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Hermanns N, Ehrmann D, Finke-Groene K, Krichbaum M, Roos T, Haak T, Freckmann G, Kulzer B. Use of smartphone application versus written titration charts for basal insulin titration in adults with type 2 diabetes and suboptimal glycaemic control (My Dose Coach): multicentre, open-label, parallel, randomised controlled trial. Lancet Reg Health Eur 2023; 33:100702. [PMID: 37954005 PMCID: PMC10636267 DOI: 10.1016/j.lanepe.2023.100702] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/07/2023] [Accepted: 07/12/2023] [Indexed: 11/14/2023]
Abstract
Background The majority of people with type 2 diabetes who require insulin therapy use only basal insulin in combination with other anti-diabetic agents. We tested whether using a smartphone application to titrate insulin could improve glycaemic control in people with type 2 diabetes who use basal insulin. Methods This was a 12-week, multicentre, open-label, parallel, randomised controlled trial conducted in 36 diabetes practices in Germany. Eligible participants had type 2 diabetes, a BMI ≥25.0 kg/m2, were on basal insulin therapy or were initiating basal insulin therapy, and had suboptimal glycaemic control (HbA1c >7.5%; 58.5 mmol/mol). Block randomisation with 1:1 allocation was performed centrally. Participants in the intervention group titrated their basal insulin dose using a smartphone application (My Dose Coach) for 12 weeks. Control group participants titrated their basal insulin dose according to a written titration chart. The primary outcome was the baseline-adjusted change in HbA1c at 12 weeks. The intention-to-treat analysis included all randomised participants. Results Between 13 July 2021 and 21 March 2022, 251 study participants were randomly assigned (control group: n = 123; intervention group: n = 128), and 236 completed the follow-up phase (control group: n = 119; intervention group: n = 117). Regarding the HbA1c a model-based adjusted between-group difference of -0.31% (95% CI: 0.01%-0.69%; p = 0.0388) in favour of the intervention group was observed. There were 30 adverse events reported: 16 in the control group, 14 in the intervention group. Of these, 15 adverse events were serious. No event was considered to be related to the investigational device. Interpretation Study results suggest that utilizing this digital health smartphone application for basal insulin titration may have resulted in a comparatively greater reduction in HbA1c levels among individuals with type 2 diabetes, as compared to basal insulin titration guided by a written titration schedule. No negative effect on safety outcomes was observed. Funding Sanofi-Aventis Deutschland GmbH.
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Affiliation(s)
- Norbert Hermanns
- Research Institute of the Diabetes Academy Mergentheim (FIDAM), Johann-Hammer-Str. 24, Bad Mergentheim 97980, Germany
- Diabetes Centre Bad Mergentheim, Theodor-Klotzbuecher-Str. 12, Bad Mergentheim 97980, Germany
- Department of Clinical Psychology and Psychotherapy, University of Bamberg, Markusplatz 3, Bamberg 96047, Germany
| | - Dominic Ehrmann
- Research Institute of the Diabetes Academy Mergentheim (FIDAM), Johann-Hammer-Str. 24, Bad Mergentheim 97980, Germany
- Department of Clinical Psychology and Psychotherapy, University of Bamberg, Markusplatz 3, Bamberg 96047, Germany
| | - Katharina Finke-Groene
- Research Institute of the Diabetes Academy Mergentheim (FIDAM), Johann-Hammer-Str. 24, Bad Mergentheim 97980, Germany
| | - Michael Krichbaum
- Research Institute of the Diabetes Academy Mergentheim (FIDAM), Johann-Hammer-Str. 24, Bad Mergentheim 97980, Germany
| | - Timm Roos
- Research Institute of the Diabetes Academy Mergentheim (FIDAM), Johann-Hammer-Str. 24, Bad Mergentheim 97980, Germany
| | - Thomas Haak
- Diabetes Centre Bad Mergentheim, Theodor-Klotzbuecher-Str. 12, Bad Mergentheim 97980, Germany
| | - Guido Freckmann
- IfDT - Institut für Diabetes-Technologie Forschungs- und Entwicklungsgesellschaft mbH, Helmholtzstr. 20, Ulm 89081, Germany
| | - Bernhard Kulzer
- Research Institute of the Diabetes Academy Mergentheim (FIDAM), Johann-Hammer-Str. 24, Bad Mergentheim 97980, Germany
- Diabetes Centre Bad Mergentheim, Theodor-Klotzbuecher-Str. 12, Bad Mergentheim 97980, Germany
