Clinical Outcomes After Insulin Initiation in Patients with Type 2 Diabetes: 24-Month Results from INSTIGATE

Patterns and trends in insulin initiation and intensification among patients with Type 2 diabetes mellitus in the Middle East and North Africa region

AIM

Current and future estimates of the burden of diabetes in the Middle East and North Africa (MENA) region are among the highest in the world. VISION, an 18-month observational study, explored patterns of insulin initiation and intensification in T2DM patients in the MENA region.

METHODS

1192 patients aged ≥18 years were enrolled from Algeria, Egypt, Saudi Arabia and the UAE. Treating physicians recorded participants' data. Patient-reported outcomes (PROs) were assessed using questionnaires completed by participants.

RESULTS

67.6% patients had HbA1c ≥9% at insulin initiation, with a mean HbA1c of 9.9%, despite 68.3% patients being on ≥2 oral anti-diabetics, indicating a significant delay in insulin initiation. Basal insulin was initiated in 50.6% and premixed insulin in 46.3% patients. After 18 months, changes in insulin therapy were observed in 33.7% patients, while 39.6% patients achieved HbA1c levels of <7.5%. The proportion of patients completely satisfied with their insulin treatment, and the QoL increased over the study course.

CONCLUSION

Results support that timely initiation and early intensification of insulin therapy are necessary in the region to achieve adequate and timely glycemic control and to prevent diabetic complications.

Towards an improved global understanding of treatment and outcomes in people with type 2 diabetes: Rationale and methods of the DISCOVER observational study program

AIM

Contemporary global real-world data on the management of type 2 diabetes are scarce. The global DISCOVER study program aims to describe the disease management patterns and a broad range of associated outcomes in patients with type 2 diabetes initiating a second-line glucose-lowering therapy in routine clinical practice.

METHODS

The DISCOVER program comprises two longitudinal observational studies involving more than 15,000 patients in 38 countries across six continents. Study sites have been selected to be representative of type 2 diabetes management in each country. Data will be collected at baseline (initiation of second-line therapy), at 6months, and yearly during a 3-year follow-up period.

RESULTS

The DISCOVER program will record patient, healthcare provider, and healthcare system characteristics, treatment patterns, and factors influencing changes in therapy. In addition, disease control (e.g. achievement of glycated hemoglobin target), management of associated risk factors (e.g. hypercholesterolemia and hypertension), and healthcare resource utilization will be recorded. Microvascular and macrovascular complications, incidence of hypoglycemic events, and patient-reported outcomes will also be captured.

CONCLUSIONS

The DISCOVER program will provide insights into the current management of patients with type 2 diabetes worldwide, which will contribute to informing future clinical guidelines and improving patient care.

Barbados Insulin Matters (BIM) study: Perceptions on insulin initiation by primary care doctors in the Caribbean island of Barbados

AIMS

With regards to insulin initiation in Barbados we explored primary care doctor (PCD) perception, healthcare system factors and predictors of PCD reluctance to initiate insulin.

METHODS

PCDs completed a questionnaire based on the theory of planned behaviour (TPB) and a reluctance to initiate insulin scale. Using linear regression, we explored the association between TPB domains and the reluctance to initiate insulin scale.

RESULTS

Of 161 PCDs, 70% responded (75 private and 37 public sector). The majority felt initiating insulin was uncomplicated (68%) and there was benefit if used before complications developed (68%), but would not use it until absolutely necessary (58%). More private than public sector PCDs (p<0.05) thought that the healthcare system allowed enough flexibility of time for education (68 vs 38%) and initiating insulin was easy (63 vs 35%), but less thought system changes would help initiating insulin (42 vs 70%). Reasons for reluctance to initiate insulin included patient nonadherence (83%) and reluctance (63%). Only the attitudes and belief domain of the TPB was associated with the reluctance to initiate insulin scale (p<0.001).

CONCLUSIONS

Interventions focusing on PCD attitudes and beliefs and restructuring services inclusive of the use of diabetes specialist nurses are required.

Clinical outcomes and resource use after 24 months of insulin therapy in Turkish patients with type 2 diabetes: subgroup analysis of the TREAT study

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.

