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Sendekie AK, Netere AK, Belachew EA. Hypoglycemic events and glycemic control effects between NPH and premixed insulin in patients with type 2 diabetes mellitus: A real-world experience at a comprehensive specialized hospital in Ethiopia. PLoS One 2022; 17:e0275032. [PMID: 36149907 PMCID: PMC9506660 DOI: 10.1371/journal.pone.0275032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 09/09/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Though initiation of insulin results in a significant change in glycemic levels, treating patients without significant hypoglycemic events remains difficult in diabetes patients initiated with different insulin-based regimens. This study assessed the association of hypoglycemic incidence and glycemic control between NPH and premixed insulin regimens in patients with type 2 diabetes mellitus (T2DM). METHODS This was a retrospective observational study in patients with T2DM who were treated with insulin-based therapy from 2015 to 2020 at the University of Gondar Comprehensive Specialized hospital. Average fasting blood glucose (FBG) between NPH and premixed insulin regimens was compared using an independent t-test. The Association of NPH and premixed insulin regimens with hypoglycemic incidences and glycemic control was examined by a logistic regression model. P < 0.05 was statistically significant. RESULTS From 405 participants, more than half (55.3%) were males with a mean age of 59.2(±9.1) years. Baseline mean HbA1C and FBG levels were 12.73(±1.1) % and 347.7(±48.5) mg/dl, respectively. Within a one-year follow-up period of insulin initiation, the rate of hypoglycemia was 13.1%. The incidence of hypoglycemia was significantly higher in patients initiated with premixed insulin compared with NPH insulin regimens (P < 0.001). After one year of insulin initiation, HbA1C decreased from 12.7 to 7.6 and from 12.8 to 7.3% and FBG levels decreased from 347.5 to 160.7 and from 348.2 to 147.3 mg/dl following initiation of NPH and premixed insulin, respectively. Patients treated with premixed-based insulin were found more likely to achieve target FBG compared with patients treated with NPH insulin regimens after one year of initiation (P = 0.02). CONCLUSION Premixed insulin-based regimen has found to have a higher hypoglycemic incidence, but a better level of glycemic control compared to NPH insulin-based therapy. Therefore, patients initiated with premixed insulin need to be highly vigilant and motivated to recognize the symptoms of hypoglycemia.
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Affiliation(s)
- Ashenafi Kibret Sendekie
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Adeladlew Kassie Netere
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Eyayaw Ashete Belachew
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
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John M, Gopinath D, Oommen T. Co-Formulations as the First Injectable in Type 2 Diabetes: A Review of Efficacy, Safety, and Implications in Clinical Practice. DUBAI DIABETES AND ENDOCRINOLOGY JOURNAL 2020. [DOI: 10.1159/000509045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
<b><i>Background:</i></b> Progression of type 2 diabetes will necessitate the use of injectable therapies in a significant number of people. Co-formulations of degludec with liraglutide (IDegLira) and glargine with lixisenatide (IGlarLixi) are currently recommended for intensification in people with type 2 diabetes on basal insulin or glucagon-like peptide receptor agonist (GLP-1RA) alone or in people with type 2 diabetes who are naïve to insulin with very high glycated haemoglobin. Co-formulation of aspart with degludec (IDegAsp) is recommended as a substitute for premixed insulin. The aim of this article is to review the evidence in the use of co-formulations as the first injectable in type 2 diabetes and its clinical implications. <b><i>Summary:</i></b> In people with type 2 diabetes who are naïve to insulin or GLP-1RA, IDegLira and IGlarLixi achieved stable and durable glycaemic control over a wide range of baseline glycated haemoglobin (HbA1c) levels. People on IDegLira and IGlarLixi had lesser risk of hypoglycaemia and weight gain in studies compared to basal insulin and lesser gastrointestinal adverse effects in comparison to GLP-1RA. IDegAsp achieved similar glycaemic control to basal and premixed insulin with lesser risk of nocturnal hypoglycaemia. <b><i>Key Messages:</i></b> IDegLira, IGlarLixi, and IDegAsp can be used as the first injectable in people with type 2 diabetes with very high glycated haemoglobin on oral antidiabetic drugs. These co-formulations combine efficacy and durability with lesser injection burden. The components of these agents have proven cardiovascular and renal safety. Their limitations in flexibility of dosing, renal and cardiovascular considerations, and adverse effects are discussed.
