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Ranganna A, Chen W, DeLacey S, Lado J, Levin L, Swamy A, Bianco ME. Comparing long-term outcomes of children treated with new-onset type 2 diabetes in an outpatient versus inpatient setting: A retrospective chart review. J Diabetes 2024; 16:e13571. [PMID: 38751370 PMCID: PMC11096808 DOI: 10.1111/1753-0407.13571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 02/08/2024] [Accepted: 04/18/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Early identification and management of pediatric type 2 diabetes mellitus (T2DM) is crucial for improving long-term outcomes. This study aimed to assess if the severity of T2DM at presentation, inferred by the location of treatment initiation (inpatient or outpatient), influences long-term clinical outcomes. METHODS A retrospective chart review was conducted on 116 pediatric T2DM patients. Data on treatment initiation location, initial and subsequent glycated hemoglobin (HbA1c) levels, prescribed insulin, and body mass index were collected from electronic medical records. RESULTS Of the 116 patients, 69 were initially treated in an inpatient setting, and 47 received outpatient treatment. At treatment initiation, the inpatient group had significantly higher HbA1c levels compared to the outpatient group (p < .001), but 3 years after treatment initiation, no significant difference in HbA1c was observed between the two groups (p = .057). Prescribed insulin dosages were higher in the inpatient group at treatment initiation (p < .001) and remained higher after 3 years (p < 0.003) compared to the outpatient group. CONCLUSIONS Pediatric patients initially treated in an inpatient setting had poorer glycemic control and higher prescribed insulin dosing at baseline. After 3 years, there was no significant difference in HbA1c levels, but patients treated as inpatients continued to have higher prescribed insulin. These findings suggest that the severity of diabetes at initial presentation may affect long-term clinical outcomes in children with T2DM.
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Affiliation(s)
- Adesh Ranganna
- Northwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Wenya Chen
- Ann & Robert H. Lurie Children's Hospital of ChicagoChicagoIllinoisUSA
| | - Sean DeLacey
- Ann & Robert H. Lurie Children's Hospital of ChicagoChicagoIllinoisUSA
- Department of PediatricsNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Juan Lado
- Ann & Robert H. Lurie Children's Hospital of ChicagoChicagoIllinoisUSA
- Department of PediatricsNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Laura Levin
- Ann & Robert H. Lurie Children's Hospital of ChicagoChicagoIllinoisUSA
- Department of PediatricsNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Anita Swamy
- Ann & Robert H. Lurie Children's Hospital of ChicagoChicagoIllinoisUSA
- Department of PediatricsNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Monica E. Bianco
- Ann & Robert H. Lurie Children's Hospital of ChicagoChicagoIllinoisUSA
- Department of PediatricsNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
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Karacaer C, Demirci T, Cengiz H, Varim C, Tamer A. The effect of short-term intensive insulin therapy in newly-diagnosed Type-2 diabetic patients. Pak J Med Sci 2021; 37:1972-1978. [PMID: 34912428 PMCID: PMC8613043 DOI: 10.12669/pjms.37.7.4013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 06/02/2021] [Accepted: 06/12/2021] [Indexed: 11/16/2022] Open
Abstract
Objectives: We aimed to determine the effect of short-term intensive insulin therapy (SIIT) on long-term glycemic control in newly-diagnosed Type-2 diabetes mellitus (nT2DM) patients. Methods: In this retrospectively study conducted at Sakarya University Medical Faculty Training and Research Hospital Outpatient Clinic between 2016 and 2019, 65 nT2DM patients were enrolled soon after their SIIT was initiated and were followed for at least a year. Intensive insulin treatment was discontinued after three or 12 months in a total of 65 (23–73-year-old) patients who had been newly diagnosed with T2DM. Intensive insulin therapy was discontinued when glycemic control and the target Glycated Hemoglobin (HbA1c) level had been attained, after which oral anti-diabetic drug (OAD), long-term insulin, and diet therapies were pursued. Results: There was a significant decrease in mean HbA1c from 11.25±1.96% to 6.67±1.07%. Fasting plasma glucose (FPG) was found to be an independent predictor of whether intensive insulin therapy could be discontinued after three months in a model that included FPG, HbA1c, and body mass index measured at baseline. Patients with FPG>13.8 mmol/L were 7.6 times more likely to require intensive insulin therapy beyond three months. There were significant decreases in HbA1c and low-density lipoprotein-cholesterol concentration, but no change in C-peptide between baseline and 3 months of therapy. Conclusion: These results demonstrate that in nT2DM patients, intensive insulin therapy could be effective on long-term glycemic control and high FPG prior to three months of SIIT may predict poor long-term glycemic control.
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Affiliation(s)
- Cengiz Karacaer
- Dr. Cengiz Karacaer Department of Internal Medicine, Sakarya University Treatment and Research Hospital, Department of Internal Medicine, Sakarya, Turkey
| | - Taner Demirci
- Taner Demirci Assistant Professor, Department of Endocrinology and Metabolism, Sakarya University Treatment and Research Hospital, Department of Endocrinology and Metabolism, Sakarya, Turkey
| | - Hasret Cengiz
- Dr. Hasret Cengiz Department of Endocrinology and Metabolism, Sakarya University Treatment and Research Hospital, Department of Endocrinology and Metabolism, Sakarya, Turkey
| | - Ceyhun Varim
- Dr. Ceyhun Varim Department of Internal Medicine, Sakarya University Treatment and Research Hospital, Department of Internal Medicine, Sakarya, Turkey
| | - Ali Tamer
- Ali Tamer Professor, Department of Internal Medicine, Sakarya University Treatment and Research Hospital, Department of Internal Medicine, Sakarya, Turkey
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3
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Delay in starting insulin therapy in patients with type 2 Diabetes Mellitus. JOURNAL OF SURGERY AND MEDICINE 2020. [DOI: 10.28982/josam.776346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Zheng HL, Xing Y, Li F, Ding W, Ye SD. Effect of short-term intensive insulin therapy on α-cell function in patients with newly diagnosed type 2 diabetes. Medicine (Baltimore) 2020; 99:e19685. [PMID: 32243407 PMCID: PMC7440309 DOI: 10.1097/md.0000000000019685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The effect of intensive insulin therapy on hyperglucagonemia in newly diagnosed type 2 diabetes (T2DM), and its associations with β-cell function, has not been elucidated. This study assessed the effect of 12 weeks of intensive insulin therapy on hyperglucagonemia in newly diagnosed T2DM and its associations with β-cell function, with reference to the effects of 12 weeks of oral hypoglycemic agents (OHAs).One hundred eight patients with newly diagnosed T2DM were enrolled from January 2015 to December 2015. The patients were randomly divided to receive, for 12 weeks, either intensive insulin therapy or OHAs. Meal tolerance tests were conducted at baseline before treatment (0 week), at 12 weeks (end of treatment), and 12 months after the initiation of treatment. The levels of glucagon, proinsulin, C-peptide (CP), and blood glucose were measured at timepoints 0, 30, and 120 minutes during the meal tolerance test.Intensive insulin treatment was associated with a decrease in glucagon levels (at 0, 30, and 120 minutes) and proinsulin/CP, and an increase in the insulin-secretion index ΔCP30/ΔG30 and ΔCP120/ΔG120, at 12 weeks and 12 months during the follow-up, compared with the corresponding effects of OHAs. Intensive insulin therapy could reduce but failed to normalize glucagon levels at 12 weeks. There were no correlations between the change of percentages in total area under the curve of glucagon and other glycemic parameters (proinsulin/CP; ΔCP30/ΔG30; or ΔCP120/ΔG120). Patients who received intensive insulin therapy were more likely to achieve their target glycemic goal and remission, compared with those who received OHAs.Short-term intensive insulin therapy facilitates the improvement of both β-cell and α-cell function in newly diagnosed T2DM mellitus. Decline of β-cell secretion and concomitant α-cell dysfunction may both be involved in the pathogenesis of T2DM.
