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Gavin JR, Abaniel RM, Virdi NS. Therapeutic Inertia and Delays in Insulin Intensification in Type 2 Diabetes: A Literature Review. Diabetes Spectr 2023; 36:379-384. [PMID: 38024219 PMCID: PMC10654128 DOI: 10.2337/ds22-0084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
Background Therapeutic inertia leading to delays in insulin initiation or intensification is a major contributor to lack of optimal diabetes care. This report reviews the literature summarizing data on therapeutic inertia and delays in insulin intensification in the management of type 2 diabetes. Methods A literature search was conducted of the Allied & Complementary Medicine, BIOSIS Previews, Embase, EMCare, International Pharmaceutical Abstracts, MEDLINE, and ToxFile databases for clinical studies, observational research, and meta-analyses from 2012 to 2022 using search terms for type 2 diabetes and delay in initiating/intensifying insulin. Twenty-two studies met inclusion criteria. Results Time until insulin initiation among patients on two to three antihyperglycemic agents was at least 5 years, and mean A1C ranged from 8.7 to 9.8%. Early insulin intensification was linked with reduced A1C by 1.4%, reduction of severe hypoglycemic events from 4 to <1 per 100 person-years, and diminution in risk of heart failure (HF) by 18%, myocardial infarction (MI) by 23%, and stroke by 28%. In contrast, delayed insulin intensification was associated with increased risk of HF (64%), MI (67%), and stroke (51%) and a higher incidence of diabetic retinopathy. In the views of both patients and providers, hypoglycemia was identified as a primary driver of therapeutic inertia; 75.5% of physicians reported that they would treat more aggressively if not for concerns about hypoglycemia. Conclusion Long delays before insulin initiation and intensification in clinically eligible patients are largely driven by concerns over hypoglycemia. New diabetes technology that provides continuous glucose monitoring may reduce occurrences of hypoglycemia and help overcome therapeutic inertia associated with insulin initiation and intensification.
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Fadini GP, Disoteo O, Candido R, Di Bartolo P, Laviola L, Consoli A. Delphi-Based Consensus on Treatment Intensification in Type 2 Diabetes Subjects Failing Basal Insulin Supported Oral Treatment: Focus on Basal Insulin + GLP-1 Receptor Agonist Combination Therapies. Diabetes Ther 2021; 12:781-800. [PMID: 33550569 PMCID: PMC7947045 DOI: 10.1007/s13300-021-01012-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/23/2021] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION The aim of this study was to elaborate a consensus on treatment intensification strategies in patients with type 2 diabetes failing basal insulin supported oral therapy (BOT). The panel focused on glucagon-like peptide-1 receptor agonists (GLP-1RA) and basal insulin (BI) combinations. METHODS The authors developed a Delphi questionnaire organized into ten statements and 77 items that focused on: the definition of BOT and BOT failure, intensification strategies, fixed-dose combinations in general and the BI/GLP-1RA fixed combination. The survey was administered in two rounds to a panel of 80 Italian diabetes specialists, who rated their level of agreement with each item on a 5-point Likert scale. Consensus was predefined as > 66% of the panel agreeing/disagreeing on any given item. RESULTS Consensus was achieved for 71 of the 77 items. The panel agreed that the use of sulfonylureas in the BOT regimen is inappropriate. BOT failure was defined as individualized targets not being met for glycated hemoglobin, fasting plasma glucose and/or postprandial plasma glucose. There was agreement that postprandial hyperglycaemia and/or presence of nocturnal hypoglycaemia or weight gain define BOT failure. Addition of a GLP-1RA to BI therapy was considered to be the best option for BOT intensification. There was consensus for the use of BI/GLP-1RA fixed combinations as valuable options to increase compliance and safely improve glycaemic control. The panel agreed in considering the fixed-ratio combination insulin degludec/liraglutide (IDegLira) to be preferable to the fixed-ratio combination insulin glargine/lixisenatide (iGlarLixi) in the control of glycaemia, body weight and cardiovascular risk. CONCLUSION According to this Delphi consensus, the addition of a GLP-1RA may be the best option to intensify BOT. The BI/GLP-1RA fixed combinations may increase compliance and optimize the advantages of each of these molecules.