- Department of Clinical Psychology and Psychotherapy, University of Bamberg, Markusplatz 3, Bamberg 96047, Germany
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2
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Mayne IK, Tyzack-Clark HM, McGovern AP. Studies are needed to support optimal insulin dose titration in gestational diabetes mellitus: A systematic review. Diabetes Metab Syndr 2023; 17:102746. [PMID: 36966543 DOI: 10.1016/j.dsx.2023.102746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 03/11/2023] [Accepted: 03/14/2023] [Indexed: 03/28/2023]
Abstract
BACKGROUND AND AIMS We aimed to summarise the existing literature on insulin dose titration in gestation diabetes. METHODS Databases: Medline, EMBASE, CENTRAL and CINAHL were systematically searched for trials and observational studies comparing insulin titration strategies in gestational diabetes. RESULTS No trials comparing insulin dose titration strategies were identified. Only one small (n = 111) observational study was included. In this study, patient-led daily basal insulin titration was associated with higher insulin doses, tighter glycaemic control, and lower birthweight, vs weekly clinician-led titration. CONCLUSIONS There is a paucity of evidence to support optimal insulin titration in gestational diabetes. Randomized trials are required.
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Affiliation(s)
| | | | - Andrew P McGovern
- University of Exeter Medical School, Exeter, UK; University Hospitals Plymouth NHS Trust, Plymouth, UK
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3
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Chan SP, Aamir AH, Bee YM, Deerochanawong C, Paz-Pacheco E, Tiu F, Foo SH, Tan KEK, Le TQ, Saraswati MR, Bunnag P, Panusunan Sibarani R, Raza SA, Tran NQ. Practical Guidance on Basal Insulin Initiation and Titration in Asia: A Delphi-Based Consensus. Diabetes Ther 2022; 13:1511-1529. [PMID: 35767186 PMCID: PMC9309111 DOI: 10.1007/s13300-022-01286-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 05/26/2022] [Indexed: 11/06/2022] Open
Abstract
The global health burden of diabetes is on the rise and has affected more than half a billion people worldwide, particularly in Southeast Asia, North Africa, Africa, and the Western Pacific, Middle East, and South and Central America regions of the International Diabetes Federation (IDF). Despite many new treatments being available for the management of diabetes, glycemic control remains suboptimal in Asia, compared to the rest of the world. Delay in timely insulin initiation and inadequate titration of insulin are regarded to be some of the important reasons for inadequate glycemic control. Additionally, Asian populations have a distinct phenotype, including a younger age of onset and higher glycemic excursions, suggestive of a lower beta-cell function, as compared to non-Asians. Although there are multiple local and international guidelines on insulin initiation and titration, some of these guidelines can be complex. There is an unmet need for guideline recommendations on basal insulin initiation and titration to be simplified and customized for the Asian population with type 2 diabetes mellitus (T2DM). A unified approach would increase adoption of basal insulin initiation by primary care and family medicine physicians, which in turn would help reduce the inertia to insulin initiation. With this background, a consensus-seeking meeting was conducted with 14 experts from seven Asian countries to delineate appropriate practices for insulin initiation and titration in the Asian context. The key objective was to propose a simple insulin titration algorithm, specific for the Asian population, to improve glycemic control and optimize therapeutic outcomes of people with T2DM on basal insulin. Following a detailed review of literature and current guidelines, and potential barriers to insulin initiation and titration, the experts proposed a simplified insulin titration algorithm based on both physician- and patient-led components. The consensus recommendations of the experts related to basal insulin initiation and titration have been summarized in this article, along with the proposed titration algorithm for optimizing glycemic control in the Asian population with T2DM.