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Valencia WM, Florez HJ, Palacio AM. Suitable Use of Injectable Agents to Overcome Hypoglycemia Risk, Barriers, and Clinical Inertia in Community-Dwelling Older Adults with Type 2 Diabetes Mellitus. Drugs Aging 2020; 36:1083-1096. [PMID: 31565780 PMCID: PMC7481154 DOI: 10.1007/s40266-019-00706-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The management of type 2 diabetes mellitus in older adults requires a comprehensive understanding of the relationship between the disease (medical) and the functional, psychological/cognitive, and social geriatric domains, to individualize both glycemic targets and therapeutic approaches. Prevention of hypoglycemia is a major priority that should be addressed as soon as its presence or risk is detected, adjusting the target and therapeutics accordingly. Nonetheless, treatment intensification should not be neglected when applicable, consistent with recommendations from organizations such as the American Geriatrics Society and the American Diabetes Association, to reduce not only long-term macrovascular and microvascular complications (individualization), but also short-term complications from hyperglycemia (polyuria, volume depletion, urinary incontinence). Such complications can negatively impact the physical and cognitive function of older adults, worsen their quality of life, and additionally affect their families and society. We emphasize individualization, utilizing the multiple classes of antihyperglycemic agents available. Metformin remains as first-line therapy, and additional agents offer advantages and disadvantages that ought to be considered when developing a patient-centric plan of care. For selected cases, injectable therapies such as long-acting basal insulin analogs and glucagon-like peptide-1 receptor agonists can offer advantages to counter hypoglycemia risk, patient-related barriers, and clinical inertia. Furthermore, some injectable agents could potentially simplify regimens while providing safe and effective glycemic control. In this review, we discuss the use of injectable therapies for selected community-dwelling older adults, barriers to transition to injectable therapy, and measures aimed at removing these barriers and assisting physicians and their teams to transition older patients to injectable therapies when appropriate.
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Affiliation(s)
- Willy M Valencia
- Geriatrics Research, Education and Clinical Center (GRECC), Miami VA Healthcare System, 1201 NW 16th St., 11 GRC, CLC 207 A2, Miami, FL, 33125, USA. .,Department of Humanities, Health and Society, Florida International University Herbert Wertheim College of Medicine, Miami, FL, 33199, USA. .,Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, 33136, USA.
| | - Hermes J Florez
- Geriatrics Research, Education and Clinical Center (GRECC), Miami VA Healthcare System, 1201 NW 16th St., 11 GRC, CLC 207 A2, Miami, FL, 33125, USA.,Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, 33136, USA.,Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, 33136, USA
| | - Ana M Palacio
- Geriatrics Research, Education and Clinical Center (GRECC), Miami VA Healthcare System, 1201 NW 16th St., 11 GRC, CLC 207 A2, Miami, FL, 33125, USA.,Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, 33136, USA.,Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, 33136, USA
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4
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Alavudeen SS, Khobrani M, Dhanapal C, Mir JI, Alshahrani SM, Khan NA, Alhossan A. Comparative evaluation of biphasic insulin with metformin and triple oral hypoglycemic agents (OHA) in type 2 diabetes patients. Saudi Pharm J 2019; 28:210-214. [PMID: 32042260 PMCID: PMC7000310 DOI: 10.1016/j.jsps.2019.11.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 11/29/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction The prevalence of secondary failure to oral hypoglycemic agents among type 2 diabetes mellitus (T2DM) patients ranges from 30 to 60%. The alternative approaches to overcome this issue are either switching to triple oral hypoglycemic agents (OHA) or intensifying the regimen by adding insulin. Objective To compare the glycemic control achieved with biphasic insulin plus metformin and triple OHA in T2DM patients who were not adequately controlled with two OHA regimen. Methods A qualitative prospective study was conducted at Asir diabetes center, Abha, KSA. Poorly controlled T2DM patients with two OHA for at least 1 year with glycated hemoglobin (HbA1c) >7.0% were included. Subjects were divided into group I (a third OHA was added to the existing two OHA regimen) and group II (switched over to Biphasic insulin and metformin). At baseline and 3-month intervals, level of HbA1C, Fasting Plasma Glucose (FPG), Postprandial Plasma Glucose (PPG), Blood Pressure (BP), lipid profile and hypoglycemic episodes were obtained and evaluated for one year. Results 41.1% of patients were in group I and 58.9% were in group II. At the end of the study, there was a significant reduction in HbA1c in group II subjects comparing to group I (8.18 ± 1.32 vs 8.79 ± 1.81, p = 0.0238). FPG and PPG were improved also in group II. The mean body weight increased from baseline in group II is +4.48 kg and decreased from baseline in group I (−0.46 kg). 11.3% from group I and 23.7% from group II reported hypoglycaemic incidences. Conclusion Biphasic insulin and metformin regimen could be an appropriate therapeutic option for achieving good glycemic control compared with triple OHA in patients with two OHA failure.