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Affiliation(s)
- Gian Paolo Fadini
- Division of Metabolic Diseases, Department of Medicine, University of Padova, Padua, Italy.
| | - Olga Disoteo
- Diabetes Unit, SSD Diabetologia, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Riccardo Candido
- Diabetes Center District 3, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Paolo Di Bartolo
- Ravenna Diabetes Clinic, Romagna Local Health Authority, Ravenna, Italy
| | - Luigi Laviola
- Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, Department of Emergency and Transplants, University of Bari Aldo Moro, Bari, Italy
| | - Agostino Consoli
- Department of Medicine and Aging Sciences (DMSI) and Center for Research on Ageing and Translational Medicine (CeSI-Met), University of Chieti, Chieti, Italy
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Hernández-Muñoz JJ, De Santiago AC, Cedrone SZ, Verduzco RA, Bazan DZ. Impact of Pharmacist-Led Drug Therapy Management Services on HbA 1c Values in a Predominantly Hispanic Population Visiting an Outpatient Endocrinology Clinic. J Pharm Pract 2020; 34:857-863. [PMID: 32495714 DOI: 10.1177/0897190020927863] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE To assess the impact pharmacists have on improving glycemic control among predominantly Hispanic diabetic patients visiting an endocrinology clinic in South Texas. Pharmacists were recently integrated into this clinic to be part of a collaborative team. METHODS This study follows a retrospective cohort design. All patients received diabetic care from endocrinologists, and some received pharmacist-led drug therapy management (PDTM). Patients with ≥1 PDTM were categorized as the intervention group and those without PDTM as the standard of care (SOC) group. The outcome variables were the mean absolute change in glycosylated hemoglobin (HbA1c) from baseline and the proportion of patients at goal HbA1c (<7%) postintervention. RESULTS Data were collected from 222 patients (n = 120 SOC patients, n = 102 PDTM patients). The mean age was 61 ± 14 years, 136 (61%) were female, and 197 (89%) were Hispanic. The mean absolute change in HbA1c was -1.3%. In the adjusted model, the mean absolute change in HbA1c in the PDTM compared to the SOC group was not significant (-0.1% ± 0.2%; P < .74), and concurrent interventions from registered dieticians (RDs) and licensed professional counselors (LPC) were identified as effect modifiers of the association. The stratum specific analysis identified the greatest decrease in HbA1c when the three interventions (ie, PDTM, RD, and LPC) coincided (-1.0% ± 0.3%; P < .01). Postintervention, 25% of those who received PDTM achieved an HbA1c<7% as compared to 19% in the SOC group. CONCLUSION The clinical importance of pharmacists is enhanced when integrated with behavioral modifying programs to achieve additional improvement in HbA1c.
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Affiliation(s)
- José J Hernández-Muñoz
- Department of Pharmaceutical Sciences, Texas A&M Irma Lerma Rangel College of Pharmacy, College Station, TX, USA
| | - Annette C De Santiago
- DHR Health, Edinburg, TX, USA.,Department of Pharmacy Practice, Texas A&M Irma Lerma Rangel College of Pharmacy, Kingsville, TX, USA
| | | | - Rene A Verduzco
- DHR Health, Edinburg, TX, USA.,Department of Pharmacy Practice, Texas A&M Irma Lerma Rangel College of Pharmacy, Kingsville, TX, USA
| | - Daniela Z Bazan
- DHR Health, Edinburg, TX, USA.,Department of Pharmacy Practice, Texas A&M Irma Lerma Rangel College of Pharmacy, Kingsville, TX, USA
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Yu HM, Park KS, Hong JH, Park KY, Lee JM, Ku BJ, Kim YJ, Oh TK. Comparison of the Efficacy and Safety of Insulin Detemir Administered Once Daily According to Two Titration Algorithms (3-0-3 and 2-4-6-8) in Patients with Type 2 Diabetes Mellitus. Endocrinol Metab (Seoul) 2020; 35:142-148. [PMID: 32207274 PMCID: PMC7090293 DOI: 10.3803/enm.2020.35.1.142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 01/02/2020] [Accepted: 01/13/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND This study was conducted to compare glycaemic control with insulin detemir administered according to two titration algorithms (3-0-3 and 2-4-6-8) after 20 weeks of treatment in subjects with type 2 diabetes mellitus inadequately controlled on metformin. METHODS This was a 20-week, randomised, multicentre, open-labelled, treat-to-target trial. Forty-six patients were randomised in a 1:1 manner to either the 3-0-3 (G3, n=23) or 2-4-6-8 (G2, n=23) algorithm. The primary endpoint was change of haemoglobin A1c (HbA1c), and the secondary safety endpoint included hypoglycaemic events. RESULTS After 20 weeks, HbA1c decreased similarly in the G3 and G2 groups, with a mean change of -0.9% from baseline. The mean change in fasting plasma glucose was numerically similar in both groups. The hypoglycaemia event rate per 100-patient-years of exposure (r) in the G2 group (r=1,427) was higher than that in the G3 group (r=807). CONCLUSION Both treatment groups had numerically similar HbA1c reductions. A trend towards fewer hypoglycaemia episodes after dose stabilisation was seen with the simpler G3. Clinically, this may be an important observation, as a simpler titration algorithm may support self-management and maintenance of insulin therapy.
