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Li L, Zhang X, Zhang T, Zeng L, Lin M, Li Y, Li W. Comparison of Efficacy and Adherence of Patient-Preferred (1 Unit Daily) and ADA/EASD Guideline-Recommended (2 Units Every 3 Days) Basal Insulin Titration Algorithms: Multicenter, Randomized, Clinical Study. Patient Prefer Adherence 2024; 18:687-694. [PMID: 38524199 PMCID: PMC10959243 DOI: 10.2147/ppa.s446855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 03/12/2024] [Indexed: 03/26/2024] Open
Abstract
Aim Insulin titration often faces inertia, hindering glycemic control. A patient-centered approach empowers patients to overcome this inertia. This study aims to compare the effectiveness of patient-preferred and guideline-recommended self-titration algorithms in achieving glycemic targets and improving adherence. Methods Outpatients with type 2 diabetes (T2D) who did not respond to oral antihyperglycemic drugs (OAD) were assessed. They were randomly assigned to patient-preferred and guideline-recommended groups. In the patient-preferred group, individuals selected an algorithm to self-adjust their insulin glargine dosage by 2 units every 3 days if the mean fasting blood glucose (FBG) over the past 3 consecutive days was ≥7.0 mmol/L, or by 1 unit daily if the FBG on the same day was ≥7.0 mmol/L. In the guideline-recommended group, insulin glargine was titrated by 2 units every 3 days if the mean FBG over the past 3 consecutive days was ≥7.0 mmol/L. The FBG target was set below <7.0 mmol/L. Results Thirty-nine participants in the patient-preferred group and 42 in the guideline-recommended group completed the study. The cumulative rates of achieving the FBG target in the patient-preferred group compared to the guideline-recommended group were 69.2% vs 54.8% (χ²=1.792, p=0.181) in week 1, 89.7% vs 73.8% (χ²=3.403, p = 0.065) in week 2, 94.9% vs 76.2% (χ²=17.638, p=0.000) in week 3, and 100.0% vs 88.1% (χ²=4.405, p=0.036) in week 4. Adherence rates were significantly higher in the patient-preferred group (97.4%, 37/38) compared to the guideline-recommended group (66.7%, 28/42) (χ²=12.688, p=0.000). Insulin glargine dosage at FBG target achievement was 21.2±4.3 U in the patient-preferred group and 18.8±6.7 U in the guideline-recommended group (t=1.888, p=0.063). Hypoglycemia was reported in 1 patient in the guideline-recommended group, with no instances in the patient-preferred group. Conclusion The patient-preferred self-titration algorithm demonstrates a higher rate of reaching glucose targets and improved adherence. Trial Registration Number ChiCTR2100050805.
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Affiliation(s)
- Ling Li
- Department of Endocrinology, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, People’s Republic of China
| | - Xiaodan Zhang
- Department of Endocrinology, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, People’s Republic of China
| | - Tong Zhang
- Department of Endocrinology, The Third Affiliated Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Liankun Zeng
- Department of Endocrinology, The Fourth Affiliated Hospital, Guangzhou Medical University, Guangzhou, People’s Republic of China
| | - Mingrun Lin
- Department of Endocrinology, The Fifth Affiliated Hospital, Guangzhou Medical University, Guangzhou, People’s Republic of China
| | - Yanli Li
- Department of Endocrinology, The Fifth Affiliated Hospital, Guangzhou Medical University, Guangzhou, People’s Republic of China
| | - Wangen Li
- Department of Endocrinology, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, People’s Republic of China
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Chan SP, Aamir AH, Bee YM, Deerochanawong C, Paz-Pacheco E, Tiu F, Foo SH, Tan KEK, Le TQ, Saraswati MR, Bunnag P, Panusunan Sibarani R, Raza SA, Tran NQ. Practical Guidance on Basal Insulin Initiation and Titration in Asia: A Delphi-Based Consensus. Diabetes Ther 2022; 13:1511-1529. [PMID: 35767186 PMCID: PMC9309111 DOI: 10.1007/s13300-022-01286-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 05/26/2022] [Indexed: 11/06/2022] Open
Abstract
The global health burden of diabetes is on the rise and has affected more than half a billion people worldwide, particularly in Southeast Asia, North Africa, Africa, and the Western Pacific, Middle East, and South and Central America regions of the International Diabetes Federation (IDF). Despite many new treatments being available for the management of diabetes, glycemic control remains suboptimal in Asia, compared to the rest of the world. Delay in timely insulin initiation and inadequate titration of insulin are regarded to be some of the important reasons for inadequate glycemic control. Additionally, Asian populations have a distinct phenotype, including a younger age of onset and higher glycemic excursions, suggestive of a lower beta-cell function, as compared to non-Asians. Although there are multiple local and international guidelines on insulin initiation and titration, some of these guidelines can be complex. There is an unmet need for guideline recommendations on basal insulin initiation and titration to be simplified and customized for the Asian population with type 2 diabetes mellitus (T2DM). A unified approach would increase adoption of basal insulin initiation by primary care and family medicine physicians, which in turn would help reduce the inertia to insulin initiation. With this background, a consensus-seeking meeting was conducted with 14 experts from seven Asian countries to delineate appropriate practices for insulin initiation and titration in the Asian context. The key objective was to propose a simple insulin titration algorithm, specific for the Asian population, to improve glycemic control and optimize therapeutic outcomes of people with T2DM on basal insulin. Following a detailed review of literature and current guidelines, and potential barriers to insulin initiation and titration, the experts proposed a simplified insulin titration algorithm based on both physician- and patient-led components. The consensus recommendations of the experts related to basal insulin initiation and titration have been summarized in this article, along with the proposed titration algorithm for optimizing glycemic control in the Asian population with T2DM.
