Initiation of Basal Insulin Analog Treatment for Type 2 Diabetes and Reasons Behind Patients' Treatment Persistence Behavior: Real-World Data from Germany

Idealistic, realistic, and unrealistic expectations of pharmacological treatment in persons with type 2 diabetes in primary care

Introduction

Information on treatment expectations in diabetes is scarce for Mexican and Latino populations. We determined idealistic, realistic, and unrealistic expectations for metformin, insulin, and glyburide in primary care. We also explored the association between sociodemographic attributes, time since diagnosis, and expectations.

Methods

This was a cross-sectional study conducted during 2020-2022 in governmental primary care centers. We consecutively included persons with type 2 diabetes aged 30-70 years under pharmacological medication (n = 907). Questions were developed using information relevant to expectation constructs. Data were collected by interview. We used descriptive statistics, a test of the difference between two proportions, and multivariate ordinal logistic regression.

Results

A high percentage of participants would like to have fewer daily pills/injections or the option of temporarily stopping their medication. Realistic expectations ranged from 47% to 70%, and unrealistic expectations from 31 to 65%. More insulin users wished they could take a temporary break (p < 0.05) or would like to be able to change the route of administration (p < 0.001) than metformin users. More persons with diabetes on insulin expected realistic expectations compared to those on metformin or glyburide (p ≤ 0.01). Being able to interrupt medication upon reaching the glucose goal was higher in combined therapy users (p < 0.001).

Conclusion

Time since diagnosis, place of residence, sex, and diabetes education were factors associated to expectations. Management of expectations must be reinforced in primary care persons with type 2 diabetes undergoing pharmacological medication.

Predictors of success and failure in achieving glycemic control targets in patients with type 2 diabetes on basal insulin: review of the real-world evidence studies

Basal insulin (BI) is the main therapeutic option for patients with type 2 diabetes (T2D) who have not reached glycemic targets on oral antidiabetic drugs and/or glucagon-like peptide-1 receptor agonists. The results of epidemiological studies indicate that the majority of patients with T2D do not achieve the targeted parameters of glycemic control on BI in the real-world settings. In this review the results of real-world evidence studies assessing predictors of success or failure of BI therapy in patients with T2D are we summarized. A number of studies have demonstrated that delayed initiation of insulin therapy with a high level of glycated hemoglobin A1c (HbA1c) at the start of the treatment reduces achieving glycemic control targets on BI. Hypoglycemia in the first weeks or months of BI treatment may reduce the adherence and persistence to treatment and likelihood of achieving treatment targets. In real-world evidence studies, glargine 300 U/mL and degludec, the long-acting second-generation insulin analogues, have shown greater potential in reduction of HbA1c levels with a lower risk of hypoglycaemia compared to other BIs. In the DUNE, ATOS, and some others studies, a lack of insulin dose titration in newly initiated BI users and those who needed treatment intensification was demonstrated. Poor treatment adherence and persistence (missed injections, incorrect dose selection, and temporary or permanent discontinuation of insulin therapy), deviations in insulin injection technique, and formation of lipohypertrophy at the injection sites are also common problems that prevent good glycemic control in these patients. Therefore, patient education with a focus on injection technique, dose titration and prevention of hypoglycemia, as well as the use of the second-generation BI analogs, increases the chances for achieving glycemic control targets in patients with T2D who initiate or need to intensify BI therapy.

Reasons for discontinuing insulin and factors associated with insulin discontinuation in patients with type 2 diabetes mellitus: a real-world evidence study

BACKGROUND

Evidence suggests that insulin therapy of patients with type 2 diabetes mellitus (T2DM) is frequently discontinued. However, the reasons for discontinuing insulin and factors associated with insulin discontinuation in this patient population are not well understood.

METHODS

We conducted a retrospective cohort study of adults with T2DM prescribed insulin between 2010 and 2017 at Partners HealthCare. Reasons for discontinuing insulin and factors associated with insulin discontinuation were studied using electronic medical records (EMR) data. Natural language processing (NLP) was applied to identify reasons from unstructured clinical notes. Factors associated with insulin discontinuation were extracted from structured EMR data and evaluated using multivariable logistic regression.

RESULTS

Among 7009 study patients, 2957 (42.2%) discontinued insulin within 12 months after study entry. Most patients who discontinued insulin (2121 / 71.7%) had reasons for discontinuation documented. The most common reasons were improving blood glucose control (33.2%), achieved weight loss (18.5%) and initiation of non-insulin diabetes medications (16.7%). In multivariable analysis adjusted for demographics and comorbidities, patients were more likely to discontinue either basal or bolus insulin if they were on a basal-bolus regimen (OR 1.6, 95% CI 1.3 to 1.8; p <  0.001) or were being seen by an endocrinologist (OR 2.6; 95% CI 2.2 to 3.0; p <  0.001).

CONCLUSIONS

In this large real-world evidence study conducted in an area with a high penetration of health insurance, insulin discontinuation countenanced by healthcare providers was common. In most cases it was linked to achievement of glycemic control, achieved weight loss and initiation of other diabetes medications. Factors associated with and stated reasons for insulin discontinuation were different from those previously described for non-adherence to insulin therapy, identifying it as a distinct clinical phenomenon.

Factors and outcomes associated with discontinuation of basal insulin therapy in patients with type 2 diabetes mellitus

OBJECTIVES

To assess treatment discontinuation, associated factors and outcomes after initiating basal insulin (BI) among Chinese insulin-naïve patients with type 2 diabetes mellitus (T2DM) who had previously uncontrolled hyperglycaemia on OADs.

PATIENTS

Insulin-naïve patients with T2DM who had uncontrolled hyperglycaemia (HbA1c ≥7%) by OADs and were willing to initiate BI treatment were enrolled from 209 secondary and tertiary hospitals in eight geographical regions in China.

DESIGN

Each participant was interviewed at baseline, 3 and 6 months to collect study information. Patients with at least one visit during follow-up were included in the analyses. BI discontinuation was defined by a question asking whether the patient discontinued BI therapy at 3 or 6 months. Analyses were conducted to identify baseline factors associated with BI discontinuation and to estimate the association between insulin treatment discontinuation and patients' clinical outcomes at 6 months.

RESULTS

Of 17 858 patients, 25.8% discontinued basal insulin therapy within 6 months after initiation, and nearly two-thirds doing so within the first 3 months. Among patients discontinued basal insulin, 70.2% stopped all insulin therapy; 25.9% switched to premixed insulin and 3.8% switched to bolus only. Three most common reasons for BI discontinuation reported by patients were being unwilling to persist basal insulin without specific reasons (46.8%), reducing the frequency of daily injection (23.5%) and medical affordability (15.1%). Factors significantly associated with BI discontinuation were hospital level, patient recruitment setting, age, education level, out-of-pocket ratio, BMI, diabetes duration, self-monitoring of blood glucose (SMBG), numbers of OADs, BI type and insulin regimen. Compared with discontinuers, patients continued BI therapy had higher FPG (46.4% vs 28.8%) and HbA1c (42.3% vs 36.5%) control rate.

CONCLUSION

Among patients with T2DM who initiated BI therapy due to uncontrolled hyperglycaemia by OADs, the proportion of insulin discontinuation was high within 6 months. Further study is needed to understand the reason behind the BI discontinuation.