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Affiliation(s)
- Siew Pheng Chan
- Subang Jaya Medical Centre, Department of Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia.
| | - Azizul Hasan Aamir
- Khyber Girls Medical College, Hayatabad Medical Complex, Peshawar, Pakistan
| | - Yong Mong Bee
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Chaicharn Deerochanawong
- Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Elizabeth Paz-Pacheco
- Division of Endocrinology, Diabetes and Metabolism, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Fatma Tiu
- Diabetes Clinic, University de Zamboanga Hospital, Zamboanga, Philippines
| | | | - Kevin E K Tan
- Mount Elizabeth Medical Centre, Singapore, Singapore
| | - Toan Q Le
- National Hospital of Endocrinology, Hanoi, Vietnam
- University of Medicine and Pharmacy, Hanoi National University, Hanoi, Vietnam
| | - Made Ratna Saraswati
- Division of Endocrinology and Metabolism, Internal Medicine Department, Faculty of Medicine, Udayana University/Sanglah Hospital Denpasar-Bali, Denpasar, Indonesia
| | - Pongamorn Bunnag
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Syed Abbas Raza
- Shaukat Khanum Cancer Hospital and Research Center, Lahore, Pakistan
| | - Nam Quang Tran
- Department of Endocrinology, University Medical Center at Ho Chi Minh City, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
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4
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Brož J, Janíčková Žďárská D, Urbanová J, Piťhová P, Doničová V, Pálová S, Pelechová B, Smržová A, Kvapil M. Insulin Management of Patients with Inadequately Controlled Type 2 Diabetes Admitted to Hospital: Titration Patterns and Frequency of Hypoglycemia as Results of a Prospective Observational Study (Hospital Study). Diabetes Ther 2021; 12:1799-1808. [PMID: 34028699 PMCID: PMC8266977 DOI: 10.1007/s13300-021-01080-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 05/12/2021] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Despite the continuously growing number of therapeutic options for type 2 diabetes mellitus (T2DM) including insulins, a large percentage of patients fail to achieve HbA1c targets. Several real-world studies focused on patients with T2DM receiving insulin treatment in outpatient settings were conducted, but information about real-world in-hospital insulin management is lacking. The aim of this study was to describe the management of insulin therapy with a focus on basal-bolus and premixed insulin regimens in patients with T2DM under routine in-hospital medical practice in the Czech Republic. METHODS This non-interventional prospective study was conducted from June 2014 to December 2017 in 22 centers in the Czech Republic under routine clinical practice conditions. Adult patients admitted to hospital with metabolically uncontrolled T2DM [HbA1c ≥ 60 mmol/mol; > 7.6% Diabetes Control and Complications Trial (DCCT)] and there treated with basal-bolus and premixed insulin regimens were documented during hospitalization. RESULTS Overall, 369 patients with T2DM (54.7% male, mean age 64.44 ± 13.84 years, BMI 31.10 ± 6.00 kg/m2, duration of diabetes 8.11 ± 9.93 years, HbA1c 95.90 ± 24.38 mmol/mol, length of stay was 7.94 ± 4.53 days) were included. The percentage of glucose values under 10 mmol/l at time of randomization (the group with basal-bolus insulin regimen vs. the premix insulin regimen group) was 24.2% vs. 33.5% (p = 0.053), at time of first insulin dose adjustment it was 43.1% vs. 50.0% (p = 0.330), and 1 day before hospital discharge it was 61.7% vs. 61.4% (p = 0.107). A hypoglycemic event occurred in a total of 15 patients in the basal-bolus regimen group, and no hypoglycemic event occurred in the premixed insulin regimen group. CONCLUSION In-hospital insulin management regarding basal-bolus and premixed insulin regimens is safe and in concordance with current international recommendations.
