Clinical and Cost Implications of Insulin Degludec in Patients with Type 1 Diabetes and Problematic Hypoglycemia: A Quality Improvement Project

Use of Degludec in Youth With Type 1 Diabetes and Recurrent Diabetic Ketoacidosis

This article describes a pediatric diabetes center quality improvement initiative to switch youth with type 1 diabetes and diabetic ketoacidosis (DKA) from insulin glargine to longer-duration insulin degludec to determine whether this change would reduce DKA recurrence. Overall, the change in DKA recurrence with degludec was not statistically significant. However, subgroup analysis showed that race/ethnicity and insurance status were significantly associated with change in DKA rates. The association of degludec and decreased rates of repeat DKA in Hispanics and privately insured individuals requires further exploration.

Insulin glargine 300 U/mL and insulin degludec: A review of the current evidence comparing these two second-generation basal insulin analogues

For most people with type 2 diabetes (T2D), treatment intensification with the addition of basal insulin therapy is required to maintain glycaemic control. However, this often does not happen in real-life practice promoting the development of long-term diabetes-related complications. The second-generation basal insulin analogues glargine 300 U/mL (Gla-300) and degludec (IDeg) provide pharmacokinetic and pharmacodynamic improvements that may allow them to be more effective in appropriately managing diabetes compared with first-generation basal insulin analogues. Both Gla-300 and IDeg have been extensively studied vs the first-generation basal insulin glargine 100 U/mL, demonstrating comparable efficacy in terms of glycaemic control, and a lower risk of hypoglycaemia. The BRIGHT randomized controlled trial is the first direct comparison of the efficacy and safety profiles of Gla-300 and IDeg in patients with T2D. Moreover, real-world data have been used to assess the effectiveness of these basal insulins during routine clinical practice. Further research is required to determine if the properties of Gla-300 and IDeg may lead to improvements in healthcare-related costs and the quality of life of patients, which are important factors for informing clinical decisions.

Management of Diabetic Ketoacidosis in Children and Adolescents with Type 1 Diabetes Mellitus

Diabetic ketoacidosis (DKA) is the end result of insulin deficiency in type 1 diabetes mellitus (T1D). Loss of insulin production leads to profound catabolism with increased gluconeogenesis, glycogenolysis, lipolysis, and muscle proteolysis causing hyperglycemia and osmotic diuresis. High levels of counter-regulatory hormones lead to enhanced ketogenesis and the release of 'ketone bodies' into the circulation, which dissociate to release hydrogen ions and cause an overwhelming acidosis. Dehydration, hyperglycemia, and ketoacidosis are the hallmarks of this condition. Treatment is effective repletion of insulin, fluids and electrolytes. Newer approaches to early diagnosis, treatment, and prevention may diminish the risk of DKA and its childhood complications including cerebral edema. However, the potential for some technical and pharmacologic advances in the management of T1D to increase DKA events must be recognized.

Insulin Degludec in Adolescents with Type 1 Diabetes: Is Newer Better? - A Retrospective Self-Control Case Series in Adolescents with a History of Diabetic Ketoacidosis

INTRODUCTION

Insulin degludec (IDeg) is the longest-acting basal insulin available. Whether IDeg compared to shorter-acting basal insulins like insulin glargine U100 (IGlarU100) reduces the rate of diabetic ketoacidosis (DKA) in adolescents with type 1 diabetes is unknown.

OBJECTIVE

We hypothesized that adolescents with type 1 diabetes would have lower DKA rates and mean hemoglobin A1c (HbA1c) when using IDeg as compared to IGlarU100.

METHODS

To avoid selection bias, we used self-control case series methodology. Adolescents with type 1 diabetes treated for DKA from January 2015 through December 2018 who switched basal insulin from IGlarU100 to IDeg were eligible for analysis. Thirty-five patients were included, each acting as their own control. Mean HbA1c and DKA rate for the 12 months prior to and after switching to IDeg were compared.

RESULTS

Mean HbA1c prior to and after switching to IDeg was unchanged (97 ± 20 vs. 97 ± 21 mmol/mol [11.0 ± 1.8 vs. 11.0 ± 1.9%]). Median DKA rate (admissions/year) while on IGlar-U100 was 1 with an interquartile range (IQR) of 1-2. After switching to IDeg, median DKA admission rate remained 1, however the IQR decreased to 0-1 (one-sided p value 0.0004). Median change in DKA rate was 1 fewer admission per year, with a maximum reduction of 3 admissions. Higher baseline rates of DKA increased the odds of a patient reducing his/her DKA rate by 1 admission per year or more.

CONCLUSIONS

Using IDeg for basal insulin in adolescent patients may decrease the rate of DKA relative to IGlarU100 despite no improvement in HbA1c and may be cost-effective.

A multicentre, UK, retrospective, observational study to assess the effectiveness of insulin glargine 300 units/ml in treating people with Type 1 diabetes mellitus in routine clinical practice (SPARTA)

AIM

To conduct an open-label study to provide UK real-world evidence regarding the use of insulin glargine 300 units/ml (U300) in people with Type 1 diabetes mellitus.

METHODS

People with Type 1 diabetes who had been prescribed U300 ≥6 months before data collection and had HbA_1c levels recorded within 3 months prior to U300 (baseline) were included. The primary endpoint was change in HbA_1c from baseline to month 6 after U300 initiation. Other endpoints included number of documented hypoglycaemic and diabetic ketoacidosis episodes, and change in daily basal insulin dose.

RESULTS

A total of 298 people with Type 1 diabetes were included [mean age 42.1 years, mean HbA_1c 79 mmol/mol (9.4%)]. After U300 initiation, the mean reduction in HbA_1c from baseline to month 6 was -4 mmol/mol (-0.4%; P<0.001; n=188). The total daily basal insulin dose at 6 months was 1.3 units higher than at the time of U300 initiation (P<0.001; n=275) but was not significantly different from the prior basal insulin dose. There was no clinically significant difference in weight between baseline and month 6 [mean difference +0.7 kg, 95% CI -0.1, 1.5; P=0.084; n=115). During the 6 months before and after U300 initiation, severe hypoglycaemic episodes were documented for 6/298 and 4/298 participants. Diabetic ketoacidosis episodes requiring Accident and Emergency department visits or hospitalization were documented for 4/298 and 6/298 participants, before and after U300 initiation, respectively.

CONCLUSIONS

In people with Type 1 diabetes, a change in basal insulin to U300 was associated with clinically and statistically significant HbA_1c improvements, without significant changes in basal insulin dose and weight. Documented severe hypoglycaemia episodes and diabetic ketoacidosis requiring Accident and Emergency department visits or hospitalization were low and similar before and after U300 initiation.