Factors associated with adherence or nonadherence to insulin therapy among adults with type 2 diabetes mellitus: A scoping review

Once-weekly Basal Insulin Fc versus daily insulin degludec for glycemic control in diabetes: a systematic review, meta-analysis, and meta-regression

Introduction

Diabetes management often requires insulin therapy, yet adherence to daily injections can be challenging due to complexity, injection pain, and fear of hypoglycemia. Basal Insulin Fc (BIF) is a novel once-weekly insulin analog designed to simplify regimens, improve adherence, and enhance glycemic control. This meta-analysis evaluates the efficacy and safety of BIF compared to once-daily insulin degludec.

Methods

A systematic search of PubMed, Google Scholar, EBSCO, ScienceDirect, and the Cochrane Library, along with ClinicalTrials.gov, was conducted up to November 2024 to identify RCTs comparing BIF with insulin degludec. The search employed MeSH terms like "type 1 diabetes mellitus," "type 2 diabetes mellitus," "once weekly basal insulin Fc," and "insulin degludec." Studies were screened in accordance with PRISMA guidelines, and data on glycemic outcomes, safety, and patient demographics were extracted. Statistical analysis included pooled mean differences (MD) and risk ratios (RR) with 95% confidence intervals (CIs) using random-effects models. Heterogeneity was assessed using the I2 statistic, and sensitivity analyses were conducted for cases of high heterogeneity. Subgroup and meta-regression analyses assessed moderators such as diabetes type, insulin status, follow-up duration, and heterogeneity.

Results

Five RCTs with 2,562 participants (Type 1 and Type 2 diabetes) were included. BIF showed non-inferiority to degludec in HbA1c reduction (MD 0.03, p = 0.37) and percentage time in range (MD 0.56, p = 0.27). No significant differences were observed in self-monitored fasting blood glucose (MD 2.73, p = 0.40) or clinically significant hypoglycemia (RR 1.00, p = 0.95). However, BIF increased time spent below range (MD 0.30, p = 0.0004) and was associated with higher treatment-emergent adverse events (RR 1.12, p = 0.006). The subgroup analysis highlighted differences in hypoglycemia risks between Type 1 and Type 2 diabetes.

Conclusion

BIF offers comparable glycemic control to insulin degludec while reducing injection frequency, potentially enhancing adherence. However, increased hypoglycemia risks in certain subgroups and higher adverse event rates warrant further evaluation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-025-01602-y.

Assessment of basal insulin adherence in people with type 2 diabetes in telemonitoring: Post-hoc analysis of novel data modalities including insulin injection data

AIMS

Adherence in people with insulin-treated type 2 diabetes (T2D) is not well understood despite it being a prerequisite for preventing complications. This study used insulin injection data from connected insulin pens to examine adherence and characteristics of people with insulin-treated T2D in telemonitoring.

METHODS

Data from 165 participants were included. We applied a three-step methodology to assess overall adherence, adherence distribution, and dose deviation, using injection data recorded by a connected insulin pen. Additionally, statistical tests were performed to evaluate differences in characteristics between adherent and non-adherent participants.

RESULTS

Weekly averaged overall adherence levels ranged between 70.6 % and 79.3 %. Deviation from the recommended dose occurred in 98.8 % of participants, primarily as increased or reduced doses. Non-adherent participants had higher HbA1c (OR = 0.96, 95 % CI = 0.93, 0.99), and total daily insulin dose (OR = 0.99, 95 % CI = 0.98, 0.99), and a lower level of physical activity (OR = 2.55, 95 % CI = 1.23, 5.28) compared to adherent participants.

CONCLUSIONS

Utilizing insulin injection data our results provide detailed insights into basal insulin adherence behavior, including irregularities and daily dose adjustments. Our findings are necessary for supporting healthcare providers' preventable efforts and optimizing diabetes care.