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Affiliation(s)
- Jan Brož
- Department of Internal Medicine, Second Faculty of Medicine, Charles University, V Úvalu 84, 150 00, Prague, Czech Republic.
| | - Denisa Janíčková Žďárská
- Department of Internal Medicine, Second Faculty of Medicine, Charles University, V Úvalu 84, 150 00, Prague, Czech Republic
| | - Jana Urbanová
- Department of Internal Medicine, Third Faculty of Medicine and Faculty Hospital Královské Vinohrady, Charles University, Prague, Czech Republic
| | - Pavlína Piťhová
- Department of Internal Medicine, Second Faculty of Medicine, Charles University, V Úvalu 84, 150 00, Prague, Czech Republic
| | - Viera Doničová
- Private Department of Diabetology, Internal Medicine and Metabolism, Kosice, Slovakia
| | - Sabina Pálová
- Department of Internal Medicine, Second Faculty of Medicine, Charles University, V Úvalu 84, 150 00, Prague, Czech Republic
| | - Barbora Pelechová
- Department of Internal Medicine, Second Faculty of Medicine, Charles University, V Úvalu 84, 150 00, Prague, Czech Republic
| | - Anna Smržová
- Institute of Biostatistics and Analyses, Ltd., Brno, Czech Republic
| | - Milan Kvapil
- Department of Internal Medicine, Second Faculty of Medicine, Charles University, V Úvalu 84, 150 00, Prague, Czech Republic
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Hancu N, Janez A, Lalic N, Papanas N, Rahelic D, Roman G, Serafinceanu C, Tentolouris N, Vukovic B, Ylli A, Tankova T. Expert Opinion: A Call for Basal Insulin Titration in Patients with Type 2 Diabetes in Daily Practice: Southeast European Perspective. Diabetes Ther 2021; 12:1575-1589. [PMID: 33721212 PMCID: PMC7957039 DOI: 10.1007/s13300-021-01037-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 02/17/2021] [Indexed: 12/14/2022] Open
Abstract
Therapeutic inertia related to insulin treatment, i.e. delays in initiation, especially titration of basal insulin, is a significant problem in daily practice in Southeast European countries. This phenomenon can be traced back to several patient-, physician- and health system-related factors. In recognition of the issue of inadequate insulin titration, 11 leading experts from countries in this region held a consensus-seeking meeting to review the current status of insulin initiation after non-insulin treatment and the potential barriers to insulin titration to provide an algorithm and tools for outpatient physicians and for patients aimed at optimizing basal insulin titration. The experts reached a consensus on the majority of the topics and proposed recommendations on how clinical inertia can be overcome. The outcomes of the meeting have been summarized in this paper.
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Affiliation(s)
- Nicolae Hancu
- Regina Maria Clinic, University of Medicine and Pharmacy Iuliu Hatieganu, Cluj Napoca, Romania.
