Responders to insulin therapy at 18 months in adults with newly diagnosed diabetes: which insulin regimen?

Medications and medical costs for diabetes patients with or without chronic respiratory disease in Beijing, China: A retrospective study

AIMS

The cost of drug regimens prescribed to Chinese patients has not been evaluated. This study aims to evaluate the medical costs and hypoglycemic agents for diabetes mellitus patients with or without chronic respiratory disease in Beijing, and to investigate the changes in the costs and number of antidiabetic medications used for diabetes patients with chronic respiratory disease from 2016 to 2018.

METHODS

This observational, retrospective study included diabetes patients with outpatient medication records from Beijing Medical Insurance between 2016 and 2018. The medications, including hypoglycemic and nonhypoglycemic drugs, insulin dosage, comorbidities, diabetes-related complications, treatment strategies, and annual medical costs, were recorded.

RESULTS

This study included 2,853,036 diabetes patients from 2016 to 2018. About 18.95%-20.53% of patients with chronic respiratory disease were predominantly distributed among those aged 45-84 years (88.7%-89.1%). Diabetes patients with chronic respiratory disease used more medications (4.48 ± 2.41 vs. 3.76 ± 2.33) and had higher total annual drug costs (¥12,286 ± 10,385 vs. ¥9700 ± 9202) to treat more comorbidities (2.52 ± 1.53 vs. 2.05 ± 1.85) than those without chronic respiratory disease (p <.0001, respectively). From 2016 to 2018, diabetes patients with chronic respiratory disease had a 4.2% increase in medication, a 1.9% decrease in comorbidities, and a 5.4% decrease in total annual drug costs.

CONCLUSIONS

In summary, diabetes patients with chronic respiratory disease had more comorbidities, required more hypoglycemic drugs, and had higher medical costs. During 2016-2018, diabetes patients with chronic respiratory disease used more medications and spent less money on medical care.

Association between insulin-induced weight change and CVD mortality: Evidence from a historic cohort study of 18,814 patients in UK primary care

BACKGROUND

This study explores the association of insulin-induced weight (wt) gain on cardiovascular outcomes and mortality among patients with type 2 diabetes (T2D) following insulin initiation using real-world data.

METHODS

A historical cohort study was performed in 18,814 adults with insulin-treated T2D derived from the UK The Health Improvement Network database. Based on the average weight change of 5 kg, 1 year postinsulin initiation, patients were grouped into 5 categories (>5 kg wt loss; 1.0-5.0 kg wt loss; no wt change; 1.0-5.0 kg wt gain; >5.0 kg wt gain) and followed-up for 5 years. Cox proportional hazard models and Kaplan-Meier estimators were fitted to estimate the hazards of a 3-point composite of nonfatal myocardial infarction, stroke, and all-cause mortality between categories.

RESULTS

The median age was 62.8 (IQR: 52.3-71.8) years, HbA_1c : 8.6% (IQR: 7.4-9.8) and mean BMI: 31.8 (6.5) kg/m² . The 5 year probability of survival differed significantly within the wt-change categories (log-rank test P value = .0005). Only 1963 composite events occurred. Compared with the weight-neutral group, the risk of composite events was 31% greater in the >5 kg wt-loss group (aHR: 1.31; 95% CI: 1.02, 1.68), the same in the 1.0 to 5.0 kg wt-gain category, but nonsignificantly increased in the 1.0 to 5.0 kg wt loss (15%) and >5.0 kg wt gain (13%) categories, respectively. In the obese subgroup, this risk was 50% (aHR: 1.50, 95% CI: 1.08-2.08) more in the >5 kg weight-loss group compared with the weight-neutral group.

CONCLUSION

Insulin-induced weight gain did not translate to adverse cardiovascular outcomes and mortality in patients with T2D. These data provide reassurance on the cardiovascular safety of insulin patients with T2D.

Premixed vs basal-bolus insulin regimen in Type 2 diabetes: comparison of clinical outcomes from randomized controlled trials and real-world data

AIM

To evaluate the concordance between data derived from randomized controlled trial (RCT) and real-world estimates of HbA_1c and weight change after 24 weeks of initiation of a basal-bolus compared with a premixed insulin regimen in people with Type 2 diabetes.

METHODS

Data eight RCTs were pooled after a systematic review of studies examining basal-bolus (n = 1893) or premixed (n = 1517) regimens. Real-world data were extracted from the UK primary care dataset for people on basal-bolus (n = 7483) or premixed insulin regimens (n=10 744). The mean differences between HbA_1c and weight from baseline were calculated using t-tests, while analysis of variance was used to compare the two treatment regimens. Linear regression analyses were used to determine the predictors of this change.