Efficacy and safety of Pueraria lobata radix as an adjuvant therapy for type 2 diabetes mellitus: rationale, design and protocol for a randomised controlled trial

INTRODUCTION

The current pharmacological management of type 2 diabetes mellitus (T2DM) faces challenges such as low rates of optimal glycaemic control, high incidences of adverse drug reactions and suboptimal treatment compliance. Pueraria lobata radix (PLR), a medicinal and edible herb, has shown hypoglycaemic effects in animal models. However, existing clinical studies have only assessed the hypoglycaemic effect of PLR-containing herb formulas or PLR extract preparations. The aim of this study is to investigate the efficacy and safety of using PLR solely as an adjuvant therapy for T2DM.

METHODS AND ANALYSIS

This study is a multicentre, randomised, double-blind, placebo-controlled trial. 200 patients with T2DM will be randomly allocated to either the PLR group or the placebo group for a consecutive 12-week intervention. Regular visits will be conducted at weeks 4, 8 and 12, following the initiation of the study to evaluate the efficacy and safety of PLR. The primary outcome is the change in haemoglobin A1c (HbA1c) from baseline at week 12. Secondary outcomes include changes in HbA1c from baseline at weeks 4 and 8; the HbA1c response rate (< 7%), changes in fasting blood glucose, 2-hour blood glucose, fasting C-peptide, body mass index, severity of diabetes symptoms, quality of life from baseline at weeks 4, 8 and 12; and changes in blood lipid indicators at week 12. Safety outcomes include the incidences of total adverse events (AEs), serious AEs and PLR-related AEs.

ETHICS AND DISSEMINATION

The protocol has been approved by the Ethics Committees of the First Affiliated Hospital of Nanchang University (approval number: IIT[2024]LLS No.303) and the Affiliated Hospital of Jiangxi University of Chinese Medicine (approval number: JZFYLL2024006200087). We will disseminate the study findings through publications in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT06494683.

Development and validation of a Chinese insulin medication literacy scale for patients with diabetes mellitus

Objective

This study aimed to develop a simplified insulin medication literacy scale for patients with diabetes mellitus in China (Ch-InMLS), assess the level of insulin medication literacy, and evaluate its psychometric properties.

Methods

We developed an initial scale based on the framework of the knowledge-attitude-practice model (KAP), with "skills" added. The items were developed from literature review and insulin-related guidelines, semi-structured interviews, and face validity. After two rounds of expert consultation and a pilot survey, a final version of the scale was developed. A cross-sectional survey was conducted with 553 patients with diabetes mellitus in Zhengzhou for psychometric evaluation. In the construct validity analysis, the number of participants was 262 for exploratory factor analysis and 291 for confirmatory factor analysis. In the reliability analysis, internal consistency reliability and split-half reliability were evaluated using Cronbach's alpha coefficients.

Results

The final scale consists of 36 items with four domains: knowledge, attitude, practice, and skill. Exploratory factor analysis suggested four factors to explain 67.556% of the total variance (Kaiser-Meyer-Olkin test = 0.944, Bartlett's test χ2 = 7384.296, P < 0.001). The results of confirmatory factor analysis showed that the model fits the data adequately. Cronbach's coefficient was 0.945 for the overall scale, and for each domain, it was 0.952, 0.947, 0.908, and 0.923. The Spearman-Brown split-half reliability coefficient was 0.803 for the total scale, and for each domain, it was 0.925, 0.944, 0.901, and 0.917. The test-retest reliability coefficient of the total scale was 0.944, and for each domain of the scale, it was 0.865, 0.845, 0.987, and 0.936.

Conclusion

The scale has acceptable content validity, construct validity, and good reliability. It can be used to evaluate the level of insulin medication literacy of patients with diabetes mellitus in China.

Icodec ONWARDS: A review of the first once-weekly diabetes treatment for nurse practitioners and physician assistants

BACKGROUND

Diabetes management is challenged by the complexity of treatment regimens and the need for frequent injections, affecting patient adherence and quality of life. Insulin icodec, a once-weekly basal insulin analog, represents a significant innovation, potentially simplifying diabetes care and improving outcomes.