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Affiliation(s)
| | - Moteb Khobrani
- Department of Clinical Pharmacy, King Khalid University, Abha, Saudi Arabia
| | - C.K. Dhanapal
- Faculty of Pharmacy, Annamalai University, Annamalai Nagar, Chidambaram, India
| | - Javid Iqbal Mir
- Department of Clinical Pharmacy, King Khalid University, Abha, Saudi Arabia
| | | | | | - Abdulaziz Alhossan
- Department of Clinical Pharmacy, King Saud University, Saudi Arabia
- Corresponding author at: Department of Clinical Pharmacy, King Saud University, Riyadh, Saudi Arabia.
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Wang W, Nevárez L, Filippova E, Song KH, Tao B, Gu L, Wang F, Li P, Yang J. Efficacy and safety of once-weekly dulaglutide versus insulin glargine in mainly Asian patients with type 2 diabetes mellitus on metformin and/or a sulphonylurea: A 52-week open-label, randomized phase III trial. Diabetes Obes Metab 2019; 21:234-243. [PMID: 30129089 PMCID: PMC6585712 DOI: 10.1111/dom.13506] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 08/09/2018] [Accepted: 08/10/2018] [Indexed: 12/24/2022]
Abstract
AIM To compare the efficacy and safety of once-weekly dulaglutide with that of insulin glargine in combination with metformin and/or a sulphonylurea in mainly Asian patients with type 2 diabetes mellitus (T2DM). MATERIALS AND METHODS In this 52-week, randomized, parallel-arm open-label study, we enrolled patients aged ≥18 years with T2DM for at least 6 months and a glycated haemoglobin (HbA1c) concentration ≥53.0 mmol/mol (7.0%) and ≤96.7 mmol/mol (11.0%). The primary outcome was change in HbA1c from baseline to week 26 to determine non-inferiority of dulaglutide 1.5 mg versus glargine. RESULTS A total of 774 patients from China, South Korea, Mexico and Russia were randomly assigned (1:1:1) to dulaglutide 1.5 mg, dulaglutide 0.75 mg or glargine treatment groups. The patients' mean age was 55 years and the average T2DM duration was ~8 years. The least squares mean (SE) changes from baseline in HbA1c at 26 weeks were - 18.9 (0.73) mmol/mol (-1.73 [0.067]%) for dulaglutide 1.5 mg and -14.5 (0.73) mmol/mol (-1.33 [0.067]%) for dulaglutide 0.75 mg, compared with -12.7 (0.73) mmol/mol (-1.16 [0.067]%) for glargine. Statistical criteria for superiority were met with both dulaglutide 1.5 mg and dulaglutide 0.75 mg. More patients in the dulaglutide 1.5 and 0.75 mg groups achieved HbA1c target <53.0 mmol/mol (<7.0%) than in the glargine group at week 26 (P < 0.001 and P = 0.004, respectively). Body weight decreased with dulaglutide and increased with glargine. The incidence and rate of total hypoglycaemia were lower with dulaglutide versus glargine. Gastrointestinal adverse events, including diarrhoea and nausea, were the most frequently reported for patients taking dulaglutide. CONCLUSIONS Once-weekly dulaglutide provides greater improvement in HbA1c, with weight loss and less hypoglycaemia, than once-daily insulin glargine in a population of mainly Asian patients with T2DM who had failed to achieve optimal glycaemic control on metformin and/or a sulphonylurea.