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Affiliation(s)
- Hea Min Yu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, Korea
| | - Kang Seo Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, Korea.
| | - Jun Hwa Hong
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, Korea
| | - Keun Yong Park
- Department of Endocrinology and Metabolism, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| | - Jong Min Lee
- Department of Endocrinology and Metabolism, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Bon Jeong Ku
- Department of Endocrinology and Metabolism, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Yeo Joo Kim
- Department of Endocrinology and Metabolism, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Tae Kun Oh
- Department of Endocrinology and Metabolism, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
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Kulzer B, Daenschel W, Daenschel I, Schramm W, Messinger D, Weissmann J, Vesper I, Parkin CG, Heinemann L. Integrated personalized diabetes management improves glycemic control in patients with insulin-treated type 2 diabetes: Results of the PDM-ProValue study program. Diabetes Res Clin Pract 2018; 144:200-212. [PMID: 30205184 DOI: 10.1016/j.diabres.2018.09.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 08/29/2018] [Accepted: 09/04/2018] [Indexed: 01/18/2023]
Abstract
AIMS Globally, many patients with insulin-treated type-2 diabetes are suboptimally controlled. The PDM-ProValue study program evaluated whether integrated personalized diabetes management (iPDM) has the potential to improve clinical outcomes. METHODS 101 practices with 907 patients participated in the 12-month, prospective, controlled, cluster-randomized study program. HbA1c levels, therapy changes, frequency of hypoglycemic episodes, patient reported outcomes, and physician satisfaction were assessed. RESULTS iPDM led to a greater reduction in HbA1c after 12 months vs. usual care (-0.5%, p < 0.0001 vs. -0.3%, p < 0.0001), (Diff. 0.2%, p = 0.0324). Most of the HbA1c reduction occurred after 3 months and remained stable thereafter. The percentage of patients with therapy adjustments was higher in the iPDM group at all visits (p < 0.01 at week 3, month 3, month 6). Patient adherence at month 12 was higher in the iPDM group compared to baseline (Odds ratio = 2.39; p = 0.0003); also, patient treatment satisfaction (DTSQc: 12.2 vs. 10.4, δ = 1.78, p = 0.004; DTSQs: 31.0 vs. 30.0, δ = 0.924, p = 0.02), and physician satisfaction was higher in the intervention group. CONCLUSIONS iPDM improved the use of diagnostic data leading to better glycemic control, more timely treatment adjustments (indicating reduced clinical inertia), and increased patient adherence and treatment satisfaction among patients and physicians.
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Affiliation(s)
- Bernhard Kulzer
- Forschungsinstitut Diabetes Akademie Bad Mergentheim, Theodor-Klotzbücher-Straße 12, D-97980 Bad Mergentheim, Germany.
| | - Wilfried Daenschel
- Medizinisches Versorgungszentrum am Küchwald GmbH, Bürgerstr. 2, D-9113 Chemnitz, Germany.
| | - Ingrid Daenschel
- Medizinisches Versorgungszentrum am Küchwald GmbH, Bürgerstr. 2, D-9113 Chemnitz, Germany; Hausarztpraxis, Karl-Marx-Str. 15-17, D-09328 Lunzenau, Germany.
| | - Wendelin Schramm
- GECKO Institute for Medicine, Informatics and Economics, Heilbronn University, Max-Planck Str. 39, D-74081 Heilbronn, Germany.
| | - Diethelm Messinger
- Biometrics Department, Prometris GmbH, Soldnerstrasse 1, D-68219 Mannheim, Germany.
| | - Joerg Weissmann
- Roche Diabetes Care GmbH, Sandhofer Straße 116, D-68305 Mannheim, Germany.
| | - Iris Vesper
- Roche Diabetes Care GmbH, Sandhofer Straße 116, D-68305 Mannheim, Germany.