OBJECTIVES

This review aims to evaluate the safety, efficacy, and clinical implications of insulin icodec for individuals with type 1 and type 2 diabetes, highlighting its potential to affect current treatment paradigms.

DATA SOURCES

A review was conducted comparing once-weekly insulin icodec with daily basal insulin analogs using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to ensure transparent reporting of systematic reviews. A search was performed in the following databases: PubMed, Google Scholar, Embase, and ClinicalTrials.gov , focusing on efficacy and safety outcomes.

CONCLUSIONS

Insulin icodec has demonstrated effective glycemic management and a safety profile comparable to daily basal insulins. Its extended half-life and steady-state glucose-lowering effect have the potential to reduce the burden of daily injections and improve patient adherence.

IMPLICATIONS FOR PRACTICE

The introduction of once-weekly insulin icodec represents an advancement in diabetes care. For front-line clinicians, this innovation aligns with the need for more straightforward medication regimens. Coupled with continuous glucose monitoring systems, it enables a more personalized and efficient approach to diabetes management, with the potential to improve patient satisfaction and clinical outcomes. This underscores the impact of integrating such advancements into practice, highlighting the role of nurse practitioners and physician assistants in adopting these innovations to optimize patient care.

Insulin therapy adherence and its associated factors among diabetic patients in a Ghanaian primary care hospital

BACKGROUND

Diabetes mellitus (DM) is a global health problem. Adherence to intensive insulin therapy is necessary to achieve better glycemic control in types 1 and 2 DM. This study aimed to evaluate the extent of adherence to insulin therapy, its predictors and to identify barriers to its adherence.

METHOD

This was a cross-sectional survey among adult (≥18 years) diabetic patients who are currently using insulin, either alone or in combination with an oral antidiabetic regimen, and seeking primary care at Kwame Nkrumah University of Science and Technology Hospital in Ghana. A total of one hundred and eight-six patients were conveniently sampled, and interviewed. Insulin adherence was determined using the Medication Adherence Reporting Scale-5. Descriptive statistics, a chi-square test of independence, and a multiple logistic regression analysis were performed using STATA version 14 (StataCorp, TX USA).

RESULTS

The majority of the patients interviewed were over 60 years (40.32%); female (61.83%); married (68.82%); and had completed secondary education (48.39%). 67.20% of the patients were adherent to insulin therapy. Adherence level was associated with age (p = 0.020), marital status (p = 0.001), employment status (p = 0.012), type of DM (p<0.001), regular follow-up (p = 0.007) and comorbidities (p = 0.002) and was only predicted by the type of DM (aOR = 14.82 C.I 1.34-163.50, p-value = 0.028).

CONCLUSION

Adherence to insulin therapy among our study population was suboptimal, which is a concern considering the associated increased risk of complications. Adherence assessment and counselling by healthcare professionals to address barriers to poor adherence must be continually undertaken to achieve optimal glycemic control.

IMPACT OF FINDINGS ON PRACTICE STATEMENTS

Continuous adherence assessment and counselling must be offered to all diabetes mellitus patients on insulin therapy as part of their ambulatory care to help improve outcomes.Using the Medication Adherence Reporting Scale-5 to determine patient adherence levels is an easy-to-use and an inexpensive method; however, it should be used with caution due to the potential for misclassification.Efforts must be made to provide appropriate strategies to deal with barriers to insulin adherence at ambulatory care clinics as part of the individualized comprehensive diabetic care to reduce diabetic complications.

Adherence to glucagon-like peptide-1 receptor agonist treatment in type 2 diabetes mellitus: A nationwide registry study

AIMS

To assess the level of adherence to glucagon-like peptide-1 receptor agonist (GLP-1RA) treatment using real-world data and to investigate the sociodemographic and clinical factors associated with discontinuation of GLP-1RAs.