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Affiliation(s)
- Siew Pheng Chan
- Subang Jaya Medical Centre, Department of Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia.
| | - Azizul Hasan Aamir
- Khyber Girls Medical College, Hayatabad Medical Complex, Peshawar, Pakistan
| | - Yong Mong Bee
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Chaicharn Deerochanawong
- Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Elizabeth Paz-Pacheco
- Division of Endocrinology, Diabetes and Metabolism, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Fatma Tiu
- Diabetes Clinic, University de Zamboanga Hospital, Zamboanga, Philippines
| | | | - Kevin E K Tan
- Mount Elizabeth Medical Centre, Singapore, Singapore
| | - Toan Q Le
- National Hospital of Endocrinology, Hanoi, Vietnam
- University of Medicine and Pharmacy, Hanoi National University, Hanoi, Vietnam
| | - Made Ratna Saraswati
- Division of Endocrinology and Metabolism, Internal Medicine Department, Faculty of Medicine, Udayana University/Sanglah Hospital Denpasar-Bali, Denpasar, Indonesia
| | - Pongamorn Bunnag
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Syed Abbas Raza
- Shaukat Khanum Cancer Hospital and Research Center, Lahore, Pakistan
| | - Nam Quang Tran
- Department of Endocrinology, University Medical Center at Ho Chi Minh City, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
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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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4
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Aradóttir TB, Bengtsson H, Jensen ML, Poulsen NK, Boiroux D, Jensen LL, Schmidt S, Nørgaard K. Feasibility of a New Approach to Initiate Insulin in Type 2 Diabetes. J Diabetes Sci Technol 2021; 15:339-345. [PMID: 31941361 PMCID: PMC8256065 DOI: 10.1177/1932296819900240] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Treatment inertia and prescription complexity are among reasons that people with type 2 diabetes (T2D) do not reach glycemic targets. This study investigated feasibility of a new approach to basal insulin initiation, where the dose needed to reach a glycemic target is estimated from two weeks of insulin and continuous glucose monitoring (CGM) data. METHODS This was an exploratory single arm study with a maximum length of 84 days. Eight insulin naïve people with T2D, planning to initiate basal insulin, wore a CGM throughout the study period. A predetermined regime was followed for the first two weeks after which the end dose was estimated. The clinician decided whether to follow this advice and continued the titration until target was reached using a twice weekly stepwise titration algorithm. The primary outcome was the comparison between the estimated and the actual end doses. RESULTS Median age of participants was 57 years (range: 50-77 years), duration of diabetes was 16 years (range: 5-29 years), and Bodi Mass Index (BMI) was 30.2 kg/m2 (range: 22.0-36.0 kg/m2). The median study end dose was 37 U (range: 20-123 U). The estimated end dose was smaller than or equal to the study end dose in all cases, with median error of 26.7% (range: 0.0%-75.8% underestimation). No self-monitoring of blood glucose values were below 70 mg/dL and no severe hypoglycemia occurred. CONCLUSION While accuracy may be improved, it was found safe to predict the study end dose of insulin degludec from two weeks of data.
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Affiliation(s)
- Tinna B. Aradóttir
- Technical University of Denmark,
Mathematical Modelling and Computer Science, Kgs. Lyngby, Denmark
- Novo Nordisk A/S, Bagsvaerd,
Denmark
- Tinna B. Aradóttir, MSc, Novo Nordisk A/S,
Brennum Park 20M, Hillerød 3400, Denmark.
| | | | | | - Niels K. Poulsen
- Technical University of Denmark,
Mathematical Modelling and Computer Science, Kgs. Lyngby, Denmark
| | - Dimitri Boiroux
- Technical University of Denmark,
Mathematical Modelling and Computer Science, Kgs. Lyngby, Denmark
- Novo Nordisk A/S, Bagsvaerd,
Denmark
| | | | - Signe Schmidt
- Steno Diabetes Center Copenhagen,
Gentofte, Denmark
- Hvidovre University Hospital, Hvidovre,
Denmark
| | - Kirsten Nørgaard
- Steno Diabetes Center Copenhagen,
Gentofte, Denmark
- Hvidovre University Hospital, Hvidovre,
Denmark
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5
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Sieber J, Weinheimer M, Kongable G, Riddle S, Chang YY, Flacke F. In Silico Examination of Initiation of Long-Acting Insulin Analogs Toujeo Compared to Lantus Under 3 Dosing Titration Rules in Virtual Type 2 Diabetes Subjects. J Diabetes Sci Technol 2020; 14:898-907. [PMID: 31288531 PMCID: PMC7753861 DOI: 10.1177/1932296819861586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite the benefits and clinical necessity of insulin treatment in type 2 diabetes (T2D), healthcare providers are reluctant to initiate insulin, and patients are reluctant to start it for several reasons, one of these being the complexity of insulin treatment. Patients and their healthcare providers can benefit from titration algorithms (TAs) or rules that assist with the initiation and titration of insulin, performing the calculations that are needed to safely initiate and conservatively adjust. METHODS The primary objective for this in silico study was to examine the effectiveness of 3 dose TAs (1-3) for optimization of basal insulin glargine (Gla-100 and Gla-300). In the simulations, 100 virtual subjects with T2D were included (50% men, age 62 ± 3 years, HbA1c 8.1% ± 2.9%, body weight 94 ± 16 kg). Subjects were studied under each TA (TA1 and TA2 fasting blood glucose [FBG] targets 90-130 mg/dL, TA3 FBG target 110-150 mg/dL). Initial dose of both insulins was based on 0.2 U/kg body weight. During 3 months, subjects reported their FBG to the LTHome web-based dose guidance system with a rules engine to safely guide long-acting insulin titration and maintenance. Subjects followed dose recommendations to reach designated FBG target ranges. RESULTS All subjects reached stable doses under all TAs with both Gla-100 and Gla-300 insulin, and 93 or more of the 100 subjects, depending on the assigned TA, achieved the target FBG range within the 3-month simulation for all TAs. Mean FBG was lowered (Gla-100: 155 ± 40 to 118 ± 11 mg/dL with TA1 and TA2 and 132 ± 12 mg/dL for TA3; Gla-300: 125 ± 14 with TA1 and TA2 and 134 ± 15 mg/dL with TA3). Calculated HbA1c improved from 8.1% ± 2.9% to 7.1% ± 2.5% for TA1 and TA2 and 7.5% ± 2.5% for TA3, a reduction of 0.9% and 0.6% over 3 months for both insulins. Three subjects on Gla-100 and one subject on Gla-300 experienced mild hypoglycemia. CONCLUSION All TAs delivered safe dose recommendations with minimal hypoglycemia, leading to a stable glucose control in the majority of subjects.