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Affiliation(s)
- Hai-Lan Zheng
- Shandong University School of Medicine, Jinan
- Department of Endocrinology, First People's Hospital of Anqing City, Anqing
| | - Yan Xing
- Department of Endocrinology, Anhui Provincial Hospital, Hefei, China
| | - Fan Li
- Department of Endocrinology, First People's Hospital of Anqing City, Anqing
| | - Wei Ding
- Department of Endocrinology, First People's Hospital of Anqing City, Anqing
| | - Shan-Dong Ye
- Shandong University School of Medicine, Jinan
- Department of Endocrinology, Anhui Provincial Hospital, Hefei, China
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5
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Liu L, Liu J, Xu L, Ke W, Wan X, Li H, He X, Wang L, Cao X, Xiao H, Li Y. Lower mean blood glucose during short-term intensive insulin therapy is associated with long-term glycemic remission in patients with newly diagnosed type 2 diabetes: Evidence-based recommendations for standardization. J Diabetes Investig 2018; 9:908-916. [PMID: 29193795 PMCID: PMC6031520 DOI: 10.1111/jdi.12782] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 11/26/2017] [Indexed: 12/16/2022] Open
Abstract
AIMS/INTRODUCTION Optimal glycemic targets during short-term intensive insulin therapy in patients with newly diagnosed type 2 diabetes are not standardized. The present study was carried out to determine the optimal glycemic targets during therapy by analyzing the impacts of glucose levels on therapeutic outcomes. MATERIALS AND METHODS A total of 95 individuals with newly diagnosed type 2 diabetes were enrolled. Short-term intensive insulin therapy was carried out using an insulin pump to achieve and maintain glycemic targets (fasting blood glucose ≤6.0 mmol/L, 2-h postprandial blood glucose ≤7.8 mmol/L) for 14 days, with daily eight-point capillary blood glucose profiles recorded. Patients were followed up for 1 year after discharge. RESULTS In most participants, the mean blood glucose and glycemic excursion parameters during the therapy were controlled within the normal range. Mean blood glucose was independently associated with amelioration of acute insulin response (r = -0.25, P = 0.015) and 1-year remission (odds ratio 0.12, 95% confidence interval 0.034-0.426), but negatively associated with more level 1 hypoglycemia (r = -0.34, P = 0.001), although major hypoglycemia was rare. Among mean blood glucose tertiles, patients in the middle (68.7%) and lower (75.0%) tertiles had a higher 1-year remission rate compared with the upper tertile (32.3%, both P < 0.001), whereas only the middle tertile did not have increased hypoglycemia compared with the upper tertile (8.1 ± 5.4 vs 7.2 ± 3.9 events/person, P = 0.48). CONCLUSIONS Stricter glycemic control during short-term intensive insulin therapy produced more remission despite self-manageable hypoglycemia. Based on glycemic parameters in the middle mean tertile, we propose new glycemic targets that are approximately 0.4 mmol/L lower than current the targets, as long-term benefit outweighs short-term risks.
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Affiliation(s)
- Liehua Liu
- Department of EndocrinologyThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
| | - Juan Liu
- Department of EndocrinologyThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
| | - Lijuan Xu
- Department of EndocrinologyThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
| | - Weijian Ke
- Department of EndocrinologyThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
| | - Xuesi Wan
- Department of EndocrinologyThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
| | - Hai Li
- Department of EndocrinologyThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
| | - Xiaoying He
- Department of EndocrinologyThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
| | - Liangjiao Wang
- Department of EndocrinologyThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Present address:
Dongguan People's Hospital, Dongguan, Guangdong ProvinceChina
| | - Xiaopei Cao
- Department of EndocrinologyThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
| | - Haipeng Xiao
- Department of EndocrinologyThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
| | - Yanbing Li
- Department of EndocrinologyThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
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6
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Chon S, Rhee SY, Ahn KJ, Baik SH, Park Y, Nam MS, Lee KW, Yoo SJ, Koh G, Lee DH, Kim YS, Woo JT. Long-term effects on glycaemic control and β-cell preservation of early intensive treatment in patients with newly diagnosed type 2 diabetes: A multicentre randomized trial. Diabetes Obes Metab 2018; 20:1121-1130. [PMID: 29272062 DOI: 10.1111/dom.13196] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 12/11/2017] [Accepted: 12/18/2017] [Indexed: 12/16/2022]
Abstract
AIM To determine the effects of early intensive glycaemic control with intensive insulin treatment (IIT) or initial combined oral antidiabetic drug (COAD) therapy on long-term glycaemic control and the preservation of β-cell function in people with type 2 diabetes mellitus (T2DM). METHODS Newly diagnosed drug-naïve patients with T2DM from 8 outpatient diabetes centres were randomized to receive either IIT (n = 50; glargine/glulisine) or COAD (n = 47; glimepiride/metformin) as intensive treatment until the termination criteria to ensure euglycaemia were met. After intensive treatment, the patients completed a follow-up period with either lifestyle modification (LSM) alone or rescue therapy to maintain target glycated haemoglobin levels of <7% (53 mmol/mol) up to week 104. The primary outcomes were analysed after excluding participants who were anti-glutamic acid decarboxylase autoantibody-positive. RESULTS Both intensive treatment methods were effective for short-term glycaemic control, but improvements in the disposition index (DI) were significantly greater in the IIT group than in the COAD group (P = .021). During the follow-up period after intensive treatment, the two groups significantly differed in rescue method regarding the maintenance of comparable levels of glycaemic control (P = .010) and more participants who received IIT exhibited well-controlled glycaemia with LSM alone. Additionally, the IIT group maintained a higher DI than the COAD group during the follow-up period. Cox regression analysis showed that the IIT method was associated with a 52.5% lower risk of failing to maintain drug-free glycaemic remission compared with the COAD method (P = .015). CONCLUSIONS The findings indicate that outpatient clinic-based IIT to ensure euglycaemia in newly diagnosed patients with T2DM might be an effective initial therapeutic option for improvements in β-cell function and glycaemic control over the long term, without serious adverse events.