Minimizing Hypoglycemia and Weight Gain with Intensive Glucose Control: Potential Benefits of a New Combination Therapy (IDegLira)

Due to the progressive nature of type 2 diabetes (T2D), the majority of patients require increasing levels of therapy to achieve and maintain good glycemic control. At present, once patients become uncontrolled on oral antidiabetic therapies, the two primary treatment options are glucagon-like peptide-1 receptor agonists (GLP-1RAs) or basal insulin, although earlier use of GLP-1RAs has also been advocated. While both of these drug classes have proven efficacy in treating T2D, there can be limitations to their use in some patients, and resistance to further treatment intensification among both patients and physicians. More recently, treatment incorporating both a GLP-1RA and a basal insulin has been used successfully in the clinic and the first such combination product, IDegLira (insulin degludec + liraglutide), has recently been approved for use in Europe. IDegLira combines insulin degludec and the GLP-1RA liraglutide in a single injection. In both insulin-naïve and basal insulin-treated individuals with T2D, IDegLira has demonstrated greater reductions in glycated hemoglobin (HbA_1c) than either of the individual components, with a low rate of hypoglycemia and weight loss. IDegLira may provide a new option for patients requiring treatment intensification but for whom increased weight or a higher risk of hypoglycemia are barriers. This article discusses the rationale behind combining these two drug classes and reviews the available clinical evidence for the efficacy and safety of IDegLira.

Insulin lispro low mixture twice daily versus basal insulin glargine once daily and prandial insulin lispro once daily in patients with type 2 diabetes requiring insulin intensification: a randomized phase IV trial

AIMS

To compare the efficacy and safety of two insulin intensification strategies in patients with type 2 diabetes inadequately controlled on basal insulin glargine with metformin and/or pioglitazone.

METHODS

A multinational, randomized, open-label trial that compared insulin lispro low mixture (LM25; n = 236) twice daily with a basal-prandial regimen of insulin glargine once daily and insulin lispro once daily (IGL; n = 240) over 24 weeks in patients with HbA1c 7.5-10.5% and fasting plasma glucose ≤ 6.7 mmol/l. The primary objective was to assess non-inferiority [per-protocol (PP) population], and then superiority [intention-to-treat (ITT) population], of LM25 versus IGL according to change in HbA1c after 24 weeks (non-inferiority margin 0.4%, two-sided significance level 0.05).

RESULTS

Estimated change [least squares (LS) mean (95% CI)] in HbA1c after 24 weeks: -1.30 (-1.44, -1.16)% with LM25 and -1.08 (-1.22, -0.94)% with IGL. Non-inferiority was shown [LS mean (95% CI) HbA1c treatment difference -0.21 (-0.38, -0.04) (PP population)]; gated superiority assessment showed a statistically significant advantage for LM25 (p = 0.010; ITT population). Mean blood glucose, glycaemic variability, overall tolerability and hypoglycaemic episodes per patient-year did not show significant differences between treatments during the study.

CONCLUSIONS

In patients with type 2 diabetes inadequately controlled on once-daily basal insulin glargine and metformin and/or pioglitazone, intensification with LM25 was superior to a basal-prandial approach in terms of reduction in HbA1c after 24 weeks and did not increase hypoglycaemia episodes.

Safety, tolerability, and efficacy of insulin aspart in people with type 2 diabetes, as biphasic insulin aspart or with Basal insulin: findings from the multinational, non-interventional a1chieve study

INTRODUCTION

The aim of the study was to investigate the clinical safety and effectiveness of starting insulin aspart (aspart) therapy in people with type 2 diabetes mellitus (T2DM) as a sub-analysis of the multinational, non-interventional A1chieve study.

METHODS

Insulin-naïve and insulin-experienced people with T2DM in routine clinical care starting aspart alone at baseline and continuing aspart alone, changing to biphasic insulin aspart 30 (aspart premix) or adding a basal insulin by study end, were included. Safety, tolerability, and efficacy were evaluated over 24 weeks.

RESULTS

Overall, 3,898 people started aspart at baseline. Of the 3,313 with 24-week data, 1,545 (46.6%) continued with aspart, 1,379 (41.6%) switched to aspart premix, and 214 (6.5%) added basal insulin, while the remainder switched to other regimens. No serious adverse drug reactions were reported. The proportion of participants reporting hypoglycemia decreased from baseline to week 24 in the aspart alone group (11.2% versus 4.1%, p < 0.001) and in the aspart + basal insulin group (13.1% versus 7.5%, p = 0.040), and was 3.7% at week 24 in the aspart premix group. The mean HbA1c decreased from baseline to week 24 (aspart: -2.1 ± 2.0% [-23 ± 22 mmol/mol], aspart premix: -2.3 ± 1.7% [-25 ± 19 mmol/mol], aspart + basal insulin: -2.0 ± 2.1% [-22 ± 23 mmol/mol]; p < 0.001).