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Affiliation(s)
- Jochen Sieber
- Sanofi-Aventis Deutschland GmbH,
Frankfurt am Main, Germany
- Jochen Sieber, MD, PhD, Sanofi-Aventis GmbH
& Co KG, Industriepark Hoechst, Frankfurt, Germany.
| | | | | | | | | | - Frank Flacke
- Sanofi-Aventis Deutschland GmbH,
Frankfurt am Main, Germany
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6
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Cowart K. Overbasalization: Addressing Hesitancy in Treatment Intensification Beyond Basal Insulin. Clin Diabetes 2020; 38:304-310. [PMID: 32699482 PMCID: PMC7364465 DOI: 10.2337/cd19-0061] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Kevin Cowart
- Department of Pharmacotherapeutics & Clinical Research, Taneja College of Pharmacy and Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL
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7
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Yousof Ali M, Zaib S, Mizanur Rahman M, Jannat S, Iqbal J, Kyu Park S, Seog Chang M. Poncirin, an orally active flavonoid exerts antidiabetic complications and improves glucose uptake activating PI3K/Akt signaling pathway in insulin resistant C2C12 cells with anti-glycation capacities. Bioorg Chem 2020; 102:104061. [PMID: 32653611 DOI: 10.1016/j.bioorg.2020.104061] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/18/2020] [Accepted: 06/28/2020] [Indexed: 12/26/2022]
Abstract
Poncirin, a natural flavanone glycoside present abundantly in many citrus fruits, contains an extensive range of biological activities. However, the antidiabetic mechanism of poncirin is unexplored yet. In this study, we examined the anti-diabetic prospective of poncirin by evaluating its ability to inhibit protein tyrosine phosphatase 1B (PTP1B), α-glucosidase, human recombinant AR (HRAR), rat lens aldose reductase (RLAR), and advanced glycation end-product (AGE) formation (IC50 = 7.76 ± 0.21, 21.31 ± 1.26, 3.56 ± 0.33, 11.91 ± 0.21, and 3.23 ± 0.09 µM, respectively). Kinetics data and docking studies showed the lowest binding energy and highestaffinityforthemixed and competitivetypeof inhibitorsof poncirin. Moreover, the molecular mechanisms underlying the antidiabetic outcomes of poncirin in insulin resistant C2C12 skeletal muscle cells were explored, which significantly increased glucose uptake and decreased the expression of PTP1B in C2C12 cells. Consequently, poncirin increased GLUT-4 expression level by activating the IRS-1/PI3K/Akt/GSK-3 signaling pathway. Moreover, poncirin (0.5-50 µM) remarkably inhibited the formation of fluorescent AGE, nonfluorescent CML, fructosamine, and β-cross amyloid structures in glucose-fructose-induced BSA glycation during 4 weeks of study. Poncirin also notably prevented protein oxidation demonstrated with decreasing the protein carbonyl and the consumption of protein thiol in the dose-dependent manner. The results clearly expressed the promising activity of poncirin for the therapy of diabetes and its related complications.
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Affiliation(s)
- Md Yousof Ali
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada.
| | - Sumera Zaib
- Centre for Advanced Drug Research, COMSATS University Islamabad, Abbottabad Campus, Abbottabad 22060, Pakistan; Department of Biochemistry, Faculty of Life Sciences, University of Central Punjab, Lahore 54590, Pakistan
| | - M Mizanur Rahman
- Department of Biotechnology and Genetic Engineering, Islamic University, Kushtia 7003, Bangladesh
| | - Susoma Jannat
- Department of Biochemistry and Molecular Biology, University of Calgary, T2N 1N4 Alberta, Canada
| | - Jamshed Iqbal
- Centre for Advanced Drug Research, COMSATS University Islamabad, Abbottabad Campus, Abbottabad 22060, Pakistan
| | - Seong Kyu Park
- Department of Korean Medicine, Graduate School, Kyung Hee University, 26, Kyunghee dae-ro, Dongdaemun-gu, Seoul 02447, Republic of Korea
| | - Mun Seog Chang
- Department of Korean Medicine, Graduate School, Kyung Hee University, 26, Kyunghee dae-ro, Dongdaemun-gu, Seoul 02447, Republic of Korea.
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Jain SM, Seshadri K, Unnikrishnan AG, Chawla M, Kalra P, Vipin VP, Ravishankar E, Chordia J, Das S, Wasir J, Bandookwala SM, Deka N, Agarwal G, Vijaykumar G, Erande S. Best Practices and Tools for Titrating Basal Insulins: Expert Opinion from an Indian Panel via the Modified Delphi Consensus Method. Diabetes Ther 2020; 11:621-632. [PMID: 32009224 PMCID: PMC7048896 DOI: 10.1007/s13300-020-00770-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Indexed: 11/11/2022] Open
Abstract
AIM To develop an evidence-based expert group consensus document on the best practices and simple tools for titrating basal insulins in persons with type 2 diabetes mellitus (T2DM). BACKGROUND Glycemic control is suboptimal in a large proportion of persons with T2DM, despite insulin therapy, thereby increasing the risk of potentially severe complications. Early initiation of insulin therapy and appropriate dose titration are crucial to achieving glycemic targets. Attitudes and practices among healthcare professionals (HCPs) and perceptions about insulin therapy among persons with diabetes contribute largely to suboptimal glycemic control. Improving HCP-patient communication, encouraging the use of additional educational tools, and providing support for the titration process to increase confidence, both at the initiation visit and at home, facilitate the optimization of dose titration. In Indian settings, specific guidelines and a consensus statement are lacking on the optimal insulin initiation dose, frequency of dose titration, and basal insulin profile needed to achieve optimal titration. In clinical practice, physicians and persons with diabetes often do not adhere to the titration algorithms that currently exist for the purpose of achieving optimal titration as they perceive these to be very cumbersome. In this context, a group of experts met at an advisory board meeting and arrived at a consensus on best practices for the titration of basal insulin in persons withT2DM in India, using the modified Delphi methodology. REVIEW RESULTS After a review of evidence and further discussions, the expert group provided recommendations on insulin initiation dose, ideal period for titration in practice, titration regimen for use in practice, basal insulin profile for titration, and choosing a self-monitoring blood glucose schedule for titration. CONCLUSIONS In the management of T2DM, insulin can be effectively titrated by following a few simple recommendations. The use of second-generation basal insulin aids in mitigating the risk of hypoglycemic events. The implementation of a simplified titration regimen is crucial to achieving glycemic targets and long-term treatment goals.
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Affiliation(s)
- Sunil M Jain
- TOTALL Diabetes and Hormone Institute, Indore, Madhya Pradesh, India.