| | - Andrej Janez
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Clinical Center Ljubljana, Ljubljana, Slovenia
| | - Nebojsa Lalic
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Nikolaos Papanas
- Diabetes Centre, Second Department of Internal Medicine, Medical School, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Dario Rahelic
- Vuk Vrhovac University Clinic for Diabetes, Endocrinology and Metabolic Diseases, Merkur University Hospital, Zagreb, Croatia
- University of Zagreb School of Medicine, Zagreb, Croatia
- Josip Juraj Strossmayer, University of Osijek School of Medicine, Osijek, Croatia
| | - Gabriela Roman
- Clinical Centre of Diabetes, Nutrition and Metabolic Diseases, Emergency Clinic County Hospital, University of Medicine and Pharmacy Iuliu Hatieganu, Cluj-Napoca, Romania
| | - Cristian Serafinceanu
- Diabetology Clinic National Institute of Diabetes, Nutrition and Metabolic Diseases Prof. NC Paulescu, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Nikolaos Tentolouris
- Laiko General Hospital, National and Kapodistrian, University of Athens, Medical School, Athens, Greece
| | - Blaženko Vukovic
- Department of Endocrinology With General Internal Medicine, University Clinical Center of Republika Srpska, Banja Luka, Bosnia and Herzegovina
| | - Agron Ylli
- Endocrinology Service in UHC Mother Teresa Tirane, Tirane, Albania
| | - Tsvetalina Tankova
- Department of Endocrinology, Faculty of Medicine, Medical University of Sofia, Sofia, Bulgaria
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Hood RC, Chen Y, Sindelar DK, Ly T, Juneja R, Pollom RD, Ilag L, Wysham C. The Effect of Prestudy Insulin Therapy on Safety and Efficacy of Human Regular U-500 Insulin by Pump or Injection: A Posthoc Analysis. Endocr Pract 2021; 27:783-789. [PMID: 33515757 DOI: 10.1016/j.eprac.2021.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 01/13/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE We conducted a posthoc analysis of the VIVID study (Safety and Efficacy of Human Regular U-500 Insulin Administered by Continuous Subcutaneous Insulin Infusion Versus Multiple Daily Injections in Subjects With Type 2 Diabetes Mellitus: A Randomized, Open-Label, Parallel Clinical Trial), comparing 2 delivery methods of human regular U-500 insulin (U-500R), continuous subcutaneous insulin infusion (CSII) versus multiple daily injection (MDI), in type 2 diabetes requiring high insulin, to determine influence of prestudy insulin on glycemic outcomes. METHODS We compared A1C, total daily insulin dose (TDD), weight, and hypoglycemia by subgroups of prestudy insulin (prestudy U-500R vs non-U-500R) and treatment (CSII vs MDI). RESULTS At baseline, prestudy U-500R had higher TDD, higher body mass index, lower A1C and fasting plasma glucose, and higher rate of hypoglycemia compared to non-U-500R. Active titration of U-500R reduced A1C in both subgroups, with maximum benefit at 8 weeks. At 26 weeks, CSII provided the greatest reduction in A1C in both subgroups, with a greater reduction in non-U-500R. MDI provided an A1C reduction in both subgroups, with the greater reduction in non-U-500R. At 8 weeks, prestudy U-500R reached its lowest A1C; thereafter, A1C rebounded with MDI and remained stable with CSII. In non-U-500R, A1C continued to decrease to study end. In non-U-500R, hypoglycemia increased during active titration, but then decreased in the posttitration maintenance period. In both subgroups, TDD increased from baseline with MDI but not with CSII. Body weight increased in both subgroups but was greater in prestudy U-500R with CSII compared to MDI. CONCLUSION Regardless of previous insulin, people on high-dose insulin could lower A1C with U-500R, with additional benefit from CSII. These results may provide guidance for use of U-500R in clinical practice.
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Affiliation(s)
- Robert C Hood
- Endocrine Clinic of Southeast Texas, Beaumont, Texas.
| | - Yun Chen
- Techdata Service Company, LLC, King of Prussia, Pennsylvania
| | - Dana K Sindelar
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana
| | - Trang Ly
- Insulet Corporation, Acton, Massachusetts
| | - Rattan Juneja
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana
| | - R Daniel Pollom
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana
| | - Liza Ilag
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana
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7
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Brož J, Janíčková Ždárská D, Urbanová J. Results of Insulin Therapy in Type 2 Diabetes Mellitus Patients in the Czech Republic: Do They Reflect the Current Status in Other Countries? Diabetes Ther 2019; 10:1181-1188. [PMID: 31131435 PMCID: PMC6612328 DOI: 10.1007/s13300-019-0637-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Indexed: 11/06/2022] Open
Abstract
The results of two large multicentric, observational and cross-sectional studies (the DIAINFORM study and BALI study) reflecting routine clinical practice for insulin treatment in type 2 diabetes mellitus in the Czech Republic were published recently. In this commentary, we analyze these results and compare them with the findings of similar studies conducted in other countries within the last decade. The analysis focuses on achievement of glycated hemoglobin goals, insulin dosage and frequency of hypoglycemia.
