycemia is the rate-limiting factor that often prevents patients with diabetes from safely and effectively achieving their glycemic goals. Recent studies have reported that severe hypoglycemia is associated with a significant increase in the adjusted risks of major macrovascular events, major microvascular events, and mortality. Minor hypoglycemic episodes can also have serious implications for patient health, psychological well being, and adherence to treatment regimens. Hypoglycemic events can impact the health economics of the patient, their employer, and third-party payers. Insulin treatment is a key predictor of hypoglycemia, with one large population-based study reporting an overall prevalence of 7.1% (type 1 diabetes mellitus) and 7.3% (type 2 diabetes mellitus) in insulin-treated patients, compared with 0.8% in patients with type 2 diabetes treated with an oral sulfonylurea. Patients with type 1 diabetes typically experience symptomatic hypoglycemia on average twice weekly and severe hypoglycemia once annually. The progressive loss of islet cell function in patients with type 2 diabetes results in a higher risk of both symptomatic and unrecognized hypoglycemia over time. Patients with diabetes who become hypoglycemic are also more susceptible to developing defective counter-regulation, also known as hypoglycemia awareness autonomic failure, which is life-threatening and must be aggressively addressed. In patients unable to recognize hypoglycemia symptoms, frequent home monitoring or use of continuous glucose sensors are critical. Primary care physicians play a key role in the prevention and management of hypoglycemia in patients with diabetes, particularly in those requiring intensive insulin therapy, yet physicians are often unaware of the multitude of consequences of hypoglycemia or how to deal with them. Careful monitoring, adherence to guidelines, and use of optimal treatment combinations are all important steps toward improving care in patients with diabetes. The most important goals are for primary care physicians to recognize that every patient treated with antihyperglycemic medications is at risk of iatrogenic hypoglycemia and to ask patients about hypoglycemia at every visit.
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Affiliation(s)
- Jeff Unger
- Correspondence: Jeff Unger, Catalina Research Institute, 14726 Ramona Avenue, Suite 110, Chino, CA 91710, USA, Tel +1 909 590 8409, Fax +1 909 899 5013, Email
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Levich BR. Diabetes management: optimizing roles for nurses in insulin initiation. J Multidiscip Healthc 2011; 4:15-24. [PMID: 21468244 PMCID: PMC3065562 DOI: 10.2147/jmdh.s16451] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Indexed: 12/01/2022] Open
Abstract
Type 2 diabetes is a major public health concern. Screening and early diagnosis followed by prompt and aggressive treatment interventions can help control progression of diabetes and its complications. Nurses are often the first healthcare team members to interact with patients and are being called on to apply their specialized knowledge, training, and skills to educate and motivate patients with diabetes about insulin use and practical ways to achieve treatment goals. Clinical nurse specialists possess specific training and skills to provide this level of care, while staff or office-based nurses may be trained by physicians to fulfill a task-specific role. This manuscript reviews the benefits of intensive glycemic control in type 2 diabetes, therapeutic goals and guidelines, advances in insulin therapy, and contribution of nurses in overcoming barriers to insulin initiation and related aspects of diabetes care. Nurses are particularly well positioned to fill the gap and improve efficiency in diabetes-related healthcare by assisting patients with insulin initiation and other aspects of glycemic self-management.
