Calculated Daily Insulin Dosages Overestimate Prescribed Insulin Doses in Type 2 Diabetes: A Primary Care Database Study

No effects of the COVID-19 pandemic on the prescription of insulin in Germany

AIMS

The aim of the study was to investigate the change of insulin doses in Germany between 2017 and 2021.

METHODS

This retrospective study used data from the longitudinal prescription LRx database (IQVIA) and included all patients with at least two insulin prescriptions per year in 2017-2021. Calculated daily dose (CDD) was assessed in 2017, 2018, 2019, 2020, and 2021, separately.

RESULTS

The number of patients was comprised between 1,079,894 in 2021 and 1,132,839 in 2018. Median (interquartile range) CDD of basal insulin was relatively stable across the years and ranged between 27.9 (18.5-38.8) in 2021 and 28.3 (18.7-39.5) in 2020. In terms of short-acting insulin, median (interquartile range) CDD slightly decreased from 40.1 (28.2-54.3) in 2017 to 38.1 (27.2-52.2) in 2021. A slight decrease was also observed for mix insulin, from 39.4 (27.5-55.3) in 2017 to 37.9 (26.5-54.2) in 2021. These results were corroborated in most age and sex subgroups.

CONCLUSIONS

COVID-19 had no substantial effects on insulin doses in Germany. Further data are warranted to corroborate or refute these findings in other settings and countries.

Patterns of insulin therapy and insulin daily doses in children and adolescents with type 1 diabetes in Germany

AIM

To describe the different insulin therapy patterns and insulin daily doses in children and adolescents (aged 1-17 years) with type 1 diabetes.

METHODS

This cross-sectional study based on the longitudinal prescription (LRx) database (IQVIA) included children and adolescents who received at least two insulin prescriptions of the same drug from 1 January 2016 to 31 December 2019. The study outcomes included the proportion of patients with insulin pumps and multiple daily injection therapy, human insulin and insulin analogue use, as well as insulin daily doses. A multivariable linear regression model was used to study the association between age, sex, insulin drugs, and daily dose.

RESULTS

A total of 22 512 children and adolescents (mean age: 13.5 years, 47.1% female) were included. The proportion of patients using insulin pump therapy decreased with age, from 72.6% (females) and 73.0% (males) in the age group of younger than 6 years to 30.8% (females) and 26.1% (males) in adolescents. Insulin aspart was the most common short-acting insulin, with the proportion of users increasing from 56% in the age group of younger than 6 years to 69%-70% in the 13-17 years age group. The daily dose of insulin pump therapy was 10 units lower than multiple daily injection (MDI) (P < .001).

CONCLUSION

We found a marked age dependency for pump use, with a strong increase observed in the youngest age group. Insulin aspart was the most frequently used analogue insulin. A higher total daily insulin dose was shown in patients on MDI versus insulin pump, along with a significant age dependency.

Slow Titration and Delayed Intensification of Basal Insulin Among Patients with Type 2 Diabetes

BACKGROUND

Clinical inertia in type 2 diabetes mellitus (T2DM) refers to the failure of clinicians to intensify therapy when indicated. Many T2DM patients remain suboptimally controlled after initiating basal insulin.

OBJECTIVE

To examine the prevalence of patients treated with basal insulin but in poor glycemic control (hemoglobin A1c [A1c] ≥ 7%) after initiation and subsequent treatment intensification patterns and glycemic outcomes in a real-world setting.

METHODS

Adults diagnosed with T2DM newly initiating a basal insulin analog (insulin glargine or detemir) from January 2010 to September 2014 were identified in the QuintilesIMS Real-World Data Adjudicated Claims linked to the QuintilesIMS Real-World Data Electronic Medical Records. Patients were previously naive to insulin and glucagon-like peptide-1 receptor agonists (GLP-1 RAs), were persistent on therapy for ≥ 6 months, and had ≥ 12 months of continuous health plan enrollment after initiation. First treatment intensification (increase in basal insulin dose [of ≥ 10%], addition of bolus insulin, GLP-1 RA, or a new oral antidiabetic drug [OAD]) was assessed among patients in poor glycemic control at 6 months after initiation over the available (minimum ≥ 12-month) follow-up. Subsequent glycemic outcomes and treatment intensification were assessed. Kaplan-Meier (KM) analysis evaluated time-to-treatment intensification and time to A1c goal.

RESULTS

Of 427 eligible patients with A1c available at 6 months, 59.3% were male; mean age was 53.9 years; mean follow-up was 29.4 months; and mean dose of the initiated prescription was 29.6 insulin units (U) (median 24U). Six months after initiating basal insulin, 81.0% of patients (n = 346) remained in poor glycemic control, and mean basal insulin dose was 31.0U (median 25U). Most (88.4%; n = 306) of these uncontrolled patients subsequently intensified treatment over the available follow-up. Using KM analysis, these patients intensified treatment in a median of 58 days (range: 17.5 days [GLP-1 RA addition] to 52 days [increase in basal insulin dose]) from the first elevated A1c measurement taken after 6 months, and 72.5% (GLP-1 RA addition) to 91.1% (OAD addition) of patients continued to remain in poor glycemic control at 12 months after intensification. Most patients (66.8%; n = 231/346) first intensified treatment by increasing their basal insulin dose, and mean dose increased to 61.7U (median 38U) at intensification. Six months following basal insulin increase, almost all patients remained on basal insulin therapy and among those with available A1c, 92.1% (140 of 152) were in poor glycemic control. In the subsequent 12 months, only a third (34%) of uncontrolled patients added another antihyperglycemic agent.

CONCLUSIONS

The vast majority of patients remained uncontrolled in the 6 months following basal insulin initiation. Basal insulin up-titration was slow and insufficient in the 6 months after initiation, indicating treatment inertia. Subsequently, most patients failed to achieve glycemic targets despite intensification with basal insulin. This finding suggests a substantial unmet need for effective treatment intensification among T2DM patients treated with basal insulin who remain uncontrolled. Improved provider education and guidelines on appropriate intensification are warranted.

DISCLOSURES

This study was funded by Novo Nordisk. Mocarski, Guerrero, Langer, and Thorsted are employees and shareholders of Novo Nordisk. Yeaw, Divino, and DeKoven are employed by QuintilesIMS, which received remuneration from Novo Nordisk for work on this study. Study concept and design were contributed by Mocarski, DeKoven, Langer, and Thorsted. Yeaw took the lead in data collection, along with Divino and DeKoven. Data interpretation was performed by Yeaw, Divino, DeKoven, and Guerrero. The manuscript was written by Mocarski and Divino and revised by Guerrero, Langer, and Thorsted, along with Yeaw and DeKoven. Some of the data from this study were presented via poster at the AMCP Annual Meeting in March 2017 and at the 53rd EASD Annual Meeting in September 2017.