| | | | | | - Manoj Chawla
- Lina Diabetes Care and Mumbai Diabetes Research Centre, Mumbai, Maharashtra, India
| | - Pramila Kalra
- M S Ramaiah Memorial Hospital, Bangalore, Karnataka, India
| | - V P Vipin
- Aster Medcity, Cochin, Kerala, India
| | | | - Jay Chordia
- Fortis JK Hospital, Udaipur, Rajasthan, India
| | - Sambit Das
- Endeavor Clinic-Center of Diabetes and Endocrinology, Bhubaneswar, Odisha, India
| | | | - S M Bandookwala
- Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
| | | | | | - G Vijaykumar
- Diabetes Medicare Center, Chennai, Tamil Nadu, India
| | - Suhas Erande
- Akshay Hospital and Diabetic Speciality Centre and Insulin Pump Centre, Pune, Maharashtra, India
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9
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Garber AJ, Handelsman Y, Grunberger G, Einhorn D, Abrahamson MJ, Barzilay JI, Blonde L, Bush MA, DeFronzo RA, Garber JR, Garvey WT, Hirsch IB, Jellinger PS, McGill JB, Mechanick JI, Perreault L, Rosenblit PD, Samson S, Umpierrez GE. CONSENSUS STATEMENT BY THE AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY ON THE COMPREHENSIVE TYPE 2 DIABETES MANAGEMENT ALGORITHM - 2020 EXECUTIVE SUMMARY. Endocr Pract 2020; 26:107-139. [PMID: 32022600 DOI: 10.4158/cs-2019-0472] [Citation(s) in RCA: 342] [Impact Index Per Article: 85.5] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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10
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Liu X, Zhang J, Li Y, Sun L, Xiao Y, Gao W, Zhang Z. Mogroside derivatives exert hypoglycemics effects by decreasing blood glucose level in HepG2 cells and alleviates insulin resistance in T2DM rats. J Funct Foods 2019. [DOI: 10.1016/j.jff.2019.103566] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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11
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Hollander PA, Kiljanski J, Spaepen E, Harris CJ. Risk of clinically relevant hypoglycaemia in patients with type 2 diabetes self-titrating insulin glargine U-100. Diabetes Obes Metab 2019; 21:2413-2421. [PMID: 31264764 PMCID: PMC6852247 DOI: 10.1111/dom.13822] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 06/17/2019] [Accepted: 06/26/2019] [Indexed: 01/10/2023]
Abstract
AIMS We evaluated risk factors for clinically relevant hypoglycaemia (blood glucose <3 mmol/L) in patients with type 2 diabetes during insulin glargine self-titration. Data were from two clinical trials in which patients were able to improve glycaemic control by self-titration of insulin glargine using a simple algorithm. MATERIALS AND METHODS We performed post hoc analyses of pooled treatment groups from each of two Phase 3 studies comparing LY2963016 with LANTUS: ELEMENT-2 (double-blind) and ELEMENT-5 (open label). Clinically relevant hypoglycaemia was analysed by category of HbA1c (<7%, 7%-8.5%, >8.5%) at Week 12 (titration period) and at Week 24 (overall study), and by subgroups of age (<65, ≥65 years) and previous insulin use (naïve or not). RESULTS In the ELEMENT-2 study (N = 756), there were no overall differences in rate or incidence of hypoglycaemia among HbA1c categories. In the ELEMENT-5 study (N = 493), patients with HbA1c greater than 8.5% had a lower rate and incidence of hypoglycaemia throughout the study compared to those in the lower HbA1c categories. In both studies, patients 65 years of age or older, compared to those less than 65 years, had a higher rate and incidence of hypoglycaemia during the titration phase, had lower baseline HbA1c, and experienced smaller increases in dose, with no differences in HbA1c post baseline. The rate and incidence of hypoglycaemia was similar between naïve patients and patients previously using basal insulin, across all levels of glycaemic control. With the exception of the older subgroup, hypoglycaemia rates were similar during titration and maintenance periods. CONCLUSION Our results support broader use of self-titration algorithms for patients with type 2 diabetes.
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Affiliation(s)
| | - Jacek Kiljanski
- Department of Diabetes, Eli Lilly and Company, Lilly Corporate CenterIndianapolisIndiana
| | - Erik Spaepen
- Department of Statistics, Eli Lilly Deutschland GmbHBad HomburgGermany
| | - Cynthia J. Harris
- Department of Diabetes, Eli Lilly and Company, Lilly Corporate CenterIndianapolisIndiana
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12
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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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13
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Abstract
Insulin initiation and titration can be challenging for many primary care providers who are involved in the treatment of patients with type 2 diabetes. Despite the introduction of advanced insulin analogs and improvements in insulin delivery devices, many patients with type 2 diabetes continue to experience suboptimal glycemic control. With an increasing number of treatment options available, type 2 diabetes management is moving away from a "one-size-fits-all" approach and toward individualized treatment regimens based on particular patient needs. Given this, nurse practitioners, physician assistants, pharmacists, and certified diabetes educators are becoming increasingly valuable resources in busy primary care practices.
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Affiliation(s)
- Ji Chun
- OptumCare Medical Group, Laguna Niguel, CA
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14
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Garber AJ, Abrahamson MJ, Barzilay JI, Blonde L, Bloomgarden ZT, Bush MA, Dagogo-Jack S, DeFronzo RA, Einhorn D, Fonseca VA, Garber JR, Garvey WT, Grunberger G, Handelsman Y, Hirsch IB, Jellinger PS, McGill JB, Mechanick JI, Rosenblit PD, Umpierrez GE. CONSENSUS STATEMENT BY THE AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY ON THE COMPREHENSIVE TYPE 2 DIABETES MANAGEMENT ALGORITHM - 2019 EXECUTIVE SUMMARY. Endocr Pract 2019; 25:69-100. [PMID: 30742570 DOI: 10.4158/cs-2018-0535] [Citation(s) in RCA: 203] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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15
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Aradottir TB, Boiroux D, Bengtsson H, Poulsen NK. Modelling of fasting glucose-insulin dynamics from sparse data .. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2018; 2018:2354-2357. [PMID: 30440879 DOI: 10.1109/embc.2018.8512792] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
With the fast growth of diabetes prevalence, the disease is now considered an epidemic. Diabetes is characterized by elevated glucose levels, that may be treated with insulin. Tight control of glucose is essential for prevention of complications and patients' well-being. In this paper we model the fasting glucose-insulin dynamics in type 2 diabetes, aiming at controlling the glucose level. Relevant clinical data are typically sparse and have a sampling period much greater than the fast dynamics in the glucose-insulin dynamics in humans. We adapt a physiological model such that important slow non-linear dynamics are identifiable and test the resulting model on deterministic simulated data and sparse, slow sampled clinical data.