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Affiliation(s)
| | | | | | - Ki Ho Song
- Yeouido St. Mary's Hospital, Seoul, Republic of Korea
| | - Bei Tao
- Rui Jin Hospital, Shanghai, China
| | - Liqun Gu
- Lilly Suzhou Pharmaceutical Company Ltd, Shanghai, China
| | - Feng Wang
- Lilly Suzhou Pharmaceutical Company Ltd, Shanghai, China
| | - Pengfei Li
- Lilly Suzhou Pharmaceutical Company Ltd, Shanghai, China
| | - Jun Yang
- Lilly Suzhou Pharmaceutical Company Ltd, Shanghai, China
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Tayek CJ, Cherukuri L, Hamal S, Tayek JA. Importance of fasting blood glucose goals in the management of type 2 diabetes mellitus: a review of the literature and a critical appraisal. ACTA ACUST UNITED AC 2018; 5:113-117. [PMID: 31404422 PMCID: PMC6688759 DOI: 10.15406/jdmdc.2018.05.00148] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Prandial insulin has been essential for the improved management of the type 1 diabetic patient. Interestingly, many studies
have evaluated the addition of prandial insulin to the type 2 diabetic patients with improved control. The greatest drop in A1c
with the use of various type of prandial insulins have resulted in the decrease of 1.3% in the A1c measurement. Interestingly,
none of the published trials with goal of fasting blood glucose (FBG) have ever obtained the goal A1c. Since a drop in FBG of
28.7mg/dl is equal to a 1% drop in A1c, a simple approach to obtain a target A1c would be to focus on the FBG (per ADA: Average
Blood Glucose = A1c (%) x 28.7 - 46.7mg/d). However, average blood glucose requires multiple measurements and may be less accurate
then using just a FBG. Since prandial insulin clinical trials have only demonstrated a drop in A1c by 0.3-1.3% the use of only a
FBG to help patients get to goal may be easier to teach and to obtain. It might save time and money. Our hypothesis is that if
patient obtain a FBG <100 mg/dl for 2-3 months then 70% will be at an A1c goal <7.0%. After a few months of good
fasting glucose control the provider can use this equation (FBG+80)/30 to estimate A1c. For example, a FBG of 130mg/dl would be
(130 + 80)/30 = 7.0%; or a FBG of 190 would be (190+80)/30 =eA1c 9% (estimate of A1c). While type 1 diabetes has a very complex
daily glucose pattern, the approach to type 2 diabetics on insulin could become simplified.
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Affiliation(s)
- Chandler J Tayek
- Department of Internal Medicine, Los Angeles Bio-Medical Research Institute, USA
| | - Lavanya Cherukuri
- Department of Internal Medicine, Los Angeles Bio-Medical Research Institute, USA
| | - Sajad Hamal
- Department of Internal Medicine, Los Angeles Bio-Medical Research Institute, USA
| | - John A Tayek
- Department of Internal Medicine, Los Angeles Bio-Medical Research Institute, USA
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7
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Silver B, Ramaiya K, Andrew SB, Fredrick O, Bajaj S, Kalra S, Charlotte BM, Claudine K, Makhoba A. EADSG Guidelines: Insulin Therapy in Diabetes. Diabetes Ther 2018; 9:449-492. [PMID: 29508275 PMCID: PMC6104264 DOI: 10.1007/s13300-018-0384-6] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Indexed: 01/25/2023] Open
Abstract
A diagnosis of diabetes or hyperglycemia should be confirmed prior to ordering, dispensing, or administering insulin (A). Insulin is the primary treatment in all patients with type 1 diabetes mellitus (T1DM) (A). Typically, patients with T1DM will require initiation with multiple daily injections at the time of diagnosis. This is usually short-acting insulin or rapid-acting insulin analogue given 0 to 15 min before meals together with one or more daily separate injections of intermediate or long-acting insulin. Two or three premixed insulin injections per day may be used (A). The target glycated hemoglobin A1c (HbA1c) for all children with T1DM, including preschool children, is recommended to be < 7.5% (< 58 mmol/mol). The target is chosen aiming at minimizing hyperglycemia, severe hypoglycemia, hypoglycemic unawareness, and reducing the likelihood of development of long-term complications (B). For patients prone to glycemic variability, glycemic control is best evaluated by a combination of results with self-monitoring of blood glucose (SMBG) (B). Indications for exogenous insulin therapy in patients with type 2 diabetes mellitus (T2DM) include acute illness or surgery, pregnancy, glucose toxicity, contraindications to or failure to achieve goals with oral antidiabetic medications, and a need for flexible therapy (B). In T2DM patients, with regards to achieving glycemic goals, insulin is considered alone or in combination with oral agents when HbA1c is ≥ 7.5% (≥ 58 mmol/mol); and is essential for treatment in those with HbA1c ≥ 10% (≥ 86 mmol/mol), when diet, physical activity, and other antihyperglycemic agents have been optimally used (B). The preferred method of insulin initiation in T2DM is to begin by adding a long-acting (basal) insulin or once-daily premixed/co-formulation insulin or twice-daily premixed insulin, alone or in combination with glucagon-like peptide-1 receptor