CONCLUSION

Insulin aspart therapy was well tolerated and was associated with improved glucose control over 24 weeks in people with T2DM.

Using Exenatide Twice Daily or Insulin in Clinical Practice: Results from CHOICE

INTRODUCTION

CHOICE (CHanges to treatment and Outcomes in patients with type 2 diabetes initiating InjeCtablE therapy; NCT00635492) assessed, as its primary objective, the time to a 'significant treatment change' (defined within this paper) after patients with type 2 diabetes mellitus initiated their first injectable, glucose-lowering therapy [exenatide twice daily (BID) or insulin] in clinical practice in six European countries and evaluated outcomes during the study.

METHODS

CHOICE was a 24-month, prospective, noninterventional observational study. Patients were invited to participate in CHOICE only after their treating physician had made the clinical decision to initiate first injectable therapy with either exenatide BID or insulin. Clinical data were collected at initiation of first injectable therapy and after approximately 3, 6, 12, 18, and 24 months.

RESULTS

A total of 2,515 patients were recruited; 1,114 patients in the exenatide BID cohort and 1,274 patients in the insulin cohort were eligible for the 24-month analysis. During the study, 42.2% and 36.0% of patients from each cohort, respectively, had a significant treatment change. By 24 months, improved mean glycated hemoglobin (p < 0.001 for both cohorts) and reduced severity of several cardiovascular risk factors were observed in both cohorts; additionally, mean weight was reduced in the exenatide BID cohort (p < 0.001) and increased in the insulin cohort (p < 0.001). Hypoglycemia was reported by 18.4% of the exenatide BID cohort and 36.8% of the insulin cohort; 25.9% of the exenatide BID cohort and 10.0% of the insulin cohort had met the secondary endpoint of glycated hemoglobin <7.0%, no weight gain, and no hypoglycemia.

CONCLUSION

CHOICE provided data on exenatide BID and insulin usage patterns and 24-month outcomes in clinical practice. On average, improved glycemic control and reduced severity of cardiovascular risk factors were observed in both cohorts, and those in the exenatide BID cohort also had mean weight loss.

Evaluation of insulin initiation on resource utilization and direct costs of treatment over 12 months in patients with type 2 diabetes in Europe: results from INSTIGATE and TREAT observational studies

OBJECTIVES

To describe the changes in resource utilization in seven European countries (Germany, Greece, Portugal, Romania, Sweden, Spain, and Turkey) and direct costs in four European countries (Germany, Spain, Sweden, and Greece) over the first 12 months of insulin treatment in patients with type 2 diabetes mellitus (T2DM).

METHODS

INSTIGATE and TREAT (2005-2010) were non-interventional, prospective, observational studies in patients with T2DM and initiating insulin for the first time. A 6-month retrospective data capture was conducted at baseline (insulin initiation) followed by prospective data collections at ∼3, 6, and 12 months. Statistical analyses were descriptive; estimated costs are presented as nominal values.

RESULTS

This study presents data for 1450 patients. Overall, in the first 6 months after insulin initiation, the use and cost of blood glucose monitoring and insulin increased, while the cost of oral diabetic medication decreased. Contributors to total direct costs differed between countries. Ranges of total mean direct costs over the 6-month period before insulin initiation were €489.10-€658.50 (Greece-Spain); 0-6 months after insulin initiation, €573.40-€1084.70 (Greece-Spain); and 6-12 months after insulin initiation, €495.80-€859.30 (Greece-Germany). Thus, the mean cost of treatment increased in all countries in the first 6 months after insulin initiation and then returned to baseline except in Germany.

LIMITATIONS

Overall, 15% of patients were lost to follow-up over 12 months. Costs were not pro-rated to account for variation of visits. Participating centres may not have been fully representative of all levels of care.