METHODS

First-time users of GLP-1RAs with type 2 diabetes mellitus (T2DM), aged ≥18 years, in the period 2007 to 2020, were identified using Danish registries, allowing all participants a minimum of 18 months' follow-up. Adherence to GLP-1RA therapy (medication possession ratio >0.80) and discontinuation of GLP-1RA therapy was estimated at 6- and 12-month follow-ups. Multivariable cause-specific Cox regression was used to identify sociodemographic and clinical factors associated with risk of discontinuation.

RESULTS

In total, 44 343 first-time users of GLP-1RAs with T2DM were identified (mean age 58.6 years, 42.7% female, median duration of T2DM 6.8 years, median glycated haemoglobin level 65 mmol/mol). The absolute risk of discontinuing GLP-1RA treatment within 6 months was 14.2% (95% confidence interval [CI] 13.9-14.6) and 21.2% (95% CI 20.8-21.5) within 12 months. At 6 months, 50.4% were adherent to GLP-1RA therapy and at 12 months, 48.6% remained adherent. In the multivariable model, younger (<40 years) and older age (>75 years), higher Charlson Comorbidity Index score, lower household income, high school and longer university degree as educational attainment level, and longer diabetes duration were associated with a higher risk of discontinuing GLP-1RA treatment.

CONCLUSION

Approximately one in five patients discontinued GLP-1RA therapy within the first 12 months and only half were adherent. Overall, lower socioeconomic status and higher comorbidity burden were associated with higher risk of discontinuing GLP-1RA treatment.

Inpatient diabetes management

Diabetes mellitus is currently approaching epidemic proportions and disproportionately affects patients in the hospital setting. In the United States, individuals living with diabetes represent over 17 million emergency department visits and 8 million admissions annually. The management of these patients in the hospital setting is complex and differs considerably from the outpatient setting. All patients with hyperglycemia should be screened for diabetes, as in-hospital hyperglycemia portends a greater risk for morbidity, mortality, admission to an intensive care unit, and increased hospital length of stay. However, the definition of hyperglycemia, glycemic targets, and strategies to manage hyperglycemia in the inpatient setting can vary greatly depending on the population considered. Moreover, the presenting illness, changing nutritional status, and concurrent hospital medications often necessitate thoughtful consideration to adjustments of home diabetes regimens and/or the initiation of new insulin doses. This review article will examine core concepts and emerging new literature surrounding inpatient diabetes management, including glycemic targets, insulin dosing strategies, noninsulin medications, new diabetes technologies, inpatient diabetes management teams, and discharge planning strategies, to optimize patient safety and satisfaction, clinical outcomes, and even hospital financial health.

Challenges in Insulin Therapy: Perspectives of Malaysian Diabetes Educators

Background

Individuals with type 2 Diabetes Mellitus (T2DM) commonly need insulin therapy as their condition advances. Healthcare providers often face difficulties in managing patients who require insulin treatment. Gaining insight into the views of healthcare professionals on the obstacles encountered by patients using insulin can aid in improving care and developing effective treatment plans.

Objective

This study explores the views of Malaysian diabetes educators on the barriers faced by patients in using insulin.

Methods

Semi-structured qualitative interviews were conducted with diabetes educators (n=8) from the northern, central, and southern regions of Malaysia who were involved in diabetes care. We used an interview guide to facilitate the in-depth interviews, which were digitally recorded, transcribed verbatim, and analyzed using a thematic approach.

Results

Five themes were identified: the occurrence of side effects, the need for better patient education, negative perceptions towards insulin, the financial burden, and the complexity of adherence to treatment. There is a lack of patient education on proper glucose monitoring and how to optimize insulin therapy. The cost of treatment and patient ignorance are highlighted when discussing patient self-monitoring of blood glucose. Diabetes educators recognize that the absence of an effective follow-up mechanism is a major issue, particularly for those patients who fail to maintain consistent appointment schedules.