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Affiliation(s)
- Suk Chon
- Department of Endocrinology and Metabolism, Kyung Hee University School of Medicine, Seoul, Korea
| | - Sang Youl Rhee
- Department of Endocrinology and Metabolism, Kyung Hee University School of Medicine, Seoul, Korea
| | - Kyu Jeung Ahn
- Department of Endocrinology and Metabolism, Kyung Hee University School of Medicine, Seoul, Korea
| | - Sei Hyun Baik
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Yongsoo Park
- Department of Internal Medicine, Hanyang University College of Medicine, Guri, Korea
| | - Moon Suk Nam
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Kwan Woo Lee
- Department of Endocrinology and Metabolism, Ajou University School of Medicine, Suwon, Korea
| | - Soon Jib Yoo
- Department of Endocrinology and Metabolism, Bucheon St. Mary's Hospital, The Catholic University of Korea, Bucheon, Korea
| | - Gwanpyo Koh
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Dae Ho Lee
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Young Seol Kim
- Department of Endocrinology and Metabolism, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jeong-Taek Woo
- Department of Endocrinology and Metabolism, Kyung Hee University School of Medicine, Seoul, Korea
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Kawamura T, Sato I, Tamura H, Nakao YM, Kawakami K. Influence of comorbidities on the implementation of the fundus examination in patients with newly diagnosed type 2 diabetes. Jpn J Ophthalmol 2017; 62:68-76. [PMID: 29210009 DOI: 10.1007/s10384-017-0551-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 10/19/2017] [Indexed: 01/24/2023]
Abstract
AIMS To investigate the influence of comorbidities on undergoing a diabetic eye examination in patients with newly diagnosed type 2 diabetes mellitus (T2DM). DESIGN Retrospective cohort study METHODS: This was a retrospective cohort study using data from health insurance claims made between January 2005 and March 2013 in Japan. The primary outcome was implementation of the fundus examination that includes fundus photography, ophthalmoscopy and optical coherence tomography by a doctor within one year of initial drug therapy for Type2 Diabetes Mellitus (T2DM). We used multivariable logistic regression models with adjustment for demographic parameters to investigate the influence of comorbidities (hypertension and/or hyperlipidemia) on patients with T2DM receiving fundus examinations. We conducted an additional analysis to investigate whether the site of treatment might influence the performance of fundus examinations in patients with T2DM. RESULTS A total of 6,492 patients were eligible for this analysis, of which 1,044 (16.1%) had comorbidities and 2,212 (34.1%) received the fundus examination. In the multivariable analysis, there was a significant association between comorbidities and a lower proportion of examination implementation (odds ratio [OR], 0.57; 95% confidence interval [CI], 0.48-0.68; P<0.001). The implementation proportion for patients treated for comorbidities and T2DM in the same facility was also low (OR, 0.52; 95% CI, 0.43-0.63; P<0.001). CONCLUSIONS These results suggest that the proportion of taking fundus examination is low among patients with comorbidities, especially in patients treated at the same facility for comorbidities and T2DM. This may help to increase the proportion of T2DM patients receiving fundus examinations.
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Affiliation(s)
- Taichi Kawamura
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan.,Senju Pharmaceutical Co., Ltd., Osaka, Japan
| | - Izumi Sato
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan.,Keihanshin Consortium for Fostering the Next Generation of Global Leaders in Research (K-CONNEX), Kyoto, Japan
| | - Hiroshi Tamura
- Division of Medical Information Technology and Administration Planning, Kyoto University Hospital, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.,Department of Ophthalmology and Visual Sciences, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.,Center for Innovative Research and Education in Data Science, Institute for Liberal Arts and Sciences, Kyoto University, Yoshida Nihonmatsu-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Yoko M Nakao
- Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, 565-8565, Japan
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan.
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Elder DA, Hornung LN, Khoury JC, D'Alessio DA. β-Cell Function Over Time in Adolescents With New Type 2 Diabetes and Obese Adolescents Without Diabetes. J Adolesc Health 2017; 61:703-708. [PMID: 28935388 PMCID: PMC5701869 DOI: 10.1016/j.jadohealth.2017.06.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 05/17/2017] [Accepted: 06/06/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE The progression of β-cell function in newly diagnosed adolescents with type 2 diabetes mellitus (T2DM) is not well documented. We hypothesized that at the time of diagnosis with T2DM, adolescents would have impaired β-cell function as demonstrated by the disposition index (calculated as: insulin secretion adjusted for insulin sensitivity), and this would be followed by a rapid decline of function despite standard medical management. METHODS Thirty-nine adolescents with recently diagnosed T2DM and 32 obese adolescent controls with normal glucose tolerance had acute insulin response to glucose, homeostatic model assessment of insulin resistance, and disposition index measured serially over 2 years. RESULTS In the adolescent T2DM group, fasting glucose increased over 2 years (p = .04), while DI was impaired at baseline and showed an overall relative decline of 25% per year. The mean Hemoglobin A1c remained below 8% (64 mmol/mol). Differences were observed between the T2DM and control adolescents in the way DI changed over time (p = .02). CONCLUSIONS β-cell function in adolescents with recently diagnosed T2DM was impaired with no improvement of β-cell function over the 2 years of study despite stable Hemoglobin A1c, body mass index markers of insulin sensitivity, and standard treatment of hyperglycemia.