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Affiliation(s)
- Bridget R Levich
- University of California Davis Health System, Sacramento, CA, USA
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King AB. No higher dose requirements with insulin detemir than glargine in type 2 diabetes: a crossover, double-blind, and randomized study using continuous glucose monitoring. J Diabetes Sci Technol 2010; 4:151-4. [PMID: 20167179 PMCID: PMC2825636 DOI: 10.1177/193229681000400119] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND In a previous publication we reported no difference in the 24-hour glucose response between two basal analog insulins, detemir and glargine, when taken once a day in type 2 diabetes mellitus (T2DM). We now report the dose comparison observed within this randomized, double-blind, crossover study. METHOD Of 36 patients on basal insulin and other noninsulin treatments, 29 completed the study. Both insulins were given once a day at 8 pm and no food was taken between 6 pm and the following morning. The dose was titrated daily by continuous glucose monitoring (CGM) until the basal glucose (between 12 and 6 am) was <120 mg/dl but not >5% of CGM readings <70 mg/dl. Subjects were then crossed over to the other insulin and titrated similarly. RESULTS Glucose goals were achieved in all subjects. The mean dosage was 0.26 U/kg with very few subjects requiring >0.4 U/kg. Only 2 required an absolute dose less than 10 U/day and all others required more, some considerably higher. Of the 29 subjects, 7 required a greater, 6 a smaller, and 16 the same dose of detemir compared to glargine. CONCLUSIONS When given once daily in T2DM and titrated using CGM to the same fasting glucose, there was no difference in the glucose response between basal insulins during the basal titration period (4-10 hours after injection) nor during the entire 24-hour period following the injection. Further, the mean dosage to achieve this glucose goal was the same with both insulins.
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Kapitza C, Fein S, Heinemann L, Schleusener D, Levesque S, Strange P. Basal-prandial insulin delivery in type 2 diabetes mellitus via the V-Go: a novel continuous subcutaneous infusion device. J Diabetes Sci Technol 2008; 2:40-6. [PMID: 19885176 PMCID: PMC2769698 DOI: 10.1177/193229680800200107] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The V-Go is a once-daily disposable device that allows coverage of basal and prandial insulin requirements over a period of 24 hours. The aim of this proof-of-concept study was to evaluate the clinical functionality, safety, and pharmacodynamics of the V-Go delivering insulin aspart and redistributing a single basal dose of insulin glargine as a constant basal infusion supplemented with prandial insulin in subjects with type 2 diabetes mellitus. METHODS In six subjects receiving once-daily subcutaneous (SC) injections of insulin glargine (> or =15 U/day) with or without concomitant oral antidiabetic drugs, glargine was discontinued following a 3-day baseline phase. The V-Go was then applied to the lower abdomen of the subjects once daily for 7 days (days 1-3 inpatient, days 4-7 outpatient). Each V-Go provided a continuous 24-hour preset basal infusion rate of insulin aspart (0.6 U/h) and up to three daily prandial doses at mealtimes. Capillary blood glucose concentrations were measured at 11 time points per day during the baseline and inpatient phases and at 4 time points per day during the outpatient phase. Additionally, glucose profiles were measured continuously on all days. RESULTS The V-Go was well tolerated and operated as anticipated. The mean +/- SEM prestudy daily dose of SC insulin glargine was 33.3 +/- 13.8 U; the mean daily total insulin aspart dose infused with the V-Go was 31.5 +/- 7.5 and 32.3 +/- 7.8 U for the inpatient and outpatient periods, respectively. Fasting blood glucose values were similar to those observed at baseline throughout the study, with nonsignificant (NS) reductions in readings collected during the outpatient phase before lunch (-35 +/- 27 mg/dl) and before dinner (-38 +/- 25 mg/dl). The 2-hour postprandial glucose trended lower from 231 to 195 mg/dl (NS) at breakfast, 234 to 166 mg/dl (NS) at lunch, and 222 to 171 mg/dl (NS) at dinner. Bedtime blood glucose decreased (mean change from baseline -52 +/- 21 mg/dl; P = 0.0313), as did nighttime (3:00 AM) measurements (-20 +/- 9 mg/dl; P = 0.0313). Overall glycemic control tended to improve, as shown by continuous glucose monitoring changing from 173 to 157 mg/dl (P = 0.063, NS) and 156 mg/dl (P = 0.219) during inpatient and outpatient periods, respectively. Glycemic variability assessed by the M value similarly tended to decrease from 33 +/- 9 to 25 +/- 4 (NS) and 21 +/- 4 (NS) for inpatient and outpatient periods, respectively. CONCLUSIONS These first data suggest that use of the V-Go is an attractive alternative to SC insulin injection therapy because metabolic control appears to be maintained or even improved without increasing daily insulin doses.
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Affiliation(s)
| | | | - Lutz Heinemann
- Profil Institute for Metabolic Research GmbH, Neuss, Germany
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