CONCLUSIONS

Contributors to total cost differed between countries, potentially reflecting local clinical practice patterns and insulin regimens. In each country, mean direct total costs of T2DM care increased during the first 6 months after insulin initiation and decreased thereafter.

Clinical outcomes after 24 months of insulin therapy in patients with type 2 diabetes in five countries: results from the TREAT study

OBJECTIVE

To assess factors associated with insulin regimens at initiation, changes in treatment and metabolic control over 2 years of insulin therapy in patients with type 2 diabetes in five countries.

RESEARCH DESIGN AND METHODS

TREAT was a prospective, 24 month, observational study in patients with type 2 diabetes initiating insulin in clinical practice. Patient characteristics were collected at baseline and metabolic outcomes at 3, 6, 12, 18 and 24 months after initiation.

RESULTS

A total of 985 patients were enrolled, 886 assessed at baseline and 734 (82.8%) at 24 months. Baseline characteristics varied between countries: 52.8% of patients were men; mean age was 60.4 years; body mass index, 29.7 kg/m²; time since diagnosis, 10.1 years; HbA1c, 9.6%. Less than 25% of patients met ADA/IDF targets for blood pressure/LDL cholesterol. Overall, 50.1% of patients were initiated on long/intermediate insulin, 39.3% on mixture and 7.8% on basal-bolus; distribution varied between countries. Patients on long/intermediate were more likely to have lower baseline HbA1c and be intensified to other regimens (19.4%). No oral antidiabetic medication was used for 16.4% initiating on long/intermediate, 47.4% on mixture and 62.3% with basal-bolus. Overall, mean HbA1c decreased from 9.6% to 7.6%, with little difference between regimens at endpoint. The percentage of patients with hypoglycaemia was highest at 6 months and with basal-bolus.

LIMITATIONS

Sites were not selected at random. Drop-out of patients prior to 24 months may have introduced a bias that favoured responders.

CONCLUSIONS

Mean baseline HbA1c was high, indicating delayed initiation of insulin treatment. Blood pressure and lipids were suboptimally controlled. Insulin regimens varied between countries, changed little and resulted in similar HbA1c levels after 24 months.

Safety and effectiveness of bolus insulin aspart in people with type 2 diabetes: a1chieve sub-analysis

INTRODUCTION

This sub-analysis evaluated clinical safety and effectiveness of bolus insulin aspart [with/without oral glucose-lowering drugs (OGLDs)] as the only insulin therapy.

METHODS

A1chieve was an international, multicenter, prospective, open-label, non-interventional, observational, 24-week study in people with type 2 diabetes mellitus starting/switching to biphasic insulin aspart 30, insulin detemir or insulin aspart treatment (alone/in combination) in routine clinical practice. This sub-analysis evaluated clinical safety and effectiveness of bolus insulin aspart (±OGLDs) as the only insulin therapy. Data were analyzed for all patients, insulin-experienced and insulin-naive sub-groups, and sub-groups defined by the number of OGLDs prescribed at baseline (no OGLDs, one OGLD or ≥two OGLDs). Safety and effectiveness endpoints were assessed at baseline and following 24 weeks' therapy.

RESULTS

In total, 2,026 patients were included (insulin-experienced, n = 561; insulin-naive, n = 1,465) in this sub-analysis. Significant improvements from baseline after 24 weeks' treatment with insulin aspart ± OGLDs were observed across all sub-groups for: glycated hemoglobin (range of means across sub-groups -1.6 to -2.4%; p < 0.001 for all comparisons), fasting plasma glucose (-2.5 to -3.8 mmol/l; p < 0.001 for all comparisons), post-breakfast post-prandial glucose (-3.4 to -5.8 mmol/l; p < 0.001 for all comparisons), and health-related quality of life (HRQoL; p < 0.001 for all comparisons). The proportion of patients reporting hypoglycemia events was significantly reduced from baseline after 24 weeks (insulin-naive cohort: 7.9-2.8%; p < 0.001; insulin-experienced cohort: 23.2-7.8%; p < 0.001). There were no reports of major hypoglycemia events at 24 weeks; risk of nocturnal hypoglycemia was <0.6 events/person-year. No serious adverse drug reactions were reported.

CONCLUSION

Insulin aspart ± OGLDs is associated with significant improvements in glycemic control and HRQoL, without increased risk of hypoglycemia, in people with type 2 diabetes and sub-optimal glucose control.