agonist (GLP-1 RA) or in combination with other oral antidiabetic drugs (OADs) (B). If the desired glucose targets are not met, rapid-acting or short-acting (bolus or prandial) insulin can be added at mealtime to control the expected postprandial raise in glucose. An insulin regimen should be adopted and individualized but should, to the extent possible, closely resemble a natural physiologic state and avoid, to the extent possible, wide fluctuating glucose levels (C). Blood glucose monitoring is an integral part of effective insulin therapy and should not be omitted in the patient's care plan. Fasting plasma glucose (FPG) values should be used to titrate basal insulin, whereas both FPG and postprandial glucose (PPG) values should be used to titrate mealtime insulin (B). Metformin combined with insulin is associated with decreased weight gain, lower insulin dose, and less hypoglycemia when compared with insulin alone (C). Oral medications should not be abruptly discontinued when starting insulin therapy because of the risk of rebound hyperglycemia (D). Analogue insulin is as effective as human insulin but is associated with less postprandial hyperglycemia and delayed hypoglycemia (B). The shortest needles (currently the 4-mm pen and 6-mm syringe needles) are safe, effective, and less painful and should be the first-line choice in all patient categories; intramuscular (IM) injections should be avoided, especially with long-acting insulins, because severe hypoglycemia may result; lipohypertrophy is a frequent complication of therapy that distorts insulin absorption, and therefore, injections and infusions should not be given into these lesions and correct site rotation will help prevent them (A). Many patients in East Africa reuse syringes for various reasons, including financial. This is not recommended by the manufacturer and there is an association between needle reuse and lipohypertrophy. However, patients who reuse needles should not be subjected to alarming claims of excessive morbidity from this practice (A). Health care authorities and planners should be alerted to the risks associated with syringe or pen needles 6 mm or longer in children (A).
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Affiliation(s)
- Bahendeka Silver
- MKPGMS-Uganda Martyrs University | St. Francis Hospital, Nsambya, Kampala, Uganda.
| | - Kaushik Ramaiya
- Shree Hindu Mandal Hospital, Chusi Street, Dar es Salaam, Tanzania
| | - Swai Babu Andrew
- Muhimbili University College of Health Sciences, United Nations Road, Dar es Salaam, Tanzania
| | - Otieno Fredrick
- Department of Clinical Medicine and Therapeutics School of Medicine, College of Health Science, University of Nairobi, Nairobi, Kenya
| | - Sarita Bajaj
- Department of Medicine, MLN Medical College, George Town, Allahabad, India
| | - Sanjay Kalra
- Bharti Research Institute of Diabetes and Endocrinology, Sector 12, PO Box 132001, Karnal, Haryana, India
| | - Bavuma M Charlotte
- University of Rwanda, College of Medicine and Health Science, Kigali University Teaching Hospital, Kigali, Rwanda
| | - Karigire Claudine
- Department of Internal Medicine, Rwanda Military Hospital, Kigali, Rwanda
| | - Anthony Makhoba
- MKPGMS-Uganda Martyrs University | St. Francis Hospital, Nsambya, Kampala, Uganda
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Berard L, Antonishyn N, Arcudi K, Blunden S, Cheng A, Goldenberg R, Harris S, Jones S, Mehan U, Morrell J, Roscoe R, Siemens R, Vallis M, Yale JF. Insulin Matters: A Practical Approach to Basal Insulin Management in Type 2 Diabetes. Diabetes Ther 2018; 9:501-519. [PMID: 29476414 PMCID: PMC6104258 DOI: 10.1007/s13300-018-0375-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Indexed: 12/14/2022] Open
Abstract
It is currently estimated that 11 million Canadians are living with diabetes or prediabetes. Although hyperglycemia is associated with serious complications, it is well established that improved glycemic control reduces the risk of microvascular complications and can also reduce cardiovascular (CV) complications over the long term. The UKPDS and ADVANCE landmark trials have resulted in diabetes guidelines recommending an A1C target of ≤ 7.0% for most patients or a target of ≤ 6.5% to further reduce the risk of nephropathy and retinopathy in those with type 2 diabetes (T2D), if it can be achieved safely. However, half of the people with T2D in Canada are not achieving these glycemic targets, despite advances in diabetes pharmacological management. There are many contributing factors to account for this poor outcome; however, one of the major factors is the delay in treatment advancement, particularly a resistance to insulin initiation and intensification. To simplify the process of initiating and titrating insulin in T2D patients, a group of Canadian experts reviewed the evidence and best clinical practices with the goal of providing guidance and practical recommendations to the diabetes healthcare community at large. This expert panel included general practitioners (GPs), nurses, nurse practitioners, endocrinologists, dieticians, pharmacists, and a psychologist. This article summarizes the panel recommendations.
