Early insulin therapy for type 2 diabetic patients: more cost than benefit

The antidiabetic potential of endophytic fungi: Future prospects as therapeutic agents

Diabetes mellitus is one of the most common systemic diseases in the world, and it occurs when the body becomes resistant to insulin or does not make enough insulin. As described by the World Health Organization, diabetes mellitus of all types has exponentially grown in the past decades across the globe and it is estimated to be 629 million by 2045. Despite this alarming prevalence of diabetes mellitus, there is still the lack of harmless preventive medicines. Natural products and compounds obtained from plants, fungi, bacteria, and other living organisms have been used for many decades in folklore medicine to prepare a varied range of natural formulations to treat multiple diseases and illnesses. Endophytic fungi reside inside the plant while causing no harm to the host plant and are relatively less explored as the primary source for the bioactive metabolites such as anticancer, antioxidant, antimicrobial, antidiabetic, and industrial enzymes. This mini-review summarizes the potential of compounds and extracts from endophytic fungi against diabetes mellitus. Not much research has been dedicated in-depth understanding of the role of extracts of endophytic fungi and their effect on diabetes mellitus. Therefore, this article will focus on recent work and warrant further commentaries on the published articles.

Should the last be first? Questions and dilemmas regarding early short-term insulin treatment in Type 2 Diabetes Mellitus

INTRODUCTION

Early short-term insulin treatment (STIT), defined as insulin administration shortly after diabetes diagnosis for only a brief period of time, is an alternative concept, aiming to entirely revise the perspective of type 2 diabetes (T2DM) management.

AREAS COVERED

The present review intends to summarize what is already known regarding early STIT in T2DM and highlight questions and dilemmas from the clinician's point of view, with a discourse on future research agenda.

EXPERT OPINION

STIT has the potential to modify the natural history of T2DM, resulting in improved drug-free remission rates by favorably affecting the underlying pathophysiology of the disease. Existing data in the field manifest significant weaknesses, mainly being the small number of trials and patients included, the lack of control groups in most studies and the wide heterogeneity between study designs and explored outcomes, which limit definitive conclusions. Therefore, before such a therapeutic strategy is incorporated into daily practice, important issues require further clarification by future trials. These issues include the optimal time point for the intervention, the ideal insulin type, the identification of patients being most likely to benefit, the STIT effects on cardiovascular and other clinical outcomes and the cost-effectiveness evaluation of this therapeutic strategy.

ABBREVIATIONS

T2DM: Type 2 Diabetes Mellitus; HbA_1C: Hemoglobin A_1c; OHA: Oral Hypoglycemic Agents; STIT: Short-term Insulin Treatment; CSII: Continuous Subcutaneous Insulin Infusion; MDI: Multiple Daily Injections; PPG: Postprandial Plasma Glucose; FPG: Fasting Plasma Glucose; HOMA-b: Homeostasis Model Assessment of beta-cell function; TDD: Total Daily Insulin Dose; DI: Disposition Index; HOMA-IR: Homeostasis Model Assessment of Insulin Resistance; ROS: Reactive Oxygen Species; TNF: Tumor Necrosis Factor; GLP-1: Glucagon-like peptide-1; GIP: Glucose-dependent Insulinotropic Polypeptide; BMI: Body Mass Index; CV: Cardiovascular; DR: Diabetic Retinopathy; SU: Sulfonylurea; IGI: Insulinogenic Index.

Health Outcomes Associated with Initiation of Basal Insulin After 1, 2, or ≥ 3 Oral Antidiabetes Drug(s) Among Managed Care Patients with Type 2 Diabetes

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a progressive disease. Despite starting with single oral antidiabetes drug (OAD) therapy and then adding OAD(s), most patients eventually require insulin therapy to achieve and maintain glycemic control. The timely initiation of insulin therapy could help patients with T2DM whose glycemic control is not adequately maintained using OADs alone.

OBJECTIVE

To describe and compare baseline characteristics and assess real-world health outcomes associated with initiating basal insulin after 1 OAD, 2 OADs, or ≥ 3 OADs among T2DM patients.