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Affiliation(s)
- Deborah A Elder
- Department of Pediatrics, Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Lindsey N Hornung
- Department of Pediatrics, Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jane C Khoury
- Department of Pediatrics, Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David A D'Alessio
- Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; Department of Medicine, Cincinnati VAMC, Cincinnati, Ohio
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9
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Weng J. Short-term intensive insulin therapy could be the preferred option for new onset Type 2 diabetes mellitus patients with HbA1c > 9. J Diabetes 2017; 9:890-893. [PMID: 28661564 DOI: 10.1111/1753-0407.12581] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Type 2 diabetes mellitus (T2DM) is a heterogeneous disease. Currently, the typical clinical therapeutic pathway for the disease consists of the stepwise addition of antihyperglycemic preparations over time, followed lastly by insulin therapy when functional β-cell capacity is severely deteriorated. Recognizing the complexity of disease management, personalized (precision) medicine approaches may enable the physician to tailor diabetes treatment based on HbA1c levels, body mass index (BMI), efficacy, risk of hypoglycemia, risk of weight gain, age, safety, cost, and even genetic characteristics. Although insulin therapy has traditionally been recommended as the last option in the sequential treatment algorithm of T2DM, it is notable that several guidelines and consensus statements suggest consideration of insulin as part of a first-line regimen. In the American Association of Clinical Endocrinologists (AACE)/American College of Endocrinology (ACE) comprehensive T2DM 2017 management algorithm, insulin is recommended for T2DM patients presenting with symptoms and an HbA1c >9.0%. In addition, the American Diabetes Association (ADA)/European Association for the Study of Diabetes (EASD) consensus statement recommends initial insulin therapy as an option when HbA1c ≥9%, and definite consideration with HbA1c ≥10-12%, and mentions that it may be possible to taper off insulin once initial glucotoxicity is reversed and to consider transfer to other types of non-insulin therapies. Based on accumulating evidence, an expert group has endorsed the concept of short-term intensive insulin (STII) therapy as an option for some patients with T2DM at the time of diagnosis. Notably, the latest Israeli guidelines suggest considering immediate, sometimes short-term, insulin treatment for patients with HbA1c >9% or with symptoms. It has been reported that nearly one-quarter (23%) of newly diagnosed T2DM patients in the US had an HbA1c ≥9.0% prior to initiation of treatment. For such patients, initiating insulin is difficult, although it has been almost 10 years since the ACE/AACE Diabetes Road Map suggested insulin therapy for treatment-naïve patients with high HbA1c. Lack of patient education resources in primary care and of provider knowledge as to approaches to insulin treatment (insulin initiation dosage, multiple daily injection or basal insulin supplement, insulin treatment duration) are major obstacles to selecting appropriately intensive but also timely therapy for newly diagnosed T2DM patients in clinical practice so as to minimize avoidable glycemic exposure. Treatment with STII early in the course of T2DM is of considerable interest. There is a wide range of evidence currently available supporting the use of STII therapy in newly diagnosed T2DM. For example, STII can quickly normalize glycemic control, improve β-cell function, restore first-phase insulin secretion, and even reduce glucagonemia in newly diagnosed T2DM, suggesting that it may provide unique capacity for modification of the natural process of diabetes. The largest and most robust clinical trial of STII therapy enrolled 382 newly diagnosed people with T2DM at nine centers in China and randomized them to either insulin (short-term continuous subcutaneous insulin infusion [CSII] or multiple daily injections [MDI]) or oral anti-hyperglycemic therapy. First-phase insulin secretion was increased in all three groups after 2 weeks of normoglycemia. Remission rates at 1 year were higher in the two insulin-treated groups (51.1% in the CSII group, 44.9% in the MDI group) than in the oral therapy group (26.7%). Furthermore, the increase in first-phase insulin response was maintained at 1 year in the two insulin-treated groups, but declined in the group allocated to oral medication (Fig. ). A beneficial effect of insulin therapy over oral anti-diabetic agents was also observed by Chen et al. [Figure: see text] A meta-analysis, including seven studies and 839 participants, further underscored the robustness of the evidence supporting STII therapy by showing that the proportion of patients in drug-free remission was 66.2% at 3 months, 58.9% at 6 months, 46.3% at 12 months, and 42.1% at 24 months. All but one study showed an improvement in β-cell function, as assessed by homeostatic model assessment of β-cell function (HOMA-B), and all but one study showed a decrease in insulin resistance, as assessed by homeostasis model assessment of insulin resistance (HOMA-IR). Therefore, STII has beneficial effects on both the fundamental pathophysiological mechanisms of T2DM (β-cell dysfunction and insulin resistance). Recent animal studies suggest a potential mechanism for such clinical benefits: β-cells dedifferentiate to endocrine progenitor-like cells during stress-induced hyperglycemia, and strictly normalizing blood glucose by insulin therapy could induce dedifferentiated cell redifferentiation to mature β-cells, and hence restoration of drug responsivity. In addition to its glucose-lowering activity, insulin may contribute to improved β-cell function by its antilipolytic, anti-inflammatory, and antiapoptotic effects. We recognized that not all newly diagnosed people with T2DM would experience improved β-cell function or achieve long-term remission following cessation of STII. It would be worthwhile to precisely identify the subpopulation more likely to benefit from this strategy. Previous studies have suggested that lower baseline fasting glucose, higher BMI, better early phase insulin secretion, and lower exogenous insulin requirements may be predictors of diabetes remission in newly diagnosed patients treated with STII therapy. A recent study demonstrated that a shorter duration of diabetes supplanted baseline HbA1c and β-cell function as an independent predictor of remission. In particular, diabetes duration <2 years predicted sustained remission, suggesting that the key determinant of inducing persistent drug-free diabetes remission with STII is early intervention. Although reluctance to initiate insulin treatment in T2DM is well described, it is interesting to see that when introduced early in the course of the disease as a short-term treatment, STII resulted in significant improvement in patient-reported quality of life and treatment satisfaction, demonstrating the patient acceptability of early insulin therapy. In our clinical experience, patients often request insulin resumption after a trial has ended because of the good clinical outcomes and the recognition that such treatment is much easier and better tolerated than expected. The pros and cons of STII therapy for new-onset T2DM patients with HbA1c >9%, based on current evidence and our understanding, are listed in Table . It is important that STII be considered an option at this early stage of the disease. Existing studies and clinical experience do indicate that this concept is very well received by patients and clinicians alike, especially when they realize that insulin only needs to be used for a few weeks, and that STII at that point in time does not necessarily require continuing long-term insulin therapy. Numerous public health, clinical efficacy and effectiveness, and cost-effectiveness questions need to be better understood before widespread adoption of this novel treatment regimen can be more endorsed. [Table: see text].
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Affiliation(s)
- Jianping Weng
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diabetology, Guangzhou, China
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10
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Echtay A, Andari E, Atallah P, Moufarrege R, Nemr R. Insulin Detemir in Combination with Oral Antidiabetic Drugs Improves Glycemic Control in Persons with Type 2 Diabetes in Near East Countries: Results from the Lebanese Subgroup. Ethn Dis 2017; 27:45-54. [PMID: 28115821 PMCID: PMC5245608 DOI: 10.18865/ed.27.1.45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To evaluate the effectiveness and safety of insulin detemir treatment as add-on therapy in a real-world setting of Lebanese insulin naïve persons, with type 2 diabetes poorly controlled on oral antidiabetic drugs (OADs). METHODS Our study was a prospective, observational study representing the Lebanese arm of the multinational prospective and observational study involving 2,155 persons across Near East countries, Lebanon, Pakistan, Israel and Jordan. Effectiveness endpoints were changes in HbA1c, fasting and post-prandial glucose (FPG, PPG) after 24 weeks of treatment with insulin detemir in eligible persons. Safety endpoints were number of hypoglycemic events, incidence of adverse drug reactions (ADRs), serious ADRs, adverse events, and body weight change between baseline and end of treatment. RESULTS 868 persons were included (mean age: 59.5 ± 10.4 years, men: 55.3%). Glycemic control improved with significant reduction in mean HbA1c from 9.7 ± 1.6% to 7.2 ± 1% (P<.0001). The percentage of persons who achieved the target of HbA1c<7% increased from .7% at baseline to 39% at week 24. Mean FPG decreased significantly from 213.7 ± 60.1 mg/dL to 120.3 ± 25.7 mg/dL (P<.001), and mean PPG from 271 ± 65.3 mg/dL to 158.1 ± 36.4 mg/dL (P<.0001). The rate of major hypoglycemic episodes decreased from .1498 at baseline to .0448 at week 24. Three adverse events but no ADR or serious ADR were reported. Body weight decreased from 80.4±13.2 Kg to 79.9±12.5 Kg (P<.0001). CONCLUSIONS Initiating insulin detemir in a clinical health care setting among Lebanese with type 2 diabetes mellitus on OADs improves glycemic control with no increase in hypoglycemia, adverse events or weight compared with baseline.