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Billings LK, Parkin CG, Price D. Baseline Glycated Hemoglobin Values Predict the Magnitude of Glycemic Improvement in Patients with Type 1 and Type 2 Diabetes: Subgroup Analyses from the DIAMOND Study Program. Diabetes Technol Ther 2018; 20:561-565. [PMID: 30044123 PMCID: PMC6080123 DOI: 10.1089/dia.2018.0163] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The DIAMOND study demonstrated that the addition of real-time continuous glucose monitoring (rtCGM) effectively lowers glycated hemoglobin (HbA1c) in patients with type 1 (T1D) and type 2 diabetes (T2D), treated with multiple daily injections (MDI). This post hoc analysis investigated whether DIAMOND study participants at progressively higher baseline HbA1c levels benefit from using rtCGM. We examined outcomes data from a large, randomized, controlled trial of MDI-treated participants with T1D (N = 158) and T2D (N = 158), comparing monitoring by rtCGM versus self-monitoring of blood glucose (SMBG). The primary outcome was the magnitude of HbA1c reductions among study participants within elevated baseline HbA1c levels (≥8.0%-10.0%, ≥8.5%-10.0%, and ≥9.0%-10.0%). Analyses were performed on three subgroups: T1D, T2D, and combined T1D/T2D. The full T1D analysis population had a mean baseline HbA1c value of 8.6 ± 0.6% (range 7.5%-9.9%), randomized to rtCGM (n = 105) or control (n = 53). The full T2D analysis population had a mean baseline HbA1c value of 8.5 ± 0.6% (range 7.5%-9.9%), randomized to rtCGM (n = 79) or control (n = 79). Participants had improvements in glycemic status regardless of monitoring method. In the three subgroups, the change in HbA1c was significantly greater in rtCGM participants compared to SMBG at all predefined baseline HbA1c levels at 12 and 24 weeks. Among the rtCGM participants, the change in HbA1c was numerically greatest at the highest baseline HbA1c subgroup (≥9.0%). Participants with elevated baseline HbA1c had improvements in glycemic status regardless of monitoring method. However, the magnitudes of improvements appeared greater among participants using rtCGM.
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Affiliation(s)
- Liana K. Billings
- Department of Clinical, NorthShore University HealthSystem, Skokie, Illinois
- University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Christopher G. Parkin
- Department of Research, CGParkin Communications, Inc., Boulder City, Nevada
- Address correspondence to:Christopher G. Parkin, MSDepartment of ResearchCGParkin Communications, Inc.932 Vista Lago WayBoulder City, NV 89005
| | - David Price
- Department of Medical Affairs, Dexcom, Inc., San Diego, California
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Orozco-Beltran D, Pan C, Svendsen AL, Faerch L, Caputo S. Basal insulin initiation in primary vs. specialist care: similar glycaemic control in two different patient populations. Int J Clin Pract 2016; 70:236-43. [PMID: 26916450 PMCID: PMC4832583 DOI: 10.1111/ijcp.12776] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE To investigate the effect of healthcare provider (HCP) type (primary vs. specialist) on glycaemic control and other treatment parameters. RESEARCH DESIGN AND METHODS Study of Once-Daily Levemir (SOLVE(™) ) is an international, 24-week, observational study of insulin initiation in people with type 2 diabetes. RESULTS A total of 17,374 subjects were included, comprising 4144 (23.9%) primary care subjects. Glycaemic control improved in both HCP groups from baseline to final visit [glycated haemoglobin (HbA1c) -1.2 ± 1.4% (-13.1 ± 15.3 mmol/mol) and -1.3 ± 1.6% (-14.2 ± 17.5 mmol/mol), respectively]. After adjustment for known confounders, there was no statistically significant effect of HCP group on final HbA1c [-0.04%, 95% confidence interval (CI) -0.09 to -0.01 (-0.4 mmol/mol, 95% CI -1.0-0.1 mmol/mol), p = 0.1590]. However, insulin doses at the final visit were higher in primary care patients (+0.06, 95% CI 0.06-0.07 U/kg, p < 0.0001). Logistic regression demonstrated a significant effect of HCP type (primary vs. specialist care) on hypoglycaemia risk [odds ratio (OR) 0.75, 95% CI 0.64-0.87, p = 0.0002]. Primary care physicians took more time to train patients and had more frequent contact with patients than specialists (both p < 0.0001). CONCLUSIONS Primary care physicians and specialists achieved comparable improvements in glycaemic control following insulin initiation.
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Affiliation(s)
- D Orozco-Beltran
- Department of Medicine, Cathedra of Family Medicine, University Miguel Hernandez, Alicante, Spain
| | - C Pan
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
| | - A L Svendsen
- Department of Biostatistics, Novo Nordisk A/S, Søborg, Denmark
| | - L Faerch
- Department of Medical Affairs, Novo Nordisk A/S, Søborg, Denmark
| | - S Caputo
- Servizio di Diabetologia, Policlinico Gemelli, Universita'Cattolica, Rome, Italy
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Omar MS, Khudada K, Safarini S, Mehanna S, Nafach J. DiabCare survey of diabetes management and complications in the Gulf countries. Indian J Endocrinol Metab 2016; 20:219-227. [PMID: 27042419 PMCID: PMC4792024 DOI: 10.4103/2230-8210.176347] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
AIM To describe the status of diabetes control and complications, and the quality of diabetes management in Saudi Arabia, Kuwait, and the United Arab Emirates, and to obtain an insight into the relationship between these factors. METHODS Patients with diabetes for>12 months were enrolled from specialist clinics and general hospitals. All available data from the patients' medical files including patient demographics; glycemic, lipid, and blood pressure status; diabetes-related complications; and diabetes management were recorded in data collection forms and analyzed. RESULTS Overall, 1290 patients with diabetes were enrolled with a mean (±standard deviation) age of 49.4 ± 12.3 years and duration of diabetes of 8.7 ± 5.9 years. Glycemic control was poor: Mean glycated hemoglobin A1c of 8.3 ± 2.0%, fasting and postprandial plasma glucose levels of 155.9 ± 57.1 mg/dL (8.7 ± 3.2 mmol/L), and 218.2 ± 87.4 mg/dL (12.1 ± 4.9 mmol/L), respectively. Diabetes-related complications such as neuropathy (34.9% of patients), background retinopathy (29.9%), and cataract (14.1%) were common. Cardiovascular complications were reported in <10% of patients, and microalbuminuria was detected in 34.4% of patients. Oral antidiabetic drug (OAD) monotherapy (43.3%) was the most common treatment, followed by insulin + OADs (39.3%) and insulin monotherapy (17.6%). CONCLUSION The status of diabetes care was found to be suboptimal. Further improvements in diabetes management are necessary to prevent or delay the development of diabetes-related complications.
