Appropriate Titration of Basal Insulin in Type 2 Diabetes and the Potential Role of the Pharmacist

Implementation and evaluation of a pharmacist-led glucagon-like peptide-1 receptor agonist titration service in two primary care clinics

BACKGROUND

People with type 2 diabetes are increasingly prescribed glucagon-like peptide-1 receptor agonists (GLP-1 RAs) which require frequent follow-up for tolerability and dose optimization. To prevent clinical inertia, ambulatory care pharmacists are well-positioned to provide titration services to reduce prescriber burden.

OBJECTIVES

The objective of this study was to describe the implementation and evaluation of a pharmacist-led GLP-1 RA titration service.

PRACTICE DESCRIPTION

The 2 clinics included in this study are part of a community-based health system serving northern Illinois.

PRACTICE INNOVATION

Included clinics are staffed by an ambulatory care pharmacist working under a delegation protocol. Initial encounters address medication accessibility and education. Follow-up visits evaluate tolerability, blood glucose control, and dose optimization.

EVALUATION METHODS

The primary endpoint was the absolute change in hemoglobin A1c (HbA1c) from baseline to 3-6 months post-titration. Paired t-tests were used for statistical comparisons.

RESULTS

From September 2022 to May 2023, 120 patients met inclusion criteria; 8 patients stopped therapy. Mean baseline HbA1c was reduced by -1.8% (P < 0.001) at 3-6 months post-titration. Average change in weight was -8.1 kg (N = 107) (P < 0.001). The number of diabetic medications decreased from an average of 2.5 to 2.1 medications. The percentage of patients meeting Healthcare Effectiveness Data and Information Set measures for diabetes after pharmacist intervention were 97.3% for blood pressure under 140/90 mm Hg, 95.5% for HbA1c under 8%, 100% for serum creatinine tested in last 12 months, and 90.2% for urine microalbumin/creatine ratio tested in last 12 months. The average patient required 6.5 encounters and 91 total pharmacist minutes to achieve GLP-1 RA optimization. Approximately 0.1 full-time equivalents of pharmacist coverage were required over 13 months to manage 120 patients.

CONCLUSIONS

Ambulatory care pharmacists can effectively optimize GLP-1 RAs to improve clinical outcomes, meet quality-based metrics, and reduce prescriber burden.

Construction on training course and training quality evaluation index system of chronic disease medication therapy management service (MTMs) in China: A Delphi study

OBJECTIVE

This study aims to construct a training course and quality evaluation index system for chronic disease Medication Therapy Management service (MTMs) that is suitable for China's national conditions. It seeks to provide tools and a scientific foundation for assessing the quality of MTMs training.

METHODS

Drawing from domestic and international literature and combining with the practice of chronic disease medication management by Chinese pharmacists, a preliminary framework for the evaluation index system was established. The Delphi method was used to solicit expert opinions, evaluate and improve the evaluation index system. Indicator weights were determined by using the Analytic Hierarchy Process (AHP).

RESULTS

Both rounds of expert inquiry achieved a positive degree of 100% (18/18 experts). The authority coefficients (Cr) were 0.90 and 0.91 respectively. The Kendall coordination coefficients (Kendall's W) of the second and third-level indicators for the first round of inquiry were 0.230 and 0.189, while those for the second round were 0.326 and 0.213. Finally, an MTMs training course and training quality evaluation index system was structured, comprising 3 first-level indicators, 11 second-level indicators, and 39 third-level indicators.

CONCLUSION

The evaluation index system constructed in this study is scientifically robust and rational, offering a foundation to standardize MTMs training practices effectively.