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Affiliation(s)
- Akram Echtay
- Division of Endocrinology, Rafic Hariri University Hospital, Beer Hassan, Beirut, Lebanon
| | - Emile Andari
- Division of Endocrinology, Notre Dame de Secours Hospital, Byblos, Lebanon
| | - Paola Atallah
- Division of Endocrinology, Saint Georges Hospital University Medical Center, Achrafieh, Lebanon
| | - Roland Moufarrege
- Private clinic, Al Manara roundabout, Lebanon and Gulf Bank building, Zalka, Lebanon
| | - Rita Nemr
- Division of Endocrinology, Saint Joseph Hospital, Dora, Beirut, Lebanon
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11
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Remedi MS, Emfinger C. Pancreatic β-cell identity in diabetes. Diabetes Obes Metab 2016; 18 Suppl 1:110-6. [PMID: 27615139 PMCID: PMC5021188 DOI: 10.1111/dom.12727] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 05/26/2016] [Indexed: 12/18/2022]
Abstract
Recovery of functional β-cell mass continues to be an ongoing challenge in treating diabetes. Initial work studying β-cells suggested apoptotic β-cell death as a main contributor for the loss of β-cell mass in diabetes. Restoration of β-cells either by transplant or stimulating proliferation of remaining β-cells or precursors would then logically be a viable therapeutic option for diabetes. However, recent work has highlighted the inherent β-cell plasticity and the critical role of loss of β-cell identity in diabetes, and has suggested that β-cells fail to maintain a fully differentiated glucose-responsive and drug-responsive state, particularly in diabetic individuals with poorly controlled, long-lasting periods of hyperglycaemia. Understanding the underlying mechanisms of loss of β-cell identity and conversion in other cell types, as well as how to regain their mature differentiated functional state, is critical to develop novel therapeutic strategies to prevent or reverse these processes. In this review, we discuss the role of plasticity and loss of β-cell identity in diabetes, the current understanding of mechanisms involved in altering this mature functional β-cell state and potential progresses to identify novel therapeutic targets providing better opportunities for slowing or preventing diabetes progression.
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Affiliation(s)
- M S Remedi
- Department of Medicine and Cell Biology and Physiology, Washington University School of Medicine, St. Louis, Missouri.
| | - C Emfinger
- Department of Medicine and Cell Biology and Physiology, Washington University School of Medicine, St. Louis, Missouri
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12
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Hanefeld M, Monnier L, Schnell O, Owens D. Early Treatment with Basal Insulin Glargine in People with Type 2 Diabetes: Lessons from ORIGIN and Other Cardiovascular Trials. Diabetes Ther 2016; 7:187-201. [PMID: 26861811 PMCID: PMC4900970 DOI: 10.1007/s13300-016-0153-3] [Citation(s) in RCA: 14] [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: 11/10/2015] [Indexed: 01/09/2023] Open
Abstract
UNLABELLED Dysglycemia results from a deficit in first-phase insulin secretion compounded by increased insulin insensitivity, exposing β cells to chronic hyperglycemia and excessive glycemic variability. Initiation of intensive insulin therapy at diagnosis of type 2 diabetes mellitus (T2DM) to achieve normoglycemia has been shown to reverse glucotoxicity, resulting in recovery of residual β-cell function. The United Kingdom Prospective Diabetes Study (UKPDS) 10-year post-trial follow-up reported reductions in cardiovascular outcomes and all-cause mortality in persons with T2DM who initially received intensive glucose control compared with standard therapy. In the cardiovascular outcome trial, outcome reduction with an initial glargine intervention (ORIGIN), a neutral effect on cardiovascular disease was observed in the population comprising prediabetes and T2DM. Worsening of glycemic control was prevented over the 6.7 year treatment period, with few serious hypoglycemic episodes and only moderate weight gain, with a lesser need for dual or triple oral treatment versus standard care. Several other studies have also highlighted the benefits of early insulin initiation as first-line or add-on therapy to metformin. The decision to introduce basal insulin to metformin must, however be individualized based on a risk-benefit analysis. The landmark ORIGIN trial provides many lessons relating to the concept and application of early insulin therapy for the prevention and safe and effective induction and maintenance of glycemic control in type 2 diabetes. FUNDING Sanofi.
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Affiliation(s)
| | - Louis Monnier
- Institute of Clinical Research, University Montpellier 1, Montpellier, France
| | | | - David Owens
- Institute of Life Sciences, Swansea University, Swansea, UK.
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13
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Pfohl M, Siegmund T, Pscherer S, Pegelow K, Seufert J. Effectiveness and tolerability of treatment intensification to basal-bolus therapy in patients with type 2 diabetes on previous basal insulin-supported oral therapy with insulin glargine or supplementary insulin therapy with insulin glulisine: the PARTNER observational study. Vasc Health Risk Manag 2015; 11:569-78. [PMID: 26604774 PMCID: PMC4642811 DOI: 10.2147/vhrm.s82720] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background Due to the progressive nature of type 2 diabetes mellitus (T2DM), antidiabetic treatment needs to be continuously intensified to avoid long-term complications. In T2DM patients on either basal insulin-supported oral therapy (BOT) or supplementary insulin therapy (SIT) presenting with HbA1c values above individual targets for 3–6 months, therapy should be intensified. This study investigated effectiveness and tolerability of an intensification of BOT or SIT to a basal–bolus therapy (BBT) regimen in T2DM patients in daily clinical practice. Methods This noninterventional, 8-month, prospective, multicenter study evaluated parameters of glucose control, occurrence of adverse events (eg, hypoglycemia), and acceptance of devices in daily clinical practice routine after 12 and 24 weeks of intensifying insulin therapy to a BBT regimen starting from either preexisting BOT with insulin glargine (pre-BOT) or preexisting SIT with ≥3 daily injections of insulin glulisine (pre-SIT). Results A total of 1,530 patients were documented in 258 German medical practices. A total of 1,301 patients were included in the full analysis set (55% male, 45% female; age median 64 years; body mass index median 30.8 kg/m2; pre-BOT: n=1,072; pre-SIT: n=229), and 1,515 patients were evaluated for safety. After 12 weeks, HbA1c decreased versus baseline (pre-BOT 8.67%; pre-SIT 8.46%) to 7.73% and 7.66%, respectively (Δ mean −0.94% and −0.80%; P<0.0001). At week 24, HbA1c was further reduced to 7.38% and 7.30%, respectively (Δ mean −1.29% and −1.15%; P<0.0001), with a mean reduction of fasting blood glucose values in both treatment groups by more than 46 mg/dL. An HbA1c goal of ≤6.5% was reached by 17.9% (pre-BOT) and 18.6% (pre-SIT), and an HbA1c ≤7.0% by 46.1% (pre-BOT) and 43.0% (pre-SIT) of patients. During 24 weeks, severe as well as serious hypoglycemic events were rare (pre-BOT: n=5; pre-SIT: n=2; pretreated with both insulins: n=1). Conclusion Intensifying glargine-based BOT or glulisine-based SIT to a BBT regimen in poorly controlled T2DM patients in daily routine care led to marked improvements of glycemic control and was well tolerated.