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Affiliation(s)
| | - Khaled Khudada
- Department of Internal Medicine, Ahmadi Hospital, Kuwait Oil Company, Al Ahmadi, Kuwait
| | - Saher Safarini
- Department of Endocrinology and Metabolic Diseases, Dallah Hospital, Riyadh, Saudi Arabia
| | | | - Jalal Nafach
- Department of Endocrinology, Dubai Diabetes Center, Dubai, United Arab Emirates
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Czech M, Rdzanek E, Pawęska J, Adamowicz-Sidor O, Niewada M, Jakubczyk M. Drug-related risk of severe hypoglycaemia in observational studies: a systematic review and meta-analysis. BMC Endocr Disord 2015; 15:57. [PMID: 26458540 PMCID: PMC4603823 DOI: 10.1186/s12902-015-0052-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 09/30/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Diabetes mellitus (DM) leads to multiple complications, including severe hypoglycaemia events (SHEs). SHEs can impact a patient's quality of life and compliance and may directly result in additional costs to the health care system. The aim of this review was to evaluate the risk of severe hypoglycaemia in patients with type 1 (T1) and 2 (T2) DM as observed in everyday clinical practice for various drug regimens. METHODS We conducted a systematic review of observational (retrospective or prospective) studies in the MEDLINE, Embase, and Cochrane Library databases that covered at least 100 children or adults with T1/T2 DM. In T1 DM, basal-bolus/pre-mix insulin (human or analogue) and insulin pump were reviewed, and in T2 DM, basal-bolus/pre-mix insulin (human or analogue), oral antidiabetic drugs supported with basal insulin (human or analogue), sulfonylureas in monotherapy, and combined oral treatment were reviewed. In order to estimate SHE rates, we extracted data on the time horizon of the study, number of patients, number of SHEs, and number of patients experiencing at least one SHE. We used a random effects model to estimate the annual SHE rate. We considered the risk for other antidiabetic medications in T2 DM to be negligible and the results of our main review yielded no observational data for premixes in T1 DM so they were assessed based on relative rates taken from additional systematic reviews. The study, being a desk research, did not involve any human subjects (including human material or human data) and no ethical committee approval was asked for. For the same reason there was no need to collect informed consent for participation in the study. RESULTS We identified 76 observational studies encompassing 707,722.30 patient-years. The estimated annual SHE rate varied from 0.168 (95 % CI 0.123-0.237) for insulin pump up to 1.628 for biphasic human insulin in T1 DM patients, and from 0.0035 for oral antidiabetic drugs up to 0.554 (95 % CI 0.157-7.534) for basal-bolus with human insulin in T2 DM patients. CONCLUSIONS Our review indicates that SHE rates differ between patients depending on treatment regimen. However, SHEs are also driven by other factors. Proper modelling techniques are needed to use various types of information in published studies.
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Affiliation(s)
- Marcin Czech
- Novo Nordisk Pharma sp. z o.o, Warsaw, Poland.
- Department of Pharmacoeconomics, Medical University of Warsaw, Warsaw, Poland.
- Business School, Warsaw University of Technology, Warsaw, Poland.
| | - Elżbieta Rdzanek
- HealthQuest spółka z ograniczoną odpowiedzialnością Sp. K, Warsaw, Poland.
| | - Justyna Pawęska
- HealthQuest spółka z ograniczoną odpowiedzialnością Sp. K, Warsaw, Poland.
| | | | - Maciej Niewada
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Warsaw, Poland.
| | - Michał Jakubczyk
- Decision Analysis and Support Unit, Warsaw School of Economics, Al. Niepodległości 162, 02-554, Warsaw, Poland.