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16
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Berard L, Antonishyn N, Arcudi K, Blunden S, Cheng A, Goldenberg R, Harris S, Jones S, Mehan U, Morrell J, Roscoe R, Siemens R, Vallis M, Yale JF. Insulin Matters: A Practical Approach to Basal Insulin Management in Type 2 Diabetes. Diabetes Ther 2018; 9:501-519. [PMID: 29476414 PMCID: PMC6104258 DOI: 10.1007/s13300-018-0375-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Indexed: 12/14/2022] Open
Abstract
It is currently estimated that 11 million Canadians are living with diabetes or prediabetes. Although hyperglycemia is associated with serious complications, it is well established that improved glycemic control reduces the risk of microvascular complications and can also reduce cardiovascular (CV) complications over the long term. The UKPDS and ADVANCE landmark trials have resulted in diabetes guidelines recommending an A1C target of ≤ 7.0% for most patients or a target of ≤ 6.5% to further reduce the risk of nephropathy and retinopathy in those with type 2 diabetes (T2D), if it can be achieved safely. However, half of the people with T2D in Canada are not achieving these glycemic targets, despite advances in diabetes pharmacological management. There are many contributing factors to account for this poor outcome; however, one of the major factors is the delay in treatment advancement, particularly a resistance to insulin initiation and intensification. To simplify the process of initiating and titrating insulin in T2D patients, a group of Canadian experts reviewed the evidence and best clinical practices with the goal of providing guidance and practical recommendations to the diabetes healthcare community at large. This expert panel included general practitioners (GPs), nurses, nurse practitioners, endocrinologists, dieticians, pharmacists, and a psychologist. This article summarizes the panel recommendations.
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Affiliation(s)
- Lori Berard
- Winnipeg Regional Health Authority, Winnipeg Diabetes Research Group, Health Sciences Centre, Winnipeg, MB, Canada.
| | - Noreen Antonishyn
- Department of Endocrinology, Alberta Health Services, Edmonton, AB, Canada
| | - Kathryn Arcudi
- Diabetes Clinic, The Montreal West Island Integrated University Health and Social Services Centre (Lakeshore General Hospital), Pointe-Claire, QC, Canada
| | - Sarah Blunden
- Diabetes Education, LMC Diabetes and Endocrinology, Montreal, QC, Canada
| | - Alice Cheng
- Division of Endocrinology and Metabolism, St. Michael's Hospital, Toronto, ON, Canada
- Trillium Health Partners, Credit Valley Hospital, Mississauga, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Stewart Harris
- Department of Family Medicine, Western University, London, ON, Canada
| | | | - Upender Mehan
- The Centre for Family Medicine, Kitchener, ON, Canada
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - James Morrell
- Diabetes Services, Island Health, Victoria, BC, Canada
| | - Robert Roscoe
- Diabetes Education Centre, Saint John Regional Hospital, Saint John, NB, Canada
| | | | - Michael Vallis
- Behaviour Change Institute, Nova Scotia Health Authority, Halifax, NS, Canada
- Department of Family Medicine, Dalhousie University, Halifax, NS, Canada
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17
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Deerochanawong C, Bajpai S, Dwipayana IMP, Hussein Z, Mabunay MA, Rosales R, Tsai ST, Tsang MW. Optimizing Glycemic Control Through Titration of Insulin Glargine 100 U/mL: A Review of Current and Future Approaches with a Focus on Asian Populations. Diabetes Ther 2017; 8:1197-1214. [PMID: 29094298 PMCID: PMC5688987 DOI: 10.1007/s13300-017-0322-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Indexed: 01/25/2023] Open
Abstract
Various data have demonstrated inadequate glycemic control amongst Asians with type 2 diabetes mellitus (T2DM), possibly on account of suboptimal titration of basal insulin-an issue which needs to be further examined. Here we review the available global and Asia-specific data on titration of basal insulin, with a focus on the use of insulin glargine 100 U/mL (Gla-100). We also discuss clinical evidence on the efficacy and safety of titrating Gla-100, different approaches to titration, including some of the latest technological advancements, and guidance on the titration of basal insulin from international and local Asian guidelines. The authors also provide their recommendations for the initiation and titration of basal insulin for Asian populations. Discussion of the data included in this review and in relation to the authors' clinical experience with treating T2DM in Asian patients is also included. Briefly, clinical studies demonstrate the achievement of adequate glycemic control in adults with T2DM through titration of Gla-100. However, studies investigating approaches to titration, specifically in Asian populations, are lacking and need to be conducted. Given that the management of insulin therapy is a multidisciplinary team effort involving endocrinologists, primary care physicians, nurse educators, and patients, greater resources and education targeted at these groups are needed regarding the optimal titration of basal insulin. Technological advancements in the form of mobile or web-based applications for automated dose adjustment can aid different stakeholders in optimizing the dose of basal insulin, enabling a larger number of patients in Asia to reach their target glycemic goals with improved outcomes.
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18
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Klonoff DC, Kerr D. A Simplified Approach Using Rate of Change Arrows to Adjust Insulin With Real-Time Continuous Glucose Monitoring. J Diabetes Sci Technol 2017; 11:1063-1069. [PMID: 28884599 PMCID: PMC5951054 DOI: 10.1177/1932296817723260] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- David C. Klonoff
- Mills-Peninsula Medical Center, San Mateo, CA, USA
- David C. Klonoff, MD, FACP, FRCPE, Fellow AIMBE, Mills-Peninsula Medical Center, 100 S San Mateo Dr, Rm 5147, San Mateo, CA 94401, USA.
| | - David Kerr
- William Sansum Diabetes Center, Santa Barbara, CA, USA
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19
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Ma X, Chien JY, Johnson J, Malone J, Sinha V. Simulation-Based Evaluation of Dose-Titration Algorithms for Rapid-Acting Insulin in Subjects with Type 2 Diabetes Mellitus Inadequately Controlled on Basal Insulin and Oral Antihyperglycemic Medications. Diabetes Technol Ther 2017; 19:483-490. [PMID: 28700249 DOI: 10.1089/dia.2016.0361] [Citation(s) in RCA: 3] [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: 12/21/2022]
Abstract
BACKGROUND The purpose of this prospective, model-based simulation approach was to evaluate the impact of various rapid-acting mealtime insulin dose-titration algorithms on glycemic control (hemoglobin A1c [HbA1c]). METHODS Seven stepwise, glucose-driven insulin dose-titration algorithms were evaluated with a model-based simulation approach by using insulin lispro. Pre-meal blood glucose readings were used to adjust insulin lispro doses. Two control dosing algorithms were included for comparison: no insulin lispro (basal insulin+metformin only) or insulin lispro with fixed doses without titration. RESULTS Of the seven dosing algorithms assessed, daily adjustment of insulin lispro dose, when glucose targets were met at pre-breakfast, pre-lunch, and pre-dinner, sequentially, demonstrated greater HbA1c reduction at 24 weeks, compared with the other dosing algorithms. Hypoglycemic rates were comparable among the dosing algorithms except for higher rates with the insulin lispro fixed-dose scenario (no titration), as expected. The inferior HbA1c response for the "basal plus metformin only" arm supports the additional glycemic benefit with prandial insulin lispro. CONCLUSIONS Our model-based simulations support a simplified dosing algorithm that does not include carbohydrate counting, but that includes glucose targets for daily dose adjustment to maintain glycemic control with a low risk of hypoglycemia.