Conclusion

This research highlights five significant obstacles to maximizing the effectiveness of insulin therapy. Diabetes educators who identify and address these challenges can empower patients to manage their condition effectively. To overcome systemic barriers, government involvement is needed in creating insulin follow-up initiatives, establishing multidisciplinary teams for diabetes care, empowering education strategies, and providing financial support for self-monitoring.

Pharmacological and Benefit-Risk Profile of Once-Weekly Basal Insulin Administration (Icodec): Addressing Patients' Unmet Needs and Exploring Future Applications

Diabetes mellitus (DM) is a chronic metabolic disease affecting over 500 million people worldwide, which leads to severe complications and to millions of deaths yearly. When therapeutic goals are not reached with diet, physical activity, or non-insulin drugs, starting/adding insulin treatment is recommended by international guidelines. A novel recombinant insulin is icodec, a once-weekly insulin that successfully completed phase III trials and that has recently obtained the marketing authorization approval from the European Medicines Agency. This narrative review aims to assess icodec pharmacological and clinical features concerning evidence on benefit-risk profile, as compared to other basal insulins, addressing the potential impact on patients' unmet needs. Icodec is a full agonist, recombinant human insulin analogue characterized by an ultra-long half-life (196 h), enabling its use in once-weekly administration. Phase III randomized clinical trials involving more than 4000 diabetic patients, mostly type 2 DM, documented non-inferiority of icodec, as compared to currently available basal insulins, in terms of estimated mean reduction of glycated hemoglobin levels; a superiority of icodec, compared to control, was confirmed in insulin-naïve patients (ONWARDS 1, 3, and 5), and in patients previously treated with basal insulin (ONWARDS 2). Icodec safety profile was comparable to the currently available basal insulins. Once-weekly icodec has the potential to improve patients' adherence, thus positively influencing patients' treatment satisfaction as well as quality of life, especially in type 2 DM insulin-naïve patients. An improved adherence might positively influence glycemic target achievement, reduce overall healthcare costs and overcome some of the unmet patients' needs. Icodec has the potential to emerge as a landmark achievement in the evolution of insulin therapy, with a positive impact also for the National Health Services and the whole society.

Current barriers to initiating insulin therapy in individuals with type 2 diabetes

Insulin is an essential drug in the treatment of diabetes, often necessary for managing hyperglycemia in type 2 diabetes mellitus (T2DM). It should be considered in cases of severe hyperglycemia requiring hospitalization, after the failure of other treatments, in advanced chronic kidney disease, liver cirrhosis, post-transplant diabetes, or during pregnancy. Moreover, in specific patient subgroups, early initiation of insulin is crucial for hyperglycemia control and prevention of chronic complications. Clinical guidelines recommend initiating insulin when other treatments fail, although there are barriers that may delay its initiation. The timing of initiation depends on individual patient characteristics. Typically, insulinization starts by adding basal insulin to the patient's existing treatment and, if necessary, progresses by gradually introducing prandial insulin. Several barriers have been identified that hinder the initiation of insulin, including fear of hypoglycemia, lack of adherence, the need for glucose monitoring, the injection method of insulin administration, social rejection associated with the stigma of injections, weight gain, a sense of therapeutic failure at initiation, lack of experience among some healthcare professionals, and the delayed and reactive positioning of insulin in recent clinical guidelines. These barriers contribute, among other factors, to therapeutic inertia in initiating and intensifying insulin treatment and to patients' non-adherence. In this context, the development of once-weekly insulin formulations could improve initial acceptance, adherence, treatment satisfaction, and consequently, the quality of life for patients. Currently, two once-weekly basal insulins, insulin icodec and basal insulin BIF, which are in different stages of clinical development, may help. Their longer half-life translates to lower variability and reduced risk of hypoglycemia. This review addresses the need for insulin in T2DM, its positioning in clinical guidelines under specific circumstances, the current barriers to initiating and intensifying insulin treatment, and the potential role of once-weekly insulin formulations as a potential solution to facilitate timely initiation of insulinization, which would reduce therapeutic inertia and achieve better early control in people with T2DM.