Insulin therapy in type 2 diabetes: Insights into clinical efficacy, patient-reported outcomes, and adherence challenges

Insulin therapy plays a crucial role in the management of type 2 diabetes as the disease progresses. Over the past century, insulin formulations have undergone significant modifications and bioengineering, resulting in a diverse range of available insulin products. These products show distinct pharmacokinetic and pharmacodynamic profiles. Consequently, various insulin regimens have em-erged for the management of type 2 diabetes, including premixed formulations and combinations of basal and bolus insulins. The utilization of different insulin regimens yields disparate clinical outcomes, adverse events, and, notably, patient-reported outcomes (PROs). PROs provide valuable insights from the patient's perspective, serving as a valuable mine of information for enhancing healthcare and informing clinical decisions. Adherence to insulin therapy, a critical patient-reported outcome, significantly affects clinical outcomes and is influenced by multiple factors. This review provides insights into the clinical effectiveness of various insulin preparations, PROs, and factors impacting insulin therapy adherence, with the aim of enhancing healthcare practices and informing clinical decisions for individuals with type 2 diabetes.

Advances in the management of type 2 diabetes in adults

Type 2 diabetes is a chronic and progressive cardiometabolic disorder that affects more than 10% of adults worldwide and is a major cause of morbidity, mortality, disability, and high costs. Over the past decade, the pattern of management of diabetes has shifted from a predominantly glucose centric approach, focused on lowering levels of haemoglobin A1c (HbA1c), to a directed complications centric approach, aimed at preventing short term and long term complications of diabetes, and a pathogenesis centric approach, which looks at the underlying metabolic dysfunction of excess adiposity that both causes and complicates the management of diabetes. In this review, we discuss the latest advances in patient centred care for type 2 diabetes, focusing on drug and non-drug approaches to reducing the risks of complications of diabetes in adults. We also discuss the effects of social determinants of health on the management of diabetes, particularly as they affect the treatment of hyperglycaemia in type 2 diabetes.

Practical guidance on the initiation, titration, and switching of basal insulins: a narrative review for primary care

Many patients with type 2 diabetes will ultimately require the inclusion of basal insulin in their treatment regimen. Since most people with type 2 diabetes are managed in the community, it is important that primary care providers understand and correctly manage the initiation and titration of basal insulins, and help patients to self-manage insulin injections. Newer, long-acting basal insulins provide greater stability and flexibility than older preparations and improved delivery systems. Basal insulin is usually initiated at a conservative dose of 10 units/day or 0.1-0.2 units/kg/day, then titrated thereafter over several weeks or months, based on patients' self-measured fasting plasma glucose, to achieve an individualized target (usually 80-130 mg/dL). Through a shared decision-making process, confirmation of appropriate goals and titration methods should be established, including provisions for events that might alter scheduled titration (e.g. travel, dietary change, illness, hospitalization, etc.). Although switching between basal insulins is usually easily accomplished, pharmacokinetic and pharmacodynamic differences between formulations require clinicians to provide explicit guidance to patients. Basal insulin is effective long-term, but overbasalization (continuing to escalate dose without a meaningful reduction in fasting plasma glucose) should be avoided.Key messagesPrimary care providers often initiate basal insulin for people with type 2 diabetes.Basal insulin is recommended to be initiated at 10 units/day or 0.1-0.2 units/kg/day, and doses must be titrated to agreed fasting plasma glucose goals, usually 80-130 mg/dL. A simple rule is to gradually increase the initial dose by 1 unit per day (NPH, insulin detemir, and glargine 100 units/mL) or 2-4 units once or twice per week (NPH, insulin detemir, glargine 100 and 300 units/mL, and degludec) until FPG levels remain consistently within the target range. If warranted, switching between basal insulins can be done using simple regimens.The dose of basal insulin should be increased as required up to approximately 0.5-1.0 units/kg/day in some cases. Overbasalization (continuing to escalate dose without a meaningful reduction in fasting plasma glucose) is not recommended; rather re-evaluation of individual therapy, including consideration of more concentrated basal insulin preparations and/or short-acting prandial insulin as well as other glucose-lowering therapies, is suggested.