RESULTS

Both insulin regimens were associated with HbA_1c reductions (real-world data -0.28%; RCT data, -1.4%) and weight gain (real-world data, +0.27 kg; RCT data, +2.96 kg) but there were no significant differences between basal-bolus and premixed insulin. Discordances in the pattern of treatment response were observed, however, between real-world and RCT data for both insulin regimens. For any given baseline HbA_1c concentration, the change in HbA_1c in the RCTs was greater than in real-world conditions and for those with baseline weight above ~60 kg, RCT data showed overall weight gain in contrast to slight weight loss in the real-world population. Lastly, for both randomized controlled trial and real-world populations, while greater baseline weight was associated with reduced response to treatment, the association was much steeper in the RCT than in the real-world population. In addition, greater baseline weight was associated with greater weight reductions in both premixed insulin and basal-bolus insulin regimens, although to a lesser extent with the latter.

CONCLUSION

These results highlight specific discrepancies in the HbA_1c reduction and weight change in insulin regimen between real world versus RCT populations; with greater reduction in HbA_1c and greater increase in weight observed in the RCT population than in the real-world population. Also, the basal-bolus regimens in both real-world and RCT populations showed greater reduction in HbA_1c compared to the premix regimen (though more marked in RCTs), while the premix regimen showed greater increase in weight in real-world, as against basal-bolus in the RCT population.

Prediction of excessive weight gain in insulin treated patients with type 2 diabetes

BACKGROUND

Weight gain is an ongoing challenge when initiating insulin therapy in patients with type 2 diabetes mellitus (T2DM). However, if prediction of insulin-associated weight gain was possible on an individual level, targeted initiatives could be implemented to reduce weight gain. The aim of the present study was to identify predictors of weight gain in insulin-treated patients with T2DM.

METHODS

In all, 412 individuals with T2DM were, in addition to metformin or placebo, randomized into 18-month treatment groups with three different insulin analog treatment regimens (biphasic, aspart, detemir). Participants with excessive weight gain were defined as the group with weight gain in the 4th quartile (>6.2 kg).We developed a pattern classification method to predict individuals prone to excessive weight gain.

RESULTS

Over the 18-month treatment period, median weight gain among all 412 patients was 2.4 kg (95% prediction interval [PI] -5.6, 12.4 kg), whereas median weight gain for those in the upper 4th quartile (n = 103) was 8.9 kg (95% PI 6.3, 15.2 kg). No clinical baseline data were strong predictors of excessive weight gain. However, the weight gain during the first 3 months of the trial and the subsequent dose of insulin yielded a useful predictor for weight gain at the 18-month follow-up. Combining these two predictors into a prediction model with other clinical available information produced a receiver operating characteristic area under the curve of 0.80.

CONCLUSIONS

We have developed a prediction model that could help identify a substantial proportion of individuals with T2DM prone to large weight gain during insulin therapy.

Determinants of weight change in patients on basal insulin treatment: an analysis of the DIVE registry

OBJECTIVE

We aimed to describe patterns of weight change in insulin-naive patients with type 2 diabetes mellitus (T2DM) starting basal insulin (BI) treatment.

RESEARCH DESIGN AND METHODS

Diabetes Versorgungs-Evaluation (DIVE) is an observational, multicenter, prospective registry in patients with T2DM. Patients were divided into those initiating BI therapy for the first time (with optional oral antidiabetic drugs (OADs)) and those initiating OADs only (OADo).

RESULTS

521 patients were included in the analysis, 113 in the BI arm and 408 in the OADo arm. Relative to baseline, the BI group gained an average of 0.98±7.1 kg at 1 year, compared with a loss of 1.52±11.8 kg in the OADo group (p<0.001). This difference remained statistically significant when expressed as a proportional change from baseline (+0.014±0.08 vs -0.015±0.12, respectively (p<0.001)). Baseline weight (regression coefficient (RC) 0.89; 95% CI 0.81 to 0.97; p<0.001) and diabetes duration (RC 2.52; 95% CI 0.53 to 4.52; p=0.01) were the only factors identified as significant predictors of weight gain between baseline and 1 year follow-up in BI patients.

CONCLUSIONS

Though BI therapy leads to modest weight gain over the subsequent year, this may be limited by BI initiation at an early stage of the disease. As such, delaying the start of insulin therapy based on fears of weight gain appears counter-productive, and should be reconsidered.

Biphasic vs basal bolus insulin regimen in Type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials

AIM

We aim to evaluate the effects of biphasic insulin compared with a basal bolus insulin regimen on glycaemic control, total daily insulin requirements, risk of hypoglycaemia, weight and quality of life in patients with diabetes mellitus.

METHODS

MEDLINE, EMBASE, PubMed and Scopus databases were searched for studies up to November 2013. Interventions that lasted for more than four weeks and were reported in English were considered for the review. Meta-analysis was performed on eligible studies.