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Affiliation(s)
- Martin Pfohl
- Medizinische Klinik I, Evangelisches Bethesda-Klinikum GmbH, Duisburg, Germany
| | - Thorsten Siegmund
- Städtisches Klinikum München GmbH, Klinikum Bogenhausen, III. Medizinische Abteilung, München, Germany
| | - Stefan Pscherer
- Klinisches Diabeteszentrum Südostbayern, Innere Medizin - Diabetologie, Traunstein, Germany
| | | | - Jochen Seufert
- Medizinische Universitätsklinik, Klinik für Innere Medizin II, Abteilung für Endokrinologie und Diabetologie, Freiburg, Germany
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14
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Weng J, Retnakaran R, Ariachery C A, Ji L, Meneghini L, Yang W, Woo JT. Short-term intensive insulin therapy at diagnosis in type 2 diabetes: plan for filling the gaps. Diabetes Metab Res Rev 2015; 31:537-44. [PMID: 25196375 DOI: 10.1002/dmrr.2603] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 07/22/2014] [Accepted: 08/24/2014] [Indexed: 12/16/2022]
Abstract
Short-term intensive insulin therapy is unique amongst therapies for type 2 diabetes because it offers the potential to preserve and improve beta-cell function without additional pharmacological treatment. On the basis of clinical experience and the promising results of a series of studies in newly diagnosed patients, mostly in Asian populations, an expert workshop was convened to assess the available evidence and the potential application of short-term intensive insulin therapy should it be advocated for inclusion in clinical practice. Participants included primary care physicians and endocrinologists. We endorse the concept of short-term intensive insulin therapy as an option for some patients with type 2 diabetes at the time of diagnosis and have identified the following six areas where additional knowledge could help clarify optimal use in clinical practice: (1) generalizability to primary care, (2) target population and biomarkers, (3) follow-up treatment, (4) education of patients and providers, (5) relevance of ethnicity, and (6) health economics.
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Affiliation(s)
- Jianping Weng
- Guangdong Provincial Key Laboratory of Diabetology, Sun Yat-sen University of Medical Sciences, Canton, China
- Department of Endocrinology at Third Affiliated Hospital, Sun Yat-sen University of Medical Sciences, Canton, China
| | - Ravi Retnakaran
- Leadership Sinai Centre for Diabetes and Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada
| | - Ammini Ariachery C
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Linong Ji
- Department of Endocrinology, Peking University Hospital, Beijing, China
| | - Luigi Meneghini
- Division of Endocrinology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Wenying Yang
- Department of Endocrinology, China-Japan Friendship Hospital, Beijing, China
| | - Jeong-Taek Woo
- Department of Endocrinology and Metabolism, School of Medicine, Kyung Hee University, Seoul, South Korea
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15
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Hanefeld M. Use of insulin in type 2 diabetes: what we learned from recent clinical trials on the benefits of early insulin initiation. DIABETES & METABOLISM 2015; 40:391-9. [PMID: 25451189 DOI: 10.1016/j.diabet.2014.08.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 08/08/2014] [Accepted: 08/22/2014] [Indexed: 01/09/2023]
Abstract
The majority of people with type 2 diabetes mellitus (T2DM) require insulin therapy to maintain HbA(1c) levels < 7% during the first decade of diagnosis. Large prospective trials investigating the cardiovascular (CV) benefits of intensive glycaemic control have produced inconsistent results; however, meta-analyses have suggested that intensive glycaemic control provides both micro- and macrovascular benefits. The ORIGIN study investigated the impact of basal insulin glargine therapy targeting ≤ 5.3 mmol/L for fasting plasma glucose compared with standard care on CV outcomes in people with pre- or early diabetes, and demonstrated a neutral effect on CV outcomes with long-term use of insulin glargine early in the course of diabetes, with a low rate of severe hypoglycaemia and modest weight gain. The EARLY, GLORY and EASIE studies also demonstrated that insulin use earlier in the treatment pathway led to improved glycaemic control, reduced weight gain and fewer hypoglycaemic episodes than when insulin was added later in the course of disease. The beneficial effect of early transient intensive insulin therapy (TIIT) at diagnosis has been demonstrated in a number of trials; it rapidly limits the damage caused by gluco- and lipotoxicity, improving residual β-cell function and potentially slowing disease progression. The evidence suggests that people newly diagnosed with T2DM and HbA(1c) > 9% should be given early TIIT to achieve normoglycaemia within weeks, after which standard care should then be adopted. Insulin use earlier in the treatment pathway should be considered, as it reduces the risk of hypoglycaemia as well as allows β-cell rest, which can help preserve β-cell function.
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16
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Cheng Q, Yang S, Zhao C, Wang Z, Feng Z, Li R, Ye P, Zhang S, Deng H, Zhou B, Long J, Gong L, Qing H, Luo C, Li Q. Efficacy of metformin-based oral antidiabetic drugs is not inferior to insulin glargine in newly diagnosed type 2 diabetic patients with severe hyperglycemia after short-term intensive insulin therapy. J Diabetes 2015; 7:182-91. [PMID: 24823280 DOI: 10.1111/1753-0407.12167] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 03/05/2014] [Accepted: 05/09/2014] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Insulin therapy should be strongly considered in newly diagnosed type 2 diabetic (T2D) patients with severe hyperglycemia. However, whether insulin be continued or patients switched to an oral antidiabetic drug (OAD) after short-term intensive insulin therapy (ITT) is not clear. METHODS After ITT for 10-14 days, 47 patients were randomized into either a glargine (n = 21) or metformin-based OAD (n = 26) group for a 6-month intervention. After these 6 months, patients in the glargine group were switched to metformin-based OAD therapy, whereas treatment in the OAD group was unchanged. Patients were followed-up for another 6 months. RESULTS At the end of the 6-month intervention, HbA1c was similarly reduced in both the glargine (from 11.81 ± 1.70% to 6.48 ± 0.79%; P < 0.001) and OAD (from 11.71 ± 1.89% to 6.16 ± 0.52%; P < 0.001) groups. At the end of 12 months, HbA1c was at comparable and near optimal levels in both groups. Similar increases were seen in homeostatic model assessment of β-cell function in the two groups after 6 months. There were no significant differences between the two groups in insulin sensitivity improvement, hypoglycemic episodes, weight change, treatment satisfaction and quality of life after the 6-month intervention. CONCLUSIONS The effects of metformin-based OAD therapy on glycemic control and improvements in β-cell function are not inferior to glargine in newly diagnosed T2D patients with severe hyperglycemia after short-term ITT. Considering the superiority of metformin in terms of safety, cost, and convenience, metformin-based OAD therapy is strongly recommended for these patients.