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Affiliation(s)
- Xiaosu Ma
- 1 Eli Lilly and Company , Indianapolis, Indiana
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20
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Polonsky WH, Arsenault J, Fisher L, Kushner P, Miller EM, Pearson TL, Tracz M, Harris S, Hermanns N, Scholz BM, Pollom RK, Perez-Nieves M, Pollom RD, Hadjiyianni I. Initiating insulin: How to help people with type 2 diabetes start and continue insulin successfully. Int J Clin Pract 2017; 71:e12973. [PMID: 28735508 PMCID: PMC5601201 DOI: 10.1111/ijcp.12973] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- William H Polonsky
- Behavioral Diabetes Institute, San Diego, CA, USA
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA
| | - Joyce Arsenault
- CIUSSS-Jewish General Hospital Endocrinology, Montreal, QC, Canada
| | - Lawrence Fisher
- Family and Community Medicine, University of California School of Medicine, San Francisco, CA, USA
| | - Pamela Kushner
- Family Medicine, University of California School of Medicine, Irvine, CA, USA
| | | | | | - Mariusz Tracz
- Department of Diabetology and Internal Medicine, Warsaw Medical University, Warsaw, Poland
| | - Stewart Harris
- Western Center For Public Health and Family Medicine, Western University, London, ON, Canada
| | - Norbert Hermanns
- Research Institute of Diabetes Academy Mergentheim (FIDAM), Bad Mergentheim, Germany
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21
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Garber AJ, Abrahamson MJ, Barzilay JI, Blonde L, Bloomgarden ZT, Bush MA, Dagogo-Jack S, DeFronzo RA, Einhorn D, Fonseca VA, Garber JR, Garvey WT, Grunberger G, Handelsman Y, Hirsch IB, Jellinger PS, McGill JB, Mechanick JI, Rosenblit PD, Umpierrez GE. CONSENSUS STATEMENT BY THE AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY ON THE COMPREHENSIVE TYPE 2 DIABETES MANAGEMENT ALGORITHM - 2017 EXECUTIVE SUMMARY. Endocr Pract 2017; 23:207-238. [PMID: 28095040 DOI: 10.4158/ep161682.cs] [Citation(s) in RCA: 330] [Impact Index Per Article: 47.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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22
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Yang W, Yang Z, Zhao J, Lu H, Luo T. Assessment of three fasting plasma glucose targets for insulin glargine-based therapy in people with type 2 diabetes mellitus in China: study protocol for a randomized controlled trial. Trials 2016; 17:470. [PMID: 27669747 PMCID: PMC5037905 DOI: 10.1186/s13063-016-1588-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 09/06/2016] [Indexed: 12/13/2022] Open
Abstract
Background A large proportion of patients with T2DM in China do not meet accepted HbA1c targets despite the availability of guidelines that describe a treatment pathway for achieving glycemic control. The aim of this study is to identify the fasting plasma glucose (FPG) target that will provide the highest control rate of HbA1c <7 % in Chinese patients with T2DM treated with an insulin glargine-based regimen as an adjunct to an established OAD regimen. This information will support improvements in diabetes care management in China. Methods Approximately 934 men and women aged ≥18 to ≤65 years with poorly controlled T2DM will be enrolled and randomized to one of three FPG target groups; ≤5.6 mmol/L, ≤6.1 mmol/L, or ≤7.0 mmol/L. They will be initiated on daily insulin glargine (Lantus®) in addition to their usual OAD regimen for 24 weeks. Patients will self-monitor fasting blood glucose (SM-FBG), and the study physician will titrate the basal insulin dose according to the SM-FBG results. In addition, HbA1c and safety will be recorded. We plan to statistically derive the optimal FPG target for an HbA1c of <7 %. Discussion In China, treatment strategies that would achieve an optimum balance between glycemic control (as per HbA1c) and hypoglycemia are imperative to ensure improvements in the management of T2DM. Furthermore, elucidating the contribution of FPG to HbA1c in Chinese patients with T2DM and identifying a predictable relationship between FPG and HbA1c would be a valuable tool for patient self-management of diabetes. Trial registration NCT02545842. Registered on 8 September 2015.
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Affiliation(s)
- Wenying Yang
- China-Japan Friendship Hospital, East Yinghuayuan Street, Hepingli, Beijing, 100029, People's Republic of China.
| | - Zhaojun Yang
- China-Japan Friendship Hospital, East Yinghuayuan Street, Hepingli, Beijing, 100029, People's Republic of China
| | - Jing Zhao
- Jing'An Kerry Centre, 19F, Tower III, No.1228M, Yan'an Road, Shanghai, 200040, People's Republic of China
| | - Hai Lu
- Jing'An Kerry Centre, 19F, Tower III, No.1228M, Yan'an Road, Shanghai, 200040, People's Republic of China
| | - Tianhong Luo
- Jing'An Kerry Centre, 19F, Tower III, No.1228M, Yan'an Road, Shanghai, 200040, People's Republic of China
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23
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Pfützner A, Stratmann B, Funke K, Pohlmeier H, Rose L, Sieber J, Flacke F, Tschoepe D. Real-World Data Collection Regarding Titration Algorithms for Insulin Glargine in Patients With Type 2 Diabetes Mellitus. J Diabetes Sci Technol 2016; 10:1122-9. [PMID: 27325389 PMCID: PMC5032964 DOI: 10.1177/1932296816654714] [Citation(s) in RCA: 9] [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: 11/16/2022]
Abstract
The primary objective of this study was to collect data regarding the effectiveness of different dose titration algorithms (TAs) for optimization or initiation of basal insulin supported oral therapy (BOT) in patients with type 2 diabetes. A total of 50 patients were enrolled in this trial (17 women, 33 men, age 63 ± 8 years, HbA1c 7.9 ± 0.8%). The investigator decided on an individual basis to apply any of 4 standard TAs: standard (S: fasting glucose target 90-130 mg/dL, n = 39), standard-fast titration (S-FT: 90-130 mg/dL, larger dose increments at FBG < 180 mg/dl, n = 1), less tight (LT: 110-150 mg/dL, n = 5), and tight (T: 70-100 mg/dL, n = 5). During the next 30 days daily contacts were used to adapt the insulin dose. The majority of all patients (70%) achieved a stable insulin glargine dose within 5 ± 6 days after initiation of the dose titration. HbA1c improved from 7.9 ± 0.8% to 7.5 ± 0.7% (P < .001). In total, 1300 dose decisions were made (1192 according to the TA and 108 by the physicians independently from the TA in 29 patients [58% of study population]). Reasons for TA-overruling dosing decisions were hypoglycemic events (14 mild/4 moderate) in 9 patients. In the majority of these cases (89.8%), the physician recommended continuation of the previous dose or a higher dose. The majority of FBG values were within the respective target range after 4 weeks. In conclusion, the insulin glargine TAs delivered safe dose recommendations with a low risk of hypoglycemia, which successfully led to a stable dose in the vast majority of patients.