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Affiliation(s)
- Jan Brož
- Department of Internal Medicine, Second Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Denisa Janíčková Ždárská
- Department of Internal Medicine, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jana Urbanová
- Second Department of Internal Medicine, Third Faculty of Medicine, Center for Research in Diabetes, Metabolism and Nutrition, Charles University, Prague, Czech Republic
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8
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Bonadonna RC, Giaccari A, Buzzetti R, Aimaretti G, Cucinotta D, Avogaro A, Perseghin G, Larosa M, Bolli GB, Fanelli CG. Italian Titration Approach Study (ITAS) with insulin glargine 300 U/mL in insulin-naïve type 2 diabetes: Design and population. Nutr Metab Cardiovasc Dis 2019; 29:496-503. [PMID: 30952575 DOI: 10.1016/j.numecd.2019.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 01/03/2019] [Accepted: 01/17/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIMS Fostering patient's self-managing of basal insulin therapy could improve glucose control, by removing patient's and physician's barriers to basal insulin initiation, titration and glucose monitoring. The Italian Titration Approaches Study (ITAS) aims at demonstrating non-inferiority (<0.3% margin) in efficacy of glucose control (change in glycated hemoglobin [HbA1c] after 24 weeks) by the same titration algorithm of insulin glargine 300 U/mL (Gla-300), managed by the (nurse assisted) patient versus the physician, in insulin naïve patients with Type 2 Diabetes Mellitus (T2DM), uncontrolled with previous treatments. METHODS AND RESULTS ITAS is a phase IV, 24-week, national, multicenter, open label, randomized (1:1) parallel group study. 458 patients were enrolled, 359 randomized, and 339 completed the study, in 46 Italian centers. Baseline characteristics and previous medications of the ITT population (N = 355) are reported. Mean ± SD age, T2DM duration, HbA1c, FPG and BMI were 64.0 ± 9.8 years, 11.6 ± 7.6 years, 8.79 ± 0.65%, 170.9 ± 42.3 mg/dL, and 30.3 ± 5.6 kg/m2, respectively. Vascular and metabolic disorders were most frequent (73.8% and 58.3%, respectively). More than 90% of patients were on metformin. CONCLUSION ITAS is the first study to compare two different managers (nurse-assisted patient vs physician) of the same titration algorithm of Gla-300 in insulin naïve patients with T2DM in unsatisfactory glucose control. This study might provide novel evidence on the efficacy/effectiveness of patient-managed titration algorithm of Gla-300 in a pragmatic setting and may reduce barriers to basal insulin initiation and its titration.
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Affiliation(s)
- R C Bonadonna
- Division of Endocrinology and Metabolic Diseases, Department of Medicine and Surgery, University of Parma, AOU of Parma, Italy.