METHODS

Data were analyzed from adult T2DM patients in a U.S. managed care claims database (IMPACT) who initiated a basal insulin (from January 1, 2001, to December 31, 2011) with continuous health plan enrollment for 6 months before (baseline) and 12 months after (follow-up) insulin initiation and who had at least 1 OAD prescription. Outcome measures according to the number of OADs used were (a) treatment discontinuation, (b) glycated hemoglobin (A1c) levels, (c) proportion of patients experiencing hypoglycemia, (d) health care resource utilization, and (e) costs.

RESULTS

Data from 71,988 patients were included (1 OAD: 19,168 patients [26.6%]; 2 OADs: 29,112 [40.4%]; and ≥ 3 OADs: 23,708 [32.9%]). All baseline characteristics, except nephropathy, were significantly different across the 3 groups. At baseline, when compared with the 1 OAD or 2 OADs groups, the ≥3 OADs group was less likely to be female or have macrovascular disease and had experienced fewer hypoglycemic events and hospitalization as well as lower costs. At follow-up, treatment discontinuation rates were 36.0%, 27.6%, and 21.4% for the 1 OAD, 2 OADs, and ≥ 3 OADs groups, respectively. A1c reduction was -1.33%, -1.05%, and -0.86%, respectively. The proportion of patients experiencing any hypoglycemia was 4.7%, 3.8%, and 3.3% at baseline; and 3.7%, 3.5%, and 3.1% at follow-up for the 1 OAD, 2 OADs, and ≥3 OADs groups, respectively. In all 3 groups, health care costs decreased compared with baseline, particularly in the 1 OAD and 2 OADs groups, with decreased inpatient costs offsetting increased drug costs.

CONCLUSIONS

This real-world analysis shows that there are significant baseline differences in patients with T2DM on 1 OAD, 2 OADs, or ≥3 OADs when adding insulin therapy. All 3 groups had significant improvements in clinical and economic outcomes compared with baseline, yet at different magnitudes. These data contribute to a growing body of evidence supporting the timely initiation of insulin therapy for T2DM patients not maintaining glycemic control with OADs.

Duration of diabetes and effectiveness of insulin in the management of insulin-naïve Korean patients uncontrolled on oral antidiabetic drugs: a sub-analysis of the MOdaliTy of Insulin treatment eValuation (MOTIV) registry results

To investigate whether duration of diabetes has an impact on the effectiveness of insulinization in diabetes management. This open-label, noninterventional, observational registry was conducted at >500 centers in Korea. Patients with diabetes, on oral antidiabetic drugs, with HbA1c ≥7 % (53 mmol/mol) in the preceding 3 months, being considered for initiation of basal insulin by their physicians, were included. Data were collected at baseline and at 3 and 6 months. Of 6,616 patients evaluated, 62.5 % had diabetes for <10 years, while only 6.5 % patients had diabetes for ≥20 years. At the end of study, average HbA1c in patients with diabetes for <10 years, for 10 to <20 years, and for ≥20 years was 7.3 ± 1.0 % (56 ± 10.9 mmol/mol), 7.4 ± 1.0 % (57 ± 10.9 mmol/mol), and 7.6 ± 1.1 % (60 ± 12.0 mmol/mol), respectively. Over half the patients (50.7 %) with diabetes <10 years achieved HbA1c <7 % (53 mmol/mol) by the end of study, while only 42.1 and 35.1 % patients with diabetes for 10 to <20 and ≥20 years, respectively, achieved their target. The average insulin dosage required for per unit HbA1c reduction was significantly different among the groups according to duration of type 2 diabetes mellitus (p < 0.05). Among patients who achieved HbA1c <7 %, proportion of patients with hypoglycemia in the ≥20 years group was higher than that in the <10 years, 10 to <20 years groups. Early insulin administration provided a better glycemic control with less insulin dosage and lower frequency of hypoglycemic events. Thus, early insulinization might hold the key to better management of type 2 diabetes mellitus.