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Affiliation(s)
| | - Bernd Stratmann
- Herz- und Diabeteszentrum NRW, Ruhr Universität Bochum, Bad Oeynhausen, Germany
| | | | | | | | | | | | - Diethelm Tschoepe
- Herz- und Diabeteszentrum NRW, Ruhr Universität Bochum, Bad Oeynhausen, Germany
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24
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Sehgal S, Khanolkar M. Starting insulin in type 2 diabetes: real-world outcomes after the first 12 months of insulin therapy in a new zealand cohort. Diabetes Ther 2015; 6:49-60. [PMID: 25680537 PMCID: PMC4374070 DOI: 10.1007/s13300-015-0100-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Indexed: 11/30/2022] Open
Abstract
AIMS Currently, there is no consensus on which form of insulin to use when initiating insulin in type 2 diabetes (T2D). Our aim was to compare glycated hemoglobin (HbA1C) reduction, weight change and severe hypoglycemia rates during the first year after initiation of intermediate-acting insulin isophane, insulin glargine and pre-mixed insulin in patients with T2D. METHODS Electronic clinical records of patients with T2D, starting insulin at a tertiary referral center in Auckland, New Zealand, from January 1 to December 31, 2012, were retrospectively evaluated. Primary outcomes were HbA1C reduction at 12 months and number of hospital admissions for hypoglycemia. RESULTS Of 339 eligible patients, 273 (80.5%) started on intermediate insulin, 24 started on insulin glargine and 42 started on pre-mixed insulin. The mean HbA1C at insulin initiation was 89-95 mmol/mol, but had decreased at 12 months by 26.6 mmol/mol with insulin glargine, 23.4 mmol/mol with pre-mixed insulin and 16.6 mmol/mol with insulin isophane (p < 0.05 vs. baseline for all groups). Patients on insulin glargine were more likely to achieve the HbA1C target of <55 mmol/mol compared with patients on insulin isophane (16.7% vs. 4.8%; p = 0.04). Persistence rates were higher in patients initiated on pre-mixed insulin vs. insulin isophane (90.5% vs. 69.6%; p = 0.01). After controlling for confounding variables, glargine was more likely to achieve an HbA1C target of <55 (p = 0.05). CONCLUSIONS All insulin types caused a significant reduction in HbA1C, but very few met HbA1C targets. Insulin isophane was the most common type of insulin prescribed at initiation, with comparable outcomes to other types of insulin. More observational studies are needed to explore the possible impact of using other insulin types at initiation.
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Affiliation(s)
- Shekhar Sehgal
- Diabetes and Endocrinology registrar, Department of Endocrinology and Diabetes, Waikato Hospital, Hamilton, New Zealand
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25
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Home PD, Bolli GB, Mathieu C, Deerochanawong C, Landgraf W, Candelas C, Pilorget V, Dain MP, Riddle MC. Modulation of insulin dose titration using a hypoglycaemia-sensitive algorithm: insulin glargine versus neutral protamine Hagedorn insulin in insulin-naïve people with type 2 diabetes. Diabetes Obes Metab 2015; 17:15-22. [PMID: 24957785 PMCID: PMC4282751 DOI: 10.1111/dom.12329] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 04/21/2014] [Accepted: 06/09/2014] [Indexed: 11/30/2022]
Abstract
AIMS To examine whether insulin glargine can lead to better control of glycated haemoglobin (HbA1c) than that achieved by neutral protamine Hagedorn (NPH) insulin, using a protocol designed to limit nocturnal hypoglycaemia. METHODS The present study, the Least One Oral Antidiabetic Drug Treatment (LANCELOT) Study, was a 36-week, randomized, open-label, parallel-arm study conducted in Europe, Asia, the Middle East and South America. Participants were randomized (1:1) to begin glargine or NPH, on background of metformin with glimepiride. Weekly insulin titration aimed to achieve median prebreakfast and nocturnal plasma glucose levels ≤5.5 mmol/l, while limiting values ≤4.4 mmol/l. RESULTS The efficacy population (n = 701) had a mean age of 57 years, a mean body mass index of 29.8 kg/m², a mean duration of diabetes of 9.2 years and a mean HbA1c level of 8.2% (66 mmol/mol). At treatment end, HbA1c values and the proportion of participants with HbA1c <7.0 % (<53 mmol/mol) were not significantly different for glargine [7.1 % (54 mmol/mol) and 50.3%] versus NPH [7.2 % (55 mmol/mol) and 44.3%]. The rate of symptomatic nocturnal hypoglycaemia, confirmed by plasma glucose ≤3.9 or ≤3.1 mmol/l, was 29 and 48% less with glargine than with NPH insulin. Other outcomes were similar between the groups. CONCLUSION Insulin glargine was not superior to NPH insulin in improving glycaemic control. The insulin dosing algorithm was not sufficient to equalize nocturnal hypoglycaemia between the two insulins. This study confirms, in a globally heterogeneous population, the reduction achieved in nocturnal hypoglycaemia while attaining good glycaemic control with insulin glargine compared with NPH, even when titrating basal insulin to prevent nocturnal hypoglycaemia rather than treating according to normal fasting glucose levels.