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Affiliation(s)
- Lori Berard
- Winnipeg Regional Health Authority, Winnipeg Diabetes Research Group, Health Sciences Centre, Winnipeg, MB, Canada.
| | - Noreen Antonishyn
- Department of Endocrinology, Alberta Health Services, Edmonton, AB, Canada
| | - Kathryn Arcudi
- Diabetes Clinic, The Montreal West Island Integrated University Health and Social Services Centre (Lakeshore General Hospital), Pointe-Claire, QC, Canada
| | - Sarah Blunden
- Diabetes Education, LMC Diabetes and Endocrinology, Montreal, QC, Canada
| | - Alice Cheng
- Division of Endocrinology and Metabolism, St. Michael's Hospital, Toronto, ON, Canada
- Trillium Health Partners, Credit Valley Hospital, Mississauga, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Stewart Harris
- Department of Family Medicine, Western University, London, ON, Canada
| | | | - Upender Mehan
- The Centre for Family Medicine, Kitchener, ON, Canada
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - James Morrell
- Diabetes Services, Island Health, Victoria, BC, Canada
| | - Robert Roscoe
- Diabetes Education Centre, Saint John Regional Hospital, Saint John, NB, Canada
| | | | - Michael Vallis
- Behaviour Change Institute, Nova Scotia Health Authority, Halifax, NS, Canada
- Department of Family Medicine, Dalhousie University, Halifax, NS, Canada
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9
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Fujita N, Yamamoto Y, Hayashino Y, Kuwata H, Okamura S, Iburi T, Furuya M, Kitatani M, Yamazaki S, Ishii H, Tsujii S, Inagaki N, Fukuhara S. Real-life glycemic control in patients with type 2 diabetes treated with insulin therapy: A prospective, longitudinal cohort study (Diabetes Distress and Care Registry at Tenri [DDCRT 9]). J Diabetes Investig 2018; 9:294-302. [PMID: 28494126 PMCID: PMC5835478 DOI: 10.1111/jdi.12693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 04/05/2017] [Accepted: 05/07/2017] [Indexed: 01/03/2023] Open
Abstract
AIMS/INTRODUCTION We investigated the association between four insulin regimens, and increase in glycated hemoglobin (HbA1c) and insulin dose in a real-life clinical setting because there are no data about them among insulin regimens. MATERIALS AND METHODS Participants included 757 patients with type 2 diabetes having been treated with insulin therapy for more than 1 year. The four insulin regimens were regimen 1 (long-acting insulin, once daily), regimen 2 (biphasic insulin, twice daily), regimen 3 (biphasic insulin, three times daily) and regimen 4 (basal-bolus therapy). Main outcomes were increases in HbA1c levels >0.5% and increases in daily insulin units after 1 year. We carried out multivariable analyses to examine differences in glycemic control and insulin dose with adjustment for possible confounders. RESULTS Mean HbA1c level and duration of insulin therapy were 7.8% and 11.3 years, respectively. HbA1c levels increased by >0.5% at follow up in 22.8, 24.9, 20.7, and 29.3% of participants using regimen 1, 2, 3 and 4, respectively, with no significant differences between groups. Daily insulin doses increased in 62.3, 68.8, 65.3 and 38.6% of patients, respectively (P < 0.001). Multivariable regression analysis showed that patients who received regimen 4 had significantly lower odds of requiring future insulin dose increases than those who had received regimen 2 (adjusted odds ratio 0.24, 95% confidence interval 0.14-0.41; P < 0.001). CONCLUSIONS Many patients receiving insulin therapy showed increases in HbA1c levels and insulin doses 1 year later. The smallest increase in insulin dose was observed in the basal-bolus therapy group compared with other regimens.