Achieving glycaemic targets with basal insulin in T2DM by individualizing treatment

Insulin therapy is an effective method for reducing blood glucose levels in patients with type 2 diabetes mellitus (T2DM), and most patients with T2DM eventually require insulin replacement to attain and preserve satisfactory glycaemic control. All patients with T2DM should be considered as potential candidates for intensive insulin treatment; however, there are certain considerations regarding replacement therapy for different types of people and special populations, such as patients with multiple comorbidities, adolescents, pregnant women and the elderly. Lowering HbA1c levels in isolation without assessing the patient as a whole is becoming redundant. HbA1c targets should be individualized to the specific patient, and insulin treatment ought to be customized accordingly. There are several questions that need to be taken into account when considering adding insulin therapy to other oral antidiabetic agents, for example, for whom and when insulin therapy is indicated and which basal insulin should be utilized. Potential barriers exist related to patients, providers and health-care systems that can delay the start of insulin therapy, and every effort should be made to identify and address these obstacles.

Predictors of achieving HbA(1c) <7% and no hypoglycaemia 6 months after initiation of biphasic insulin aspart 30 in patients with type 2 diabetes in the IMPROVE study

BACKGROUND

Early initiation of insulin therapy has widely been associated with numerous benefits, including improved glycaemic control and reduced long-term risk of developing microvascular diseases. Biphasic insulins offer a convenient option for insulin initiation, addressing both basal and postprandial insulin requirements with one injection, making them relatively simple for patients to dose. Development of biphasic insulin aspart (BIAsp) has further offered improved postprandial glycaemic control and lower rates of nocturnal and major hypoglycaemia than biphasic human insulin.

METHODS

The safety and efficacy of the 30/70 rapid-acting/intermediate-acting formulation of BIAsp (BIAsp 30) in patients with type 2 diabetes was examined in the IMPROVE study, a 26-week, international, observational trial. In this subanalysis, baseline clinical factors that predicted treatment success, defined as HbA1c <7% (<53 mmol/mol) without experiencing hypoglycaemia after 26 weeks on BIAsp 30 therapy, were assessed.

RESULTS

The composite endpoint was defined for 44,010 (77%) patients from the total cohort of 57,478, and 28,696 of these were included in the statistical examination. The results of the analysis suggest that those with lower baseline HbA1c of ≤8% (≤64 mmol/mol), shorter duration of diabetes at baseline (<5 years) and no incidence of major hypoglycaemia at 13 weeks, or minor hypoglycaemia at 4 weeks, before the beginning of the trial were more likely to achieve treatment success.

CONCLUSION

Lower baseline HbA1c, shorter duration of diabetes and no incidence of hypoglycaemia up to 13 weeks prior to initiation are predictors of achieving HbA1c <7% without hypoglycaemia with a BIAsp 30 regimen. These results suggest that it is easier to reach target without hypoglycaemia with BIAsp 30 when prescribed earlier. As this was an observational study, lack of control groups or randomisation, as well as varying clinical practices in study countries, potentially introduced bias.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00659282.

Insulin adherence behaviours and barriers in the multinational Global Attitudes of Patients and Physicians in Insulin Therapy study

AIMS

To examine patient and physician beliefs regarding insulin therapy and the degree to which patients adhere to their insulin regimens.

METHODS

Internet survey of 1250 physicians (600 specialists, 650 primary care physicians) who treat patients with diabetes and telephone survey of 1530 insulin-treated patients (180 with Type 1 diabetes, 1350 with Type 2 diabetes) in China, France, Japan, Germany, Spain, Turkey, the UK or the USA.