iGlarLixi reduces residual hyperglycemia in Japanese patients with type 2 diabetes uncontrolled on basal insulin: A post-hoc analysis of the LixiLan JP-L trial

INTRODUCTION

Treatments for type 2 diabetes targeting baseline glucose levels but not postprandial glucose can result in normalized fasting blood glucose but suboptimal overall glycemic control (high glycated hemoglobin): residual hyperglycemia. In Japanese patients with type 2 diabetes the predominant pathophysiology is a lower insulin secretory capacity, and residual hyperglycemia is common with basal insulin treatment. Single-injection, fixed-ratio combinations of glucagon-like peptide-1 receptor agonists and basal insulin have been developed. iGlarLixi (insulin glargine 100 units/mL [iGlar]: lixisenatide ratio of 1 unit:1 µg) is for specific use in Japan. Post-hoc analysis of the LixiLan JP-L trial (NCT02752412) compared the effect of iGlarLixi with iGlar on this specific subpopulation with residual hyperglycemia.

MATERIALS AND METHODS

Outcomes at week 26 (based on the last observation carried forward) were assessed in patients in the modified intent-to-treat population with baseline residual hyperglycemia.

RESULTS

Overall, 83 (32.5%) patients in the iGlarLixi group and 79 (30.7%) patients in the iGlar group had baseline residual hyperglycemia. The proportion of patients with residual hyperglycemia at week 26 decreased to 15.7% in the iGlarLixi group, and increased to 36.9% in the iGlar group. Patients in the iGlarLixi group had significantly greater reductions in glycated hemoglobin compared with the iGlar group (-0.72% difference between groups; P < 0.0001).

CONCLUSIONS

New data from this post-hoc analysis of the JP-L trial show that treatment with the fixed-ratio combination iGlarLixi reduced the proportion of Japanese patients with residual hyperglycemia from baseline to week 26 and significantly reduced glycated hemoglobin vs similar doses of iGlar alone.

Prevalence of and Characteristics Associated With Overbasalization Among Patients With Type 2 Diabetes Using Basal Insulin: A Cross-Sectional Study

This article describes a cross-sectional analysis of 655 patients to determine the prevalence of and patient-specific characteristics associated with overbasalization in patients with type 2 diabetes. Overbasalization was defined as uncontrolled A1C (>8%) plus a basal insulin dose >0.5 units/kg/day. The period prevalence of overbasalization was found to be 38.1, 42.7, and 42% for those with an A1C >8, ≥9, and ≥10%, respectively. Those with an A1C ≥9% had the greatest likelihood of experiencing overbasalization. These results suggest that overbasalization may play a role in patients not achieving optimal glycemic control in type 2 diabetes.

Practical application of short-term intensive insulin therapy based on the concept of "treat to target" to reduce hypoglycaemia in routine clinical site

The aim is to devise a new short-term intensive insulin therapy (N-SIIT) based on the concept of "treat to target" to avoid hypoglycaemia and was applied it to various diabetic state. We determined dosage of 1 basal and 3 bolus "treat" insulin based on "target" blood glucose level and changed each insulin dose by small units (2 units) every day for 2 weeks. We evaluated the effects of N-SIIT in 74 subjects with type 2 diabetes (male 45, female 29, 64.9 ± 16.6 years old, HbA1c 10.4 ± 2.6%). Glargine U300 ("treat") and morning blood glucose level ("target") was significantly correlated with increasing insulin dose and decreasing blood glucose level in day 1-7, indicating that insulin amount was determined by target blood glucose level and lowered next target blood glucose level. Remission rates were 67.3% (Hypoglycaemia rate 5.6 %) in N-SIIT and 47.3% (Hypoglycaemia rate 38.1%) in conventional SIIT. Required amount of insulin would be automatically determined, depending on each patient pathophysiology and life style. This method is pretty simple, flexible and cheap, and provides information about the dynamic pathophysiological alteration of insulin resistance and glucotoxicity from the profile of blood glucose levels and insulin shot.