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Affiliation(s)
- Naotaka Fujita
- Department of Healthcare EpidemiologySchool of Public Health in the Graduate School of MedicineKyoto UniversityKyotoJapan
- Department of Diabetes, Endocrinology and NutritionGraduate School of MedicineKyoto UniversityKyotoJapan
| | - Yosuke Yamamoto
- Department of Healthcare EpidemiologySchool of Public Health in the Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Yasuaki Hayashino
- Department of Healthcare EpidemiologySchool of Public Health in the Graduate School of MedicineKyoto UniversityKyotoJapan
- Department of EndocrinologyTenri HospitalTenriNaraJapan
| | | | | | - Tadao Iburi
- Department of EndocrinologyTenri HospitalTenriNaraJapan
| | - Miyuki Furuya
- Department of EndocrinologyTenri HospitalTenriNaraJapan
| | | | - Shin Yamazaki
- Department of Healthcare EpidemiologySchool of Public Health in the Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Hitoshi Ishii
- Department of DiabetologyNara Medical UniversityKashiharaNaraJapan
| | - Satoru Tsujii
- Department of EndocrinologyTenri HospitalTenriNaraJapan
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and NutritionGraduate School of MedicineKyoto UniversityKyotoJapan
| | - Shunichi Fukuhara
- Department of Healthcare EpidemiologySchool of Public Health in the Graduate School of MedicineKyoto UniversityKyotoJapan
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Liu G, Dou J, Pan Y, Yan Y, Zhu H, Lu J, Gaisano H, Ji L, He Y. Comparison of the Effect of Glycemic Control in Type 2 Diabetes Outpatients Treated With Premixed and Basal Insulin Monotherapy in China. Front Endocrinol (Lausanne) 2018; 9:639. [PMID: 30420835 PMCID: PMC6215808 DOI: 10.3389/fendo.2018.00639] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 10/09/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Basal and premixed insulin have been widely used for insulin therapy of type 2 diabetes mellitus (T2DM) in China. The aim of this study is to compare the sustained efficacy of basal and premixed insulin therapies in T2DM outpatients with insulin monotherapy. Materials and Methods: The survey was conducted in 602 hospitals across China from April to June in 2013. The participants included outpatients who were receiving basal or premixed insulin monotherapy for more than 3 months, and the outcome was attaining a glycated hemoglobin A1C (HbA1c) of <7.0% as a measure of sustained glycemic control. Results: A total of 49,119 T2DM outpatients on basal (n = 11,967) or premixed insulin (n = 37,152) monotherapy were included in the final analyses. Using multivariable model analysis, patients using premixed insulin exhibited a better glycemic control, with more outpatients achieving the target HbA1c level than those using basal insulin (model 1, OR 0.695, 95%CI 0.664-0.728; model 2, OR 0.708, 95%CI 0.676-0.742; model 3, OR 0.717, 95%CI 0.684-0.752; model 4, OR 0.750, 95%CI 0.715-0.787). Using subgroup analysis stratified by age, sex, duration of diabetes, duration of insulin treatment, and complications, still more outpatients in every subgroup treated with premixed insulin achieved the target HbA1c (HbA1c < 7%) than those receiving basal insulin. Conclusions: Premixed insulin monotherapy had a better glycemic control (HbA1c < 7.0%) than basal insulin monotherapy for Chinese T2DM outpatients in daily.