RESULTS

One third (33.2%) of patients reported insulin omission/non-adherence at least 1 day in the last month, with an average of 3.3 days. Three quarters (72.5%) of physicians report that their typical patient does not take their insulin as prescribed, with a mean of 4.3 days per month of basal insulin omission/non-adherence and 5.7 days per month of prandial insulin omission/non-adherence. Patients and providers indicated the same five most common reasons for insulin omission/non-adherence: too busy; travelling; skipped meals; stress/emotional problems; public embarrassment. Physicians reported low patient success at initiating insulin in a timely fashion and adjusting insulin doses. Most physicians report that many insulin-treated patients do not have adequate glucose control (87.6%) and that they would treat more aggressively if not for concern about hypoglycaemia (75.5%). Although a majority of patients (and physicians) regard insulin treatment as restrictive, more patients see insulin treatment as having positive than negative impacts on their lives.

CONCLUSIONS

Glucose control is inadequate among insulin-treated patients, in part attributable to insulin omission/non-adherence and lack of dose adjustment. There is a need for insulin regimens that are less restrictive and burdensome with lower risk of hypoglycaemia.

Initiation of insulin among veterans with type 2 diabetes and sustained elevation of A1c

AIM

To examine if the relationship between insulin initiation and glycemic control among veterans with poorly controlled type 2 diabetes (T2DM) varies by the number of oral-glucose-lowering-medication classes used prior to insulin initiation.

METHODS

The cohort consisted of veterans with T2DM with at least two glycosolated hemoglobins (A1c) ≥8.0% within a 12-month period but without prior insulin use. The study period was October 1998 until May 2006. Cox regression analyses were used to assess the predictors of the rate of insulin initiation.

RESULTS

Among 40,537 who met the inclusion criteria, 17,519 (43.2%) had insulin initiated over a median follow-up period of 58.6 months. The rate of insulin initiation due to 1% increase in A1c increased by 33.6%, 28.8%, 24.2%, 19.7%, 15.4% for patients exposed to 0, 1, 2, 3, 4 classes of oral-glucose-lowering agents. A higher insulin initiation rate was also associated with younger age, more comorbidities, non-Hispanic white race/ethnicity, obesity, longer diabetes duration, and attending endocrinology clinics.

CONCLUSIONS

Poor glycemic control is associated with increased rates of insulin initiation. This relationship is attenuated by the number of distinct oral-glucose-lowering-medication classes used prior to insulin initiation.

Barriers to diabetes management: patient and provider factors

Despite significant advances in diagnosis and treatment, the persistence of inadequate metabolic control continues. Poor glycemic control may be reflected by both the failure of diabetes self-management by patients as well as inadequate intervention strategies by clinicians. The purpose of this systematic review is to summarize existing knowledge regarding various barriers of diabetes management from the perspectives of both patients and clinicians. A search of PubMed, CINAHL, ERIC, and PsycINFO identified 1454 articles in English published between 1990 and 2009, addressing type 2 diabetes, patient's barriers, clinician's barriers, and self-management. Patients' adherence, attitude, beliefs, and knowledge about diabetes may affect diabetes self-management. Culture and language capabilities influence the patient's health beliefs, attitudes, health literacy, thereby affecting diabetes self-management. Other influential factors include the patient's financial resources, co-morbidities, and social support. Clinician's attitude, beliefs and knowledge about diabetes also influence diabetes management. Clinicians may further influence the patient's perception through effective communication skills and by having a well-integrated health care system. Identifying barriers to diabetes management is necessary to improve the quality of diabetes care, including the improvement of metabolic control, and diabetes self-management. Further research that considers these barriers is necessary for developing interventions for individuals with type 2 diabetes.

Successes and challenges of insulin therapy for type 2 diabetes in a managed-care setting

OBJECTIVE

Although insulin is the most effective diabetes medication for lowering blood glucose, how insulin is used in clinical practice and how well patients respond to insulin therapy over the course of several years has not been documented. Our objective was to describe glycemic control, side-effects and dose titration over 7 years among persons starting insulin in a health plan that has long used a treatment algorithm similar to the current American Diabetes Association/European Association for the Study of Diabetes (ADA-EASD) algorithm for the management of hyperglycemia.