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Oguz A, Cevizci E, Ertekin A, Abdulnabi R. Clinical outcomes and resource use after 24 months of insulin therapy in Turkish patients with type 2 diabetes: subgroup analysis of the TREAT study. Int J Clin Pract 2015; 69:588-96. [PMID: 25472768 DOI: 10.1111/ijcp.12584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 10/10/2014] [Indexed: 11/29/2022] Open
Abstract
PURPOSE This study evaluated levels of metabolic control, resource use and quality of life in Turkish patients with type 2 diabetes initiated on insulin in routine care. PATIENTS AND METHODS The prospective, observational TREAT study evaluated patients from five different countries who were initiated on insulin and followed for 24 months. In this paper, we present the results of a cohort analysis specific to Turkish patients from the study. RESULTS A total of 211 patients in the Turkish multicenter cohort [male patients 50.2%, age 56.5 year±8.9 SD, body mass index (BMI) 30.6 kg/m2±5.4 SD, diabetes duration 9.7 year±5.9 SD] initiated insulin at baseline. Oral antidiabetic drugs had been used by 93.4% of patients prior to insulin initiation, and 65.9% had used more than one regimen. Pre-existing metformin therapy was continued by 68.7% of patients after insulin initiation. In the three most common insulin regimens, glycosylated haemoglobin (HbA1C) declined over 24 months from 10.27% to 7.82% (long/intermediate acting), from 10.82% to 7.52% (premixed) and from 10.42% to 7.67% (basal-bolus). Less than 25% achieved a glycaemic goal of HbA1C≤7.0% and changes in insulin dose or regimen rarely occurred. Premixed insulin regimens were associated with greatest weight gain. Hypoglycaemic episodes were reported by more patients at 3, 6 and 12 months than at baseline or at 18 or 24 months. Healthcare use increased over baseline levels in the first 6 months, but was closer to baseline levels at subsequent assessments. Patient recorded health profiles improved after initiating insulin, particularly quality of life scores related to psychological distress and pain/discomfort. Morisky scores predictive of medication adherence and treatment persistence also improved. CONCLUSIONS In Turkish patients with type 2 diabetes, metabolic control remained suboptimal after initiating insulin as part of routine care even after 24 months of insulin treatment. Apparent shortcomings in routine care in most patients included a high baseline HbA1C because of delayed insulin initiation and an unwillingness to individualise insulin regimens.
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Affiliation(s)
- A Oguz
- Department of Internal Medicine, Istanbul Medeniyet University Göztepe Training and Research Hospital, Istanbul, Turkey
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Yang C, Chen W, Wu G, Tang L, Zhang Q. Impact of hepatogenous diabetes on clinical features of patients with HBV related chronic liver failure. Shijie Huaren Xiaohua Zazhi 2014; 22:5036-5040. [DOI: 10.11569/wcjd.v22.i32.5036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the impact of hepatogenous diabetes (HD) on the clinical features of patients with hepatitis B virus (HBV) related chronic liver failure (CLF).
METHODS: One hundred and eighty-seven patients with HBV related CLF were divided into either an HD group (n = 65) or a control group (n = 122). The liver and kidney function, HBV DNA level, coagulation function, glycosylated hemoglobin Alc (HbAlc) level, Child-Pugh score, model for end-stage liver disease (MELD) score, complications and mortality at 24 wk were analyzed. The correlations between HbAlc level and Child-Pugh score and MELD score were analyzed by linear correlation analysis. Unconditional binary response logistic regression model was used to determine the correlations between HbAlc level and the incidence of complications and mortality at 24 wk.
RESULTS: The incidence of HD in patients with HBV related CLF was 34.76%. The level of total bilirubin (TBIL), international normalized ratio (INR), creatinine (CRE), HbAlc, Child-Pugh score and MELD score were significantly higher in the HD group (P < 0.05). The incidence rates of spontaneous peritonitis and hepatorenal syndrome and mortality at 24 wk were also significantly higher in the HD group (P < 0.05). There were positive correlations between the HbAlc level and Child-Pugh score (r2 = 0.17, F = 14.74, P = 0.021) and MELD score (r2 = 0.19, F = 16.61, P = 0.014) in patients with CLF. Logistic regression analysis identified that high HbAlc level was related to the high incidence of spontaneous peritonitis (P = 0.019, OR = 2.27) and hepatorenal syndrome (P = 0.023, OR = 1.02) and high mortality at 24 wk (P = 0.032, OR = 0.85).
CONCLUSION: The clinical features of patients with HBV related CLF complicated with HD are more serious. High HbAlc level is a risk factor for spontaneous peritonitis, hepatorenal syndrome and worse prognosis in patients with HBV related CLF.