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Affiliation(s)
- P D Home
- Institute for Cellular Medicine – Diabetes, Newcastle UniversityNewcastle upon Tyne, UK
- Correspondence to: Prof. Philip Home, Institute for Cellular Medicine – Diabetes, Newcastle University, The Medical School, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK. E-mail:
| | - G B Bolli
- Department of Medicine, University of PerugiaPerugia, Italy
| | - C Mathieu
- Department of Endocrinology, University Hospital GasthuisbergLeuven, Belgium
| | - C Deerochanawong
- Rajavithi Hospital, College of Medicine, Rangsit University, Ministry of Public HealthBangkok, Thailand
| | | | | | | | | | - M C Riddle
- Oregon Health & Science UniversityPortland, OR, USA
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26
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Blackberry ID, Furler JS, Ginnivan LE, Manski-Nankervis JA, Jenkins A, Cohen N, Best JD, Young D, Liew D, Ward G, O'Neal DN. An exploratory trial of basal and prandial insulin initiation and titration for type 2 diabetes in primary care with adjunct retrospective continuous glucose monitoring: INITIATION study. Diabetes Res Clin Pract 2014; 106:247-55. [PMID: 25271117 DOI: 10.1016/j.diabres.2014.08.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 08/12/2014] [Accepted: 08/23/2014] [Indexed: 11/21/2022]
Abstract
AIMS To evaluate basal and prandial insulin initiation and titration in people with type 2 diabetes mellitus (T2DM) in primary care and to explore the feasibility of retrospective-continuous glucose monitoring (r-CGM) in guiding insulin dosing. The new model of care features General Practitioners (GPs) and Practice Nurses (PNs) working in an expanded role, with Credentialed Diabetes Educator - Registered Nurse (CDE-RN) support. METHODS Insulin-naïve T2DM patients (HbA1c >7.5% [>58 mmol/mol] despite maximal oral therapy) from 22 general practices in Victoria, Australia commenced insulin glargine, with glulisine added as required. Each was randomised to receive r-CGM or self-monitoring of blood glucose (SMBG). Glycaemic control (HbA1c) was benchmarked against specialist ambulatory patients referred for insulin initiation. RESULTS Ninety-two patients mean age (range) 59 (28-77) years; 40% female; mean (SD) diabetes duration 10.5 (6.1) years participated. HbA1c decreased from (median (IQR)) 9.9 (8.8, 11.2)%; 85 (73, 99) mmol/mol to 7.3 (6.9, 7.8)%; 56 (52, 62) mmol/mol at 24 weeks (p < 0.0001). Comparing r-CGM (n = 46) with SMBG (n = 42), there were no differences in major hypoglycaemia (p=0.17) or ΔHbA1c (p = 0.31). More r-CGM than SMBG participants commenced glulisine (26/48 vs. 7/44; p < 0.001). Results were comparable to 82 benchmark patients, with similar low rates of major hypoglycaemia (2/89 vs. 0/82; p = 0.17) and less loss to follow up in the INITIATION group (3/92 vs. 14/82; p = 0.002). CONCLUSIONS Insulin initiation and titration for T2DM patients in primary care was safe and improved HbA1c with low rates of major hypoglycaemia. CDE-RNs were effective in a new consultant role. r-CGM use in primary care was feasible and enhanced post-prandial hyperglycaemia recognition. Trial registration ACTRN12610000797077.
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Affiliation(s)
- Irene D Blackberry
- General Practice and Primary Health Care Academic Centre, The University of Melbourne, 200 Berkeley St, Carlton 3053, Australia.
| | - John S Furler
- General Practice and Primary Health Care Academic Centre, The University of Melbourne, 200 Berkeley St, Carlton 3053, Australia.
| | - Louise E Ginnivan
- General Practice and Primary Health Care Academic Centre, The University of Melbourne, 200 Berkeley St, Carlton 3053, Australia.
| | - Jo-Anne Manski-Nankervis
- General Practice and Primary Health Care Academic Centre, The University of Melbourne, 200 Berkeley St, Carlton 3053, Australia.
| | - Alicia Jenkins
- Department of Medicine, St Vincent's Hospital, The University of Melbourne, Level 4, Clinical Sciences Building, 29 Regent St Fitzroy, Melbourne, VIC 3065, Australia.
| | - Neale Cohen
- Baker-IDI Heart and Diabetes Institute, PO Box 6492, St Kilda Road Central, 8008, Australia.
| | - James D Best
- Melbourne Medical School, Level 2 West, Medical Building, The University of Melbourne, VIC 3010, Australia.
| | - Doris Young
- General Practice and Primary Health Care Academic Centre, The University of Melbourne, 200 Berkeley St, Carlton 3053, Australia.
| | - Danny Liew
- Melbourne EpiCentre, The University of Melbourne, c/- The Royal Melbourne Hospital, 7 East, Main Building, Grattan St, Parkville, VIC 3050, Australia.
| | - Glenn Ward
- Department of Endocrinology and Diabetes, St Vincent's Hospital, Level 4, Clinical Sciences Building, 29 Regent St Fitzroy, Melbourne, VIC 3065, Australia.
| | - David N O'Neal
- Department of Medicine, St Vincent's Hospital, The University of Melbourne, Level 4, Clinical Sciences Building, 29 Regent St Fitzroy, Melbourne, VIC 3065, Australia.
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Rossetti P, Ampudia-Blasco FJ, Ascaso JF. Old and new basal insulin formulations: understanding pharmacodynamics is still relevant in clinical practice. Diabetes Obes Metab 2014; 16:695-706. [PMID: 24401118 DOI: 10.1111/dom.12256] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 07/05/2013] [Accepted: 12/20/2013] [Indexed: 12/17/2022]
Abstract
Long-acting insulin analogues have been developed to mimic the physiology of basal insulin secretion more closely than human insulin formulations (Neutral Protamine Hagedorn, NPH). However, the clinical evidence in favour of analogues is still controversial. Although their major benefit as compared with NPH is a reduction in the hypoglycaemia risk, some cost/effectiveness analyses have not been favourable to analogues, largely because of their higher price. Nevertheless, these new formulations have conquered the insulin market. Human insulin represents currently no more than 20% of market share. Despite (in fact because of) the widespread use of insulin analogues it remains critical to analyse the pharmacodynamics (PD) of basal insulin formulations appropriately to interpret the results of clinical trials correctly. Importantly, these data may help physicians in tailoring insulin therapy to patients' individual needs and, additionally, when clinical evidence is not available, to optimize insulin treatment. For patients at low risk for/from hypoglycaemia, it might be acceptable and also cost-effective not to use long-acting insulin analogues as basal insulin replacement. Conversely, in patients with a higher degree of insulin deficiency and increased risk for hypoglycaemia, analogues are the best option due to their more physiological profile, as has been shown in PD and clinical studies. From this perspective optimizing basal insulin treatment, especially in type 2 diabetes patients who are less prone to hypoglycaemia, would be suitable making significant resources available for other relevant aspects of diabetes care.
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MESH Headings
- Chemistry, Pharmaceutical
- Diabetes Mellitus, Type 1/drug therapy
- Diabetes Mellitus, Type 2/drug therapy
- Evidence-Based Medicine
- Humans
- Hypoglycemic Agents/chemistry
- Hypoglycemic Agents/pharmacokinetics
- Hypoglycemic Agents/pharmacology
- Hypoglycemic Agents/therapeutic use
- Insulin, Long-Acting/chemistry
- Insulin, Long-Acting/pharmacokinetics
- Insulin, Long-Acting/pharmacology
- Insulin, Long-Acting/therapeutic use
- Insulin, Short-Acting/chemistry
- Insulin, Short-Acting/pharmacokinetics
- Insulin, Short-Acting/pharmacology
- Insulin, Short-Acting/therapeutic use
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Affiliation(s)
- P Rossetti
- Department of Internal Medicine, Sant Francesc de Borja Hospital, Gandia, Spain
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