| | - A Giaccari
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome and Università Cattolica del Sacro Cuore, Rome, Italy
| | | | | | | | | | | | | | - G B Bolli
- Section of Endocrinology and Metabolism, Department of Medicine, Perugia University Medical School, Italy
| | - C G Fanelli
- Section of Endocrinology and Metabolism, Department of Medicine, Perugia University Medical School, Italy
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9
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Berard L, Antonishyn N, Arcudi K, Blunden S, Cheng A, Goldenberg R, Harris S, Jones S, Mehan U, Morrell J, Roscoe R, Siemens R, Vallis M, Yale JF. Insulin Matters: A Practical Approach to Basal Insulin Management in Type 2 Diabetes. Diabetes Ther 2018; 9:501-519. [PMID: 29476414 PMCID: PMC6104258 DOI: 10.1007/s13300-018-0375-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Indexed: 12/14/2022] Open
Abstract
It is currently estimated that 11 million Canadians are living with diabetes or prediabetes. Although hyperglycemia is associated with serious complications, it is well established that improved glycemic control reduces the risk of microvascular complications and can also reduce cardiovascular (CV) complications over the long term. The UKPDS and ADVANCE landmark trials have resulted in diabetes guidelines recommending an A1C target of ≤ 7.0% for most patients or a target of ≤ 6.5% to further reduce the risk of nephropathy and retinopathy in those with type 2 diabetes (T2D), if it can be achieved safely. However, half of the people with T2D in Canada are not achieving these glycemic targets, despite advances in diabetes pharmacological management. There are many contributing factors to account for this poor outcome; however, one of the major factors is the delay in treatment advancement, particularly a resistance to insulin initiation and intensification. To simplify the process of initiating and titrating insulin in T2D patients, a group of Canadian experts reviewed the evidence and best clinical practices with the goal of providing guidance and practical recommendations to the diabetes healthcare community at large. This expert panel included general practitioners (GPs), nurses, nurse practitioners, endocrinologists, dieticians, pharmacists, and a psychologist. This article summarizes the panel recommendations.
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Affiliation(s)
- Lori Berard
- Winnipeg Regional Health Authority, Winnipeg Diabetes Research Group, Health Sciences Centre, Winnipeg, MB, Canada.
| | - Noreen Antonishyn
- Department of Endocrinology, Alberta Health Services, Edmonton, AB, Canada
| | - Kathryn Arcudi
- Diabetes Clinic, The Montreal West Island Integrated University Health and Social Services Centre (Lakeshore General Hospital), Pointe-Claire, QC, Canada
| | - Sarah Blunden
- Diabetes Education, LMC Diabetes and Endocrinology, Montreal, QC, Canada
| | - Alice Cheng
- Division of Endocrinology and Metabolism, St. Michael's Hospital, Toronto, ON, Canada
- Trillium Health Partners, Credit Valley Hospital, Mississauga, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Stewart Harris
- Department of Family Medicine, Western University, London, ON, Canada
| | | | - Upender Mehan
- The Centre for Family Medicine, Kitchener, ON, Canada
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - James Morrell
- Diabetes Services, Island Health, Victoria, BC, Canada
| | - Robert Roscoe
- Diabetes Education Centre, Saint John Regional Hospital, Saint John, NB, Canada
| | | | - Michael Vallis
- Behaviour Change Institute, Nova Scotia Health Authority, Halifax, NS, Canada
- Department of Family Medicine, Dalhousie University, Halifax, NS, Canada
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10
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Abstract
Worldwide, both underdiagnosis and undertreatment leave many patients exposed to long periods of hyperglycemia and contribute to irreversible diabetes complications. Early glucose control reduces the risk of both macrovascular and microvascular complications, while tight control late in diabetes has little or no macrovascular benefit. Insulin therapy offers the most potent antihyperglycemic effect of all diabetes agents, and has a unique ability to induce diabetes remission when used to normalize glycemia in newly diagnosed patients. When used as a second-line therapy, basal insulin is more likely to safely and durably maintain A1C levels ≤7% than when insulin treatment is delayed. The use of basal insulin analogs is associated with a reduced risk of hypoglycemia and weight gain compared to NPH insulin and pre-mixed insulin. Patient self-titration algorithms can improve glucose control while decreasing the burden on office staff. Finally, recent data suggest that addition of incretin agents to basal insulin may improve glycemic control with very little, if any increased risk of hypoglycemia or weight gain.
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Affiliation(s)
- Dragana Lovre
- Tulane University Health Sciences Center, New Orleans, LA
| | - Vivian Fonseca
- Tulane University Health Sciences Center, New Orleans, LA.
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