Glycemic Relapse in Type 2 Diabetes

Glycemic relapse in a collaborative primary care-based type 2 diabetes management program

OBJECTIVES

The purpose of this study is to evaluate the incidence of glycemic relapse in patients who attained their glycosylated hemoglobin (A1C) goal through a health system-wide collaborative primary care-based pharmacist- and Certified Diabetes Care and Education Specialist (CDCES)-led type 2 diabetes (T2D) management program and to identify relapse risk factors.

METHODS

This retrospective cohort study examined patients with T2D in the diabetes management program with a baseline A1C of at least 9% who attained their A1C goal. The primary outcome was incidence of glycemic relapse. Time to relapse was estimated using Kaplan-Meier curve, and a cox proportional hazards model was fitted to identify the risk factors for glycemic relapse.

RESULTS

Three hundred sixty-two patients were followed-up for a median of 10.5 (interquartile range 12.1) months after program completion; 38 patients (10.5%) experienced a glycemic relapse. Kaplan-Meier analysis estimated a 12-month relapse rate of 8.3%. The presence of a medication adherence barrier, presence of a higher number of chronic medications at baseline, presence of a baseline body mass index (BMI) of 30-39.9, and use of insulin at program completion increased risk for glycemic relapse in a univariate model. In multivariate regression, baseline BMI of 30-39.9 remained statistically significant. Older age at baseline was associated with a statistically significantly decreased relapse risk in both models.

CONCLUSION

This study highlights a low incidence of glycemic relapse for patients with T2D who reach their A1C goal through a collaborative primary care-based pharmacist- and CDCES-led T2D management program. The presence of risk factors for glycemic relapse may indicate a need for ongoing intensive care despite achieving A1C goal.

Effect of baseline glycosylated hemoglobin A1c on glycemic control and diabetes management following initiation of once-daily insulin detemir in real-life clinical practice

OBJECTIVE

The SOLVE study investigated the initiation of basal insulin in patients with type 2 diabetes on oral antidiabetic (OAD) treatment and outcomes in patients with varying levels of glycemic control at baseline.

METHODS

This was an observational cohort study conducted in 10 countries using insulin detemir. Data were collected at 3 clinic visits (baseline, 12-week interim, and 24-week final visit).

RESULTS

A total of 13,526 (77.9%) patients were included in the glycosylated hemoglobin A1c (HbA1c) subset analysis. Patients were grouped according to pre-insulin HbA1c values as follows: HbA1c <7.6% (n = 2,797); HbA1c 7.6-9% (n = 5,366), and HbA1c >9% (n = 5,363). A total of 27 patients experienced serious adverse drug reactions (SADRs) and/or severe hypoglycemia (3, 10, and 11 patients with pre-insulin HbA1c <7.6%, 7.6-9.0%, and >9.0%, respectively). All patient subgroups realized improvements in HbA1c, with the pre-insulin HbA1c >9% subgroup having the largest HbA1c reduction (-2.4% versus -0.9% and -0.2% for HbA1c subgroups 7.6-9% and <7.6%, respectively). In the total cohort (n = 17,374), the incidence of severe hypoglycemia decreased from 4 events per 100 person years to <1 event per 100 person years by final visit; the incidence of minor hypoglycemia increased from 1.6 to 1.8 events per person year.

CONCLUSIONS

In this study, insulin initiation was delayed until late in disease course, and overall concordance with internationally recognized guidelines was low. The initiation of once-daily insulin detemir was associated with substantial improvements in glycemic control and was not associated with an increase in severe hypoglycemia or weight gain.

Weight and glycaemic control in type 2 diabetes: what is the outcome of insulin initiation?

AIMS

Little information is available on the association between obesity at time of insulin initiation and attainment of glycaemic targets in type 2 diabetic (T2DM) patients. This study describes changes in HbA1c, weight and body mass index (BMI) over 24 months postinsulin initiation.

METHODS

First-time insulin users with T2DM were selected from the UK General Practice Research Database for the period 1st January 2002 to 31st March 2008. The cohort was stratified into BMI categories (kg/m(2) ) at the time of insulin initiation. Data were reviewed at 6-monthly intervals. A multivariate repeated-measures linear model was fitted assessing weight change over 12 months.

RESULTS

3783 patients were included (normal weight, n = 672; overweight, n = 1259; obese, n = 1070; clinically obese, n = 480; morbidly obese, n = 302). The largest reductions in HbA1c were observed 6 months postinsulin initiation and were greatest in lower BMI categories: median observed HbA1c at initiation and 6 months was 9.7 and 7.9% in normal weight patients and 9.6 and 8.2% in the clinically obese, respectively. A minority of patients achieved HbA1c ≤ 7.5% and by 24 months the proportion achieving this was: normal weight 41%; overweight 34%; obese 30%; clinically obese 26%; morbidly obese 31%; trend p < 0.001. The greatest weight gain occured by 6 months and multivariate adjusted models showed that normal weight patients had the highest gains 5.07 kg (95% CI: 3.35, 6.79), as did those with HbA1c ≥ 12.1%-5.55 kg (95% CI: 3.81, 7.28).

CONCLUSION

Obesity is associated with a poorer response to insulin illustrated by higher HbA1c values and lower achievement of targets.

Preventing glycaemic relapse in recently controlled type 2 diabetes patients: a randomised controlled trial

AIMS/HYPOTHESIS

After achieving glycaemic control, many type 2 diabetic patients relapse to clinically significant levels of hyperglycaemia. We sought to determine the optimal frequency of telephone contact by nurse practitioners that was necessary to prevent glycaemic relapse.

METHODS

This parallel, randomised controlled trial ran from June 2002 to February 2006 at an academic medical centre, studying 164 type 2 diabetic patients who had recently achieved glycaemic control. Participants were randomly assigned by sequential, concealed, computer-generated allocation to a 2 year maintenance strategy consisting of: (1) routine follow-up (n = 54); (2) routine follow-up and quarterly telephone contact (n = 55); or (3) routine follow-up and monthly telephone contact (n = 55). Blinding was not possible. The primary outcome was cumulative incidence of glycaemic relapse, defined as an increase in HbA(1c) of > or =1%; all participants were analysed. Cumulative incidence and prevalent proportions were compared. Weight change and hypoglycaemia were also assessed.

RESULTS

All participants randomised were included in the analyses. The study was completed by 90% of participants and intervention fidelity was high. At 24 months, the cumulative incidence of relapse was 41%. At 12 months, prevalent proportions of relapse were 20%, 14% and 15% for control, quarterly contact and monthly contact, respectively. At 24 months, they were 25%, 21% and 29%, respectively. There was no statistically significant difference in cumulative incidence or prevalent proportions of relapse among the study arms. Adverse events did not differ between study arms.

CONCLUSIONS/INTERPRETATION

This first randomised controlled trial to test an intervention to prevent glycaemic relapse found that regularly scheduled telephone contact by a nurse practitioner was no more effective than routine follow-up care in preventing glycaemic relapse.