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Damci T, Emral R, Svendsen AL, Balkir T, Vora J. Lower risk of hypoglycaemia and greater odds for weight loss with initiation of insulin detemir compared with insulin glargine in Turkish patients with type 2 diabetes mellitus: local results of a multinational observational study. BMC Endocr Disord 2014; 14:61. [PMID: 25048824 PMCID: PMC4223563 DOI: 10.1186/1472-6823-14-61] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 07/15/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this analysis is to evaluate the safety and effectiveness of insulin initiation with once-daily insulin detemir (IDet) or insulin glargine (IGlar) in real-life clinical practice in Turkish patients with type 2 diabetes mellitus (T2DM). METHODS This was a 24-week multinational observational study of insulin initiation in patients with T2DM. RESULTS The Turkish cohort (n = 2886) included 2395 patients treated with IDet and 491 with IGlar. The change in glycosylated haemoglobin (HbA1c) from the pre-insulin levels was -2.21% [95% confidence interval (CI) -2.32, -2.09] in the IDet group and -1.88% [95% CI -2.17, -1.59] in the IGlar group at the final visit. The incidence rate of minor hypoglycaemia increased in both groups from the pre-insulin to the final visit (+0.66 and +2.23 events per patient year in the IDet and IGlar groups, respectively). Weight change in the IDet group was -0.23 kg [95% CI -0.49, 0.02 kg], and +1.55 kg [95% CI 1.11, 2.00 kg] in the IGlar group. Regression analysis with adjustment for previously identified confounders (age, gender, duration of diabetes, body mass index, previous history of hypoglycaemia, microvascular disease, number and change in oral anti-diabetic drug therapy, HbA1c at baseline and insulin dose) identified an independent effect of insulin type (IDet versus IGlar) with a risk of at least one episode of hypoglycaemia (odds ratio (OR): 0.33 [95% CI 0.21, 0.52], p <0.0001), and weight loss ≥1 kg (OR: 1.75 [95% CI 1.18, 2.59], p = 0.005), but not on HbA1c (+0.05% [95% CI -0.15, 0.25%], p = 0.6). CONCLUSIONS Initiation of basal insulin analogues, IDet and IGlar, were associated with clinically significant glycaemic improvements. A lower risk of minor hypoglycaemia and greater odds of weight loss ≥1 kg was observed with IDet compared with IGlar. TRIAL REGISTRATION NCT00825643 and NCT00740519.
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Affiliation(s)
- Taner Damci
- Department of Endocrinology, Diabetes and Metabolism, Cerrahpasa Medical School, Istanbul University, 34363 Istanbul, Turkey
| | - Rifat Emral
- Department of Endocrinology and Metabolic Diseases, Faculty of Medicine, Ankara University, Ibn-i Sina Hospital, Ankara, Turkey
| | | | - Tanzer Balkir
- Department of Clinical, Medical, & Regulatory Affairs, Novo Nordisk Saglik Urunleri Tic. Ltd. Sti., Etiler-Istanbul, Turkey
| | - Jiten Vora
- Department of Diabetes and Endocrinology, Royal Liverpool University Hospital, Liverpool, UK
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Khamseh ME, Prusty V, Latif Z, Gonzalez-Galvez G, Dieuzeide G, Zilov A. Type 2 diabetes mellitus management and body mass index: experiences with initiating insulin detemir in the a1chieve study. Diabetes Ther 2014; 5:127-40. [PMID: 24477670 PMCID: PMC4065301 DOI: 10.1007/s13300-014-0054-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION This sub-analysis of the A1chieve study aimed to examine the safety and efficacy of insulin detemir (IDet) initiation over 24 weeks in relation to baseline body mass index (BMI) in people with type 2 diabetes mellitus (T2DM). METHODS A1chieve was a 24-week non-interventional study to assess the safety and efficacy of insulin analogs in routine practice. This sub-analysis included insulin-naïve patients who initiated IDet therapy based on their physicians' decision. Patients were stratified according to baseline BMI (Group I, <25.0 kg/m(2); Group II, 25.0 to <30.0 kg/m(2); Group III, 30.0 to <35.0 kg/m(2); Group IV ≥35.0 kg/m(2)). Safety and efficacy variables were assessed over 24 weeks. RESULTS Overall, 10,650 insulin-naïve patients were included (3,045 patients in Group I, 4,186 patients in Group II, 2,365 patients in Group III, and 1,054 patients in Group IV). Four serious adverse drug reactions (SADRs) were reported. From baseline to Week 24, there was no statistically significant difference in the proportion of patients reporting overall hypoglycemia in Group I (4.0% vs. 4.4%), while a significant decrease in Group II (4.8% vs. 4.0%, p = 0.0335) and significant increases in Groups III and IV (3.3% vs. 5.4% and 3.4% vs. 7.0%, respectively, p < 0.001) were noted. The mean body weight increased from baseline to Week 24 in Group I (60.7 ± 8.4 vs. 61.8 ± 8.5 kg) and reduced in Groups II, III, and IV (74.5 ± 9.2 vs. 74.2 ± 9.2 kg, 87.4 ± 10.3 vs. 86.0 ± 9.8 kg, and 102.2 ± 14.3 vs. 100.1 ± 14.2 kg, respectively; all p < 0.001). Significant improvements were noted in glycemic parameters, systolic blood pressure, and lipids over 24 weeks, irrespective of baseline BMI status. CONCLUSION IDet therapy was associated with improved glycemic control and a low number of SADRs. Greater weight loss was observed with higher BMI.