RESEARCH DESIGN AND METHODS

Patients (n = 2417) who initiated insulin therapy between 1 January 1999 and 31 December 2004 were followed for a mean of 49.5 months until 30 June 2007, death, or health plan termination. Mean hemoglobin A1C, number of units of insulin purchased and body weight were assessed on a quarterly basis. The proportion experiencing edema or hypoglycemia was assessed annually.

RESULTS

Mean population A1C declined from 9.3 to 7.8% following insulin initiation and remained at that level for 7 years. However, A1C remained above 8% for 40% of patients, half of whom remained above 9.0%. The mean individual coefficient of variation in A1C was 0.12 (inter-quartile range 0.072-0.143). Mean daily insulin dosage started at 55 units and increased to approximately 100 units. Patients gained a mean of 6 lb (2.7 kg) during the first year then gained weight more gradually thereafter. Physicians diagnosed edema in 8-9% of patients annually. Hypoglycemia occurred in fewer than 2% of patients in any given year, with no cases requiring hospitalization.

CONCLUSIONS

Insulin lowered mean A1C by about 1.5 percentage points to stable levels, but this required ongoing dosage increases. Nevertheless, many patients remained in poor control. Insulin is effective when used per ADA-EASD guidelines but health plans wishing to optimize diabetes care may need to intensify insulin therapy or consider the use of adjunct therapies in the years after initiation. This study was limited by its observational descriptive design, and its reliance on insulin purchases rather than actual consumption.

Factors affecting use of insulin pens by patients with type 2 diabetes

OBJECTIVE

To assess factors that might affect patient use of insulin pens.

RESEARCH DESIGN AND METHODS

Patients (n = 600: 300 using vial and syringe and 300 using pen) were recruited from national panels to participate in computer-assisted telephone interviews. Measures included: demographic characteristics; diabetes treatment and self-care factors; perceptions of pen convenience, clinical efficacy, facilitation of self-care, and cost; and degree of physicians' recommending pen use.

RESULTS

Physician recommendation of pen use powerfully discriminated pen users from nonusers (odds ratio 135.6). Other factors that discriminated pen users included physicians' presenting pens as an option (14.1) and patient perceptions that pens facilitate diabetes self-care (20.2) and are not costly (4.8).

CONCLUSIONS

The physician's role in presenting the pen as an option and recommending pen use was a critical factor in patient pen use. Enhanced physician education regarding the potential benefits of pen use and encouraging physicians to discuss pen use with patients could improve diabetes outcomes.

Resistance to insulin therapy among patients and providers: results of the cross-national Diabetes Attitudes, Wishes, and Needs (DAWN) study

OBJECTIVE

To examine the correlates of patient and provider attitudes toward insulin therapy.

RESEARCH DESIGN AND METHODS

Data are from surveys of patients with type 2 diabetes not taking insulin (n = 2,061) and diabetes care providers (nurses = 1,109; physicians = 2,681) in 13 countries in Asia, Australia, Europe, and North America. Multiple regression analysis is used to identify correlates of attitudes toward insulin therapy among patients, physicians, and nurses.

RESULTS

Patient and provider attitudes differ significantly across countries, controlling for individual characteristics. Patients rate the clinical efficacy of insulin as low and would blame themselves if they had to start insulin therapy. Self-blame is significantly lower among those who have better diet and exercise adherence and less diabetes-related distress. Patients who are not managing their diabetes well (poor perceived control, more complications, and diabetes-related distress) are significantly more likely to see insulin therapy as potentially beneficial. Most nurses and general practitioners (50-55%) delay insulin therapy until absolutely necessary, but specialists and opinion leaders are less likely to do so. Delay of insulin therapy is significantly less likely when physicians and nurses see their patients as more adherent to medication or appointment regimens, view insulin as more efficacious, and when they are less likely to delay oral diabetes medications.

CONCLUSIONS

Patient and provider resistance to insulin therapy is substantial, and for providers it is part of a larger pattern of reluctance to prescribe blood glucose-lowering medication. Interventions to facilitate timely initiation of insulin therapy will need to address factors associated with this resistance.