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Affiliation(s)
- Qingfeng Cheng
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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17
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Li Q, Wang L, Xiao L, Wang Z, Wang F, Yu X, Yan S, Wang Y. Effect of intensive insulin therapy on first-phase insulin secretion in newly diagnosed type 2 diabetic patients with a family history of the disease. Exp Ther Med 2014; 9:612-618. [PMID: 25574243 PMCID: PMC4280938 DOI: 10.3892/etm.2014.2114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 11/10/2014] [Indexed: 12/12/2022] Open
Abstract
Intensive insulin treatment is known to improve β-cell function in the majority of patients with newly diagnosed type 2 diabetes mellitus (T2DM), and family history (FH) is known to be an important independent risk factor for T2DM. Thus, the aim of the present study was to investigate the difference in first-phase insulin secretion and the effect of intensive insulin therapy on the improvement of β-cell function between T2DM patients with and without a FH of diabetes. Patients with newly diagnosed T2DM and healthy controls were divided into groups according to their FH of diabetes. Improvement in β-cell function was evaluated with an arginine stimulation test after two weeks of continuous subcutaneous insulin infusion (CSII). Compared with the control group, the level of fasting insulin and the homeostasis model assessment of insulin resistance (HOMA2-IR) were higher in the DM group, while the homeostasis model assessment of β-cell insulin secretion (HOMA2-%β) and the first-phase peak ratio were lower (P<0.05). In addition, the first-phase peak ratio in the FH- control group was higher compared with that in the FH+ control group (P=0.023). Following CSII, all the patients achieved excellent blood glucose control in 6.2±3.6 days, without severe adverse effects. In the DM groups, the fasting insulin level and HOMA2-IR were lower, while the HOMA2-%β and first-phase peak ratio were higher, when compared with the values prior to treatment, particularly in the FH- DM group. The HOMA2-%β in the FH+ DM group was lower compared with the FH- DM group (P=0.027). Therefore, T2DM patients with and without a FH of the disease were shown to have a good response to CSII in the improvement of insulin resistance and β-cell function; however, the improvements were less significant in patients with a FH compared with patients without a FH of diabetes.
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Affiliation(s)
- Qing Li
- Department of Clinical Laboratory, The First People's Hospital of Zibo City, Zibo, Shandong 255200, P.R. China
| | - Luan Wang
- Department of Endocrinology, Stem Cell Research Center, The Affiliated Hospital of Medical College, Qingdao University, Qingdao, Shandong 266003, P.R. China
| | - Lin Xiao
- Biochemistry Office, Weifang Medical College, Weifang, Shandong 261042, P.R. China
| | - Zhongchao Wang
- Department of Endocrinology, Stem Cell Research Center, The Affiliated Hospital of Medical College, Qingdao University, Qingdao, Shandong 266003, P.R. China
| | - Fang Wang
- Department of Endocrinology, Stem Cell Research Center, The Affiliated Hospital of Medical College, Qingdao University, Qingdao, Shandong 266003, P.R. China
| | - Xiaolong Yu
- Department of Endocrinology, Stem Cell Research Center, The Affiliated Hospital of Medical College, Qingdao University, Qingdao, Shandong 266003, P.R. China
| | - Shengli Yan
- Department of Endocrinology, Stem Cell Research Center, The Affiliated Hospital of Medical College, Qingdao University, Qingdao, Shandong 266003, P.R. China
| | - Yangang Wang
- Department of Endocrinology, Stem Cell Research Center, The Affiliated Hospital of Medical College, Qingdao University, Qingdao, Shandong 266003, P.R. China
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Hanefeld M, Fleischmann H, Schiffhorst G, Bramlage P. Predictors of response to early basal insulin treatment in patients with type 2 diabetes--the EARLY experience. Diabetes Technol Ther 2014; 16:241-6. [PMID: 24229089 DOI: 10.1089/dia.2013.0246] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND It was the aim of this study to assess baseline predictors for glycosylated hemoglobin (HbA1c) reduction, treatment-to-target, and insulin glargine dose in patients with an HbA1c level of ≥ 7.5% (58 mmol/mol) at baseline despite 3 months of maximum tolerated dose of metformin under daily conditions. SUBJECTS AND METHODS This was an open, multicenter, prospective observational study with a 6-month follow-up including 1,438 patients with type 2 diabetes. Baseline variables independently associated with HbA1c (overall reduction and achievement of target values) and insulin glargine dose used were determined using a stepwise multivariate linear regression analysis. RESULTS In a multivariate linear regression analysis (R(2)=0.545) baseline HbA1c (β=-0.722; P<0.001) and retinopathy (β=-0.064; P=0.007) were associated with a greater HbA1c reduction at 6 months, whereas duration of diabetes was associated with a lesser HbA1c reduction (β=0.084; P<0.001). In another multivariate linear regression analysis, weight (odds ratio [OR] 0.99; 95% confidence interval [CI] 0.98 to <1.00), duration of diabetes (OR 0.96; 95% CI 0.93-0.99), and baseline HbA1c (OR 0.65; 95% CI 0.56-0.76) were associated with a reduced likelihood of achieving an HbA1c level of <7% (53 mmol/mol); baseline HbA1c (OR 0.66; 95% CI 0.51-0.85) was the only variable associated with a reduced likelihood of achieving an HbA1c level of <6.5% (48 mmol/mol). In a further analysis (R(2)=0.135) the insulin dose needed was increased in those with a higher body weight (β=0.230; P<0.001), a longer duration of diabetes (β=0.134; P<0.001), a higher baseline HbA1c level (β=0.205; P<0.001), and the presence of microalbuminuria (β=0.096; P=0.003). CONCLUSIONS Identified predictors of greater HbA1c reduction, target goal achievement, and insulin dose needed may help to optimize the balance of benefits and risks with the use of insulin glargine.
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Affiliation(s)
- Markolf Hanefeld
- 1 Study Centre Professor Hanefeld, Company for the Transfer of Knowledge and Technology of the Dresden University of Technology , Dresden, Germany
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Resultados a medio plazo de un programa de insulinización en régimen de Hospital de Día para pacientes con diabetes tipo 2. Med Clin (Barc) 2014; 142:243-7. [DOI: 10.1016/j.medcli.2013.01.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2012] [Revised: 01/11/2013] [Accepted: 01/17/2013] [Indexed: 11/17/2022]
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20
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Winkler G. [Timely commencement of insulin in type 2 diabetes: benefits and risks]. Orv Hetil 2014; 155:255-61. [PMID: 24509354 DOI: 10.1556/oh.2014.29828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The introduction of insulin in type 2 diabetes is often too late, though the immediate as well as late consequences of inadequate metabolic control are well known. That is the reason, why a special attention is given in recent therapeutic guidelines for the importance of early, at least timely insulinisation. This review article summarizes the advantages (mitigation of the beta-cell dysfunction, long lasting good metabolic control) and potential risks (hypoglycemia, weight gain, possible deteriorating patient compliance) of early or timely insulin therapy. It is pointed out that the introduction of insulin is effective and safe therapeutic option during the whole course of type 2 diabetes, the use of different regimes is suitable to reach and maintain the individual glycemic target and, with a structured patient education, it does not disturb the quality of life and the compliance of patients.