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Affiliation(s)
- Mohammed E Khamseh
- Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran,
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Ross S, Dzida G, Ji Q, Kaiser M, Ligthelm R, Meneghini L, Nazeri A, Orozco-Beltran D, Pan C, Svendsen AL. Safety of once-daily insulin detemir in patients with type 2 diabetes treated with oral hypoglycemic agents in routine clinical practice. J Diabetes 2014; 6:243-50. [PMID: 24103141 DOI: 10.1111/1753-0407.12091] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Revised: 08/21/2013] [Accepted: 09/13/2013] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The aim of the present study was to identify demographic and treatment factors that were predictive of hypoglycemia in a large cohort of type 2 diabetic patients initiating insulin detemir. METHODS The present 24-week observational study of insulin initiation included 17 374 participants from 10 countries. Severe hypoglycemia was defined as an event requiring third party assistance; minor hypoglycemia was defined as a daytime or nocturnal glucose measurement <3.1 mmol/L. RESULTS Prior to initiating insulin therapy, 4.9% of the cohort reported hypoglycemia (pre-insulin hypoglycemia), with most (94.2%) reporting minor events and 9.6% reporting severe events. Compared with patients without pre-insulin hypoglycemia, those with pre-insulin hypoglycemia had a higher incidence of events of minor hypoglycemia (1.72 vs 4.46 events per patient-year [ppy], respectively), nocturnal hypoglycemia (0.25 vs 1.09 events ppy, respectively), and severe hypoglycemia (<0.01 vs 0.04 events ppy, respectively) at final visit. Age (P < 0.047), body mass index (P < 0.001), a prior history of microvascular disease (P < 0.001), pre-insulin hypoglycemia (P < 0.001), increased number of oral hypoglycemic agents (OHAs; P < 0.001), OHA intensification (P < 0.001), and the use of glinides (P = 0.004) were all found to be independently associated with the occurrence of hypoglycemia during the study. CONCLUSIONS Once-daily insulin detemir therapy was safe and effective, and rates of hypoglycemia were low. Concerns about hypoglycemia should not deter the initiation of basal insulin analogs.
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Affiliation(s)
- Stuart Ross
- Department of Medicine, University of Calgary, Calgary, Canada
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Home PD, Shen C, Hasan MI, Latif ZA, Chen JW, González Gálvez G. Predictive and explanatory factors of change in HbA1c in a 24-week observational study of 66,726 people with type 2 diabetes starting insulin analogs. Diabetes Care 2014; 37:1237-45. [PMID: 24595628 DOI: 10.2337/dc13-2413] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Individualization of therapy choices requires the prediction of likely response. Predictor and explanatory factors of change in HbA1c were studied using data from a large observational study of starting insulin analog therapy (the A1chieve study). RESEARCH DESIGN AND METHODS Univariate analyses were performed for insulin-naive people and prior insulin users in the A1chieve study. Statistically significant factors were carried forward to baseline factor-only multivariate analyses ("predictor" analysis), and separately using all significant factors ("explanatory" analysis). Power was considered in terms of the variance explained. RESULTS Geographical region, baseline HbA1c level, lipid levels, and baseline insulin dose were the most powerful predictors of HbA1c change (mean change -2.1% [-23 mmol/mol]) observed in the univariate analysis (r2 > 0.010, P < 0.001). However, although the predictor and explanatory multivariate models explained 62-82% of the variance in HbA1c change, this was mainly associated with baseline HbA1c (r2 = 0.544-0.701) and region (r2 = 0.014-0.037). Other factors were statistically significant but had low predictive power (r2 < 0.010); in the explanatory analysis, this included end-of-study hypoglycemia (insulin-naive group), insulin dose, and health-related quality of life (r(2) < 0.001-0.006, P ≤ 0.007). CONCLUSIONS Many factors can guide clinicians in predicting the response to starting therapy with insulin analogs, but many are interdependent and thus of poor utility. The factor explaining most of the variance in HbA1c change is baseline HbA1c level, with each increase of 1.0%-units (11 mmol/mol) providing a 0.7-0.8%-units (8-9 mmol/mol) greater fall. Other factors do not explain much of the remaining variance, even when including all end-of-trial measures.
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Affiliation(s)
- Itamar Raz
- Diabetes Unit, Hadassah University Hospital, Jerusalem, Israel.
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