RESULTS

Fifteen randomized controlled trial studies, involving 4384 patients, were included. Greater HbA1c reductions were seen with basal-bolus compared with biphasic insulin regimens, between-treatment weighted mean difference (WMD) for baseline-to-endpoint changes in HbA1c was -0.2% (95% CI: -0.36 to -0.03) [-2.2 (-3.9, -0.3) mmol/mol]. In non-insulin naïve (n = 8) patients with Type 2 diabetes, HbA1c reduction was greater in the basal bolus group; WMD = -0.22% (95% CI: -0.42 to -0.02) [-2.4 (-4.6, -0.2) mmol/mol], but in insulin naïve patients (n = 5), HbA1c was equivalent between the two regimens; WMD (-0.15% (95% CI: -0.52 to 0.22) [-1.6 (-5.7, 2.4) mmol/mol]. Total daily insulin requirements and weight were increased with both regimens, whereas hypoglycaemia rates were comparable between the two regimens. Greater HbA1c reduction was observed in the basal bolus group compared with the biphasic regimen at the expense of higher daily insulin requirements and weight gain, but with no greater risk of hypoglycaemia.

CONCLUSIONS

Biphasic and basal bolus regimens were equally effective in reducing HbA1c in insulin naïve patients with Type 2 diabetes and both regimens are equally effective for initiating insulin in Type 2 diabetes.

Factors associated with weight gain in people with type 2 diabetes starting on insulin

OBJECTIVE

Moderate weight gain is usual after starting insulin therapy. The identification and quantification of factors associated with weight gain may help target strategies for avoidance of weight gain.

RESEARCH DESIGN AND METHODS

The noninterventional CREDIT (Cardiovascular Risk Evaluation in people with type 2 Diabetes on Insulin Therapy) study included data from people with type 2 diabetes starting any insulin in 314 centers, in 12 countries. From a number of predefined candidate explanatory variables, analyses identified factors associated with weight gain 1 year after starting insulin treatment, after adjusting for investigational site as a random factor. A multivariable backward regression analysis selected a subset of these factors associated with weight gain.

RESULTS

We studied the 2,179 people with data for body weight change at 1 year and for potential predictive factors. The mean weight gain was 1.78 kg, and 24% gained ≥5.0 kg. Baseline factors associated with weight gain were BMI, A1C, insulin regimen, insulin dose, other glucose-lowering therapies, and hypertension; at 1 year, additional factors were A1C, insulin regimen, insulin dose, and use of other glucose-lowering therapies. In multivariable analysis, weight gain at 1 year was associated with a higher A1C at baseline, a higher insulin dose at baseline and at 1 year, and a lower baseline BMI.

CONCLUSIONS

By the time insulin was started, a high baseline A1C and insulin dose requirements were independently associated with greater weight gain, as was lower baseline BMI. Insulin regimen per se was not a predictive factor.

Obesity independently predicts responders to biphasic insulin 50/50 (Humalog Mix50 and Insuman Comb 50) following conversion from other insulin regimens: a retrospective cohort study

AIMS

This study aims to examine the metabolic effects of intensification or initiation of insulin treatment with biphasic insulin 50/50, and determine the predictors of responders or non-responders to biphasic insulin 50/50.

METHODS

A cohort of 2183 patients ≥18 years with diabetes, newly treated with biphasic insulin 50/50 between January 2000 and May 2012, were sourced from UK General Practices via The Health Improvement Network (THIN) database. Baseline clinical parameters of 1267 patients with suboptimal glycated hemoglobin (HbA1c) >7.5% (>58 mmol/mol) who had received background insulin regimens for at least 6 months preceding biphasic insulin 50/50 were compared against 12-month outcome data. Responders were defined as those with HbA1c <7.5% (58 mmol/mol) and/or HbA1c reduction of ≥1% (10.9 mmol/mol) at 12 months. Comparative analyses were carried out on subgroups of 237 patients initiating insulin therapy with biphasic insulin 50/50, and between users of the Humalog Mix50 (HM50) versus Insuman Comb 50 (IC50). Associations were examined using t tests and multivariate logistic regression techniques.

RESULTS

The overall mean HbA1c reduction at 12 months as a result of intensification and initiation with biphasic insulin 50/50 was 0.5% (5.5 mmol/mol) and 1.6% (17.5 mmol/mol), respectively. Adjusted ORs show obesity (body mass index >30 kg/m(2)), treatment duration for ≥9 months, and baseline HbA1c are independent determinants of responders. In addition, stratified for baseline HbA1c levels, HM50 was associated with better HbA1c outcome compared with IC50.

CONCLUSIONS

biphasic insulin 50/50 is effective for achieving glycemic control in suboptimal HbA1c levels, especially among obese patients with insulin-treated diabetes. Stratified for baseline HbA1c, HM50 was associated with improved HbA1c outcome compared with IC50.