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Affiliation(s)
- Gábor Winkler
- Szent János Kórház II. Belgyógyászat-Diabetológia Budapest Diós árok 1-3. 1125 Miskolci Egyetem, Egészségügyi Kar Elméleti Egészségtudományi Intézet Miskolc
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Abstract
The natural history of type 2 diabetes mellitus (T2DM) is a relentless progression of β-cell failure and dysregulation of β-cell function with increasing metabolic derangement. Insulin remains the only glucose-lowering therapy that is efficacious throughout this continuum. However, the timing of introduction and the choice of insulin therapy remain contentious because of the heterogeneity of T2DM and the well-recognized behavioral and therapeutic challenges associated with this mode of therapy. Nevertheless, the early initiation of basal insulin has been shown to improve glycemic control and affect long-term outcomes in people with T2DM and is a treatment strategy supported by international guidelines as part of an individualized approach to chronic disease management. The rationale for early initiation of insulin is based on evidence demonstrating multifaceted benefits, including overcoming the glucotoxic effects of hyperglycemia, thereby facilitating "β-cell rest," and preserving β-cell mass and function, while also improving insulin sensitivity. Independent of its effects on glycemic control, insulin possesses anti-inflammatory and antioxidant properties that may help protect against endothelial dysfunction and damage resulting in vascular disease. Insulin therapy and the achievement of good glycemic control earlier in T2DM provide long-term protection to end organs via "metabolic memory" regardless of subsequent treatments and degree of glycemic control. This is evidenced from long-term observations continuing from trials such as the United Kingdom Prospective Diabetes Study. As such, early initiation of insulin therapy may not only help to avoid the effects of prolonged glycemic burden, but may also positively alter the course of disease progression.
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Affiliation(s)
- David R Owens
- Diabetes Research Group, Institute of Life Sciences College of Medicine, Swansea University, Swansea SA2 8PP, United Kingdom.
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Mudaliar S. Choice of early treatment regimen and impact on β-cell preservation in type 2 diabetes. Int J Clin Pract 2013; 67:876-87. [PMID: 23952467 DOI: 10.1111/ijcp.12154] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 02/15/2013] [Indexed: 12/21/2022] Open
Abstract
The progressive deterioration of glycaemic control in individuals with type 2 diabetes mellitus (T2DM) results from insulin resistance combined with the ongoing loss of β-cell function. Although it had been suggested that most β-cell dysfunction occurs after the development of T2DM, studies have documented a substantial early loss of β-cell function, particularly during the prediabetic state. In patients diagnosed with T2DM, β-cell function continues to decline despite treatment with commonly prescribed antihyperglycaemic medications, and ultimately exogenous insulin administration is required to maintain optimal glycaemic control. Thus, interventions to address the early decline in β-cell function could potentially alter the course of T2DM, preventing or delaying its onset and decreasing the incidence of complications. Original research and review articles on this topic were identified in a PubMed search from January 2000 through August 2012. Data from prospective studies and clinical trials suggest that lifestyle modifications and certain antihyperglycaemic medications, including thiazolidinediones (TZDs), glucagon-like peptide-1 (GLP-1) agonists, dipeptidyl peptidase-4 (DPP-4) inhibitors and insulin, may preserve or enhance β-cell function. The implication of current data is that early initiation of lifestyle modifications and antihyperglycaemic agents that preserve β-cell function might reverse or delay progression to T2DM in those with prediabetes. Moreover, improved β-cell function may confer more durable glucose control and perhaps reduce/delay the incidence of diabetic complications. Long-term studies are needed to validate this hypothesis.
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Affiliation(s)
- S Mudaliar
- Center for Metabolic Research, VA San Diego Healthcare System, San Diego, CA, USA.
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Abstract
There has been a recent shift from a uniform treatment targeting HbA1c to a patient centered approach due to disappointing results of intensified glucose control in mega-trials such as VADT, ADVANCE, and ACCORD. In addition, morbidity and mortality has been substantially reduced since the UKPDS leading to an overestimation of the absolute risk for cardiovascular complications in randomized controlled trials. With substantial progress in prevention of cardiovascular complications, patients with type 2 diabetes now survive long enough to face diabetes-related complications and cancer risk. This requires rethinking of antidiabetic treatment strategies as exemplified by a recent consensus statement of the EASD and ADA, calling for a more patient centered treatment. Within this context the value of early insulin initiation was reinforced, the clinical utility of which has been demonstrated in the recent ORIGIN trial. ORIGIN demonstrated neutral results for the primary endpoint, but reduced microangiopathy in patients with an HbA1c value of ≥6.4 % with basal insulin glargine. After 5 years of follow-up 77 % of the patients in the glargine arm and 66 % with standard care remained at an HbA1c <7 %. An ongoing long-term follow-up (ORIGINALE) will clarify whether this also translates into a reduction of macrovascular events and mortality.
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Affiliation(s)
- Markolf Hanefeld
- GWT-TUD mbH, Study Center Professor Hanefeld, Fiedlerstr. 34, 01307 Dresden, Germany
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Menzelstrasse 21, 15831 Mahlow, Germany
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Hu J, Li C, Wang L, Zhang X, Zhang M, Gao H, Yu X, Wang F, Zhao W, Yan S, Wang Y. Long term effects of the implantation of autologous bone marrow mononuclear cells for type 2 diabetes mellitus. Endocr J 2012; 59:1031-9. [PMID: 22814142 DOI: 10.1507/endocrj.ej12-0092] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Previous studies have shown that several types of stem cells can differentiate into insulin-secreting islet beta-cells and that these cells can reduce blood glucose in some trials, but there has been no report of a long-term follow-up. We assessed the long-term effects of the use of autologous bone marrow mononuclear cells in the treatment of type 2 diabetes mellitus (T2DM). Based on the willingness to receive implantation of bone marrow mononuclear cells, One hundred and eighteen patients with T2DM were divided into two groups; the patients in group I were treated with autologous bone marrow mononuclear cells and patients in group II were treated with insulin intensification therapy. Mononuclear cells from bone marrow were injected back into the patient's pancreas via a catheter. Patients were followed-up after the operation at monthly intervals for the first 3 months and thereafter every 3 months for the next 33 months, the occurrence of any side effects and the results of laboratory examinations were evaluated. There were no reported acute or chronic side effects in group I and both the HbA1c and C-peptide in group I patients were significantly better than either pretherapy values or group II patients during the follow-up period. These data suggested that the implantation of autologous bone marrow mononuclear cells for the treatment of T2DM is safe and effective. This therapy can partially restore the function of islet beta-cells and maintain blood glucose homeostasis in a longer time.
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Affiliation(s)
- Jianxia Hu
- Stem Cell Research Center, the Affiliated Hospital of Medical College, Qingdao University, Qingdao 266003, China
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