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Affiliation(s)
- Guangxu Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Capital Medical University, Beijing, China
- Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China
| | - Jingtao Dou
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
- Department of Endocrinology, Hainan Branch of Chinese PLA General Hospital, Sanya, China
| | - Yuesong Pan
- Department of Epidemiology and Biostatistics, School of Public Health, Capital Medical University, Beijing, China
- Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China
| | - Yuxiang Yan
- Department of Epidemiology and Biostatistics, School of Public Health, Capital Medical University, Beijing, China
- Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China
| | - Huiping Zhu
- Department of Epidemiology and Biostatistics, School of Public Health, Capital Medical University, Beijing, China
- Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China
| | - Juming Lu
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
| | - Herbert Gaisano
- Departments of Medicine and Physiology, University of Toronto, Toronto, ON, Canada
| | - Linong Ji
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
- *Correspondence: Linong Ji
| | - Yan He
- Department of Epidemiology and Biostatistics, School of Public Health, Capital Medical University, Beijing, China
- Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China
- Yan He
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11
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Hirose T, Awata T, Yamamoto Y, Hemmingsen MP. Clinical considerations for use of insulin degludec/insulin aspart in Japanese patients. Expert Opin Biol Ther 2017; 18:77-85. [PMID: 29017373 DOI: 10.1080/14712598.2018.1389888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Co-formulation of basal and bolus insulin components provides a simpler regimen for patients with type 2 diabetes than separate basal-bolus treatment. However, conventional premixed insulin products include a suboptimal protaminated basal component that requires resuspension prior to injection. Insulin degludec/insulin aspart (IDegAsp) is the first soluble co-formulation of a basal insulin with an ultra-long duration of action (IDeg) and a rapid-acting bolus insulin (IAsp) in a single injection. AREAS COVERED In this review, the authors summarize findings from pre-clinical studies and the clinical trial program and provide guidance for the initiating and switching of IDegAsp in different patient populations. Pharmacodynamic analyses have revealed a rapid onset of action and distinct peak (IAsp), followed by a separate, flat and stable basal effect (IDeg component). Phase 3 studies have demonstrated the efficacy and safety of IDegAsp, with greater glycemic improvements than basal-only therapy in international and Japanese type 2 diabetes populations. IDegAsp also results in reduced insulin dose requirements and lower rates of hypoglycemia than premixed insulin. EXPERT OPINION IDegAsp provides a simple and effective insulin regimen in appropriately selected Japanese patients, with the flexibility to suit individual needs. The benefits of IDegAsp over conventional insulin regimens might help tackle clinical inertia with insulin intensification.
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Affiliation(s)
- Takahisa Hirose
- a Division of Diabetes, Metabolism and Endocrinology, Department of Medicine , Toho University School of Medicine , Tokyo , Japan
| | - Takuya Awata
- b Department of Diabetes, Endocrinology and Metabolism , International University of Health and Welfare Hospital , Tochigi , Japan
| | - Yuiko Yamamoto
- c Medical & Scientific Affairs Department , Novo Nordisk Pharma Ltd , Tokyo , Japan
| | - Mads Peter Hemmingsen
- d Medical & Scientific Affairs Department , Novo Nordisk Pharma Ltd ., Tokyo , Japan
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12
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Festa A, Heller SR, Seaquist E, Duan R, Hadjiyianni I, Fu H. Association between mild and severe hypoglycemia in people with type 2 diabetes initiating insulin. J Diabetes Complications 2017; 31:1047-1052. [PMID: 28389158 DOI: 10.1016/j.jdiacomp.2016.12.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 12/14/2016] [Accepted: 12/17/2016] [Indexed: 11/30/2022]
Abstract
AIMS Primary objective: Identify risk factors associated with severe hypoglycemia (SH) and investigate the association between mild hypoglycemia and SH in people with type 2 diabetes starting insulin. Secondary objectives: Investigate the association of demographics and clinical factors with SH incidence. METHODS Integrated trial database data were obtained for 3 randomized controlled trials that included insulin-naïve people with type 2 diabetes initiating basal (insulin glargine) versus biphasic (insulin lispro mixture) insulin. Standard definitions were used for SH; mild hypoglycemia was defined as all non-SH. Cox regression identified risk factors associated with SH and the correlation between SH and mild hypoglycemia. RESULTS Data were pooled (N=2931). During 24-48weeks' treatment, 2127 (72.6%) participants experienced ≥1 mild hypoglycemic event but no SH (mean mild hypoglycemia rate=2.33/month). 56 participants (1.9%) experienced ≥1 SH event plus mild hypoglycemia (mean mild hypoglycemia rate=3.95/month); 748 participants (25.5%) had no hypoglycemia. Among factors tested, only mild hypoglycemia rate/month was associated with SH. SH risk was higher (HR=4.24; 95%CI=2.57-6.99;p<0.0001) for participants experiencing multiple mild hypoglycemic events/month compared with those experiencing ≤1 mild hypoglycemic event/month. CONCLUSIONS Mild hypoglycemia may predict the first SH event, which is important because SH is a strong and consistent risk factor for morbidity/mortality.
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Affiliation(s)
- Andreas Festa
- Eli Lilly Regional Operations Ges.m.b.H., Vienna, Austria.
| | - Simon R Heller
- Sheffield Teaching Hospitals Foundation Trust, University of Sheffield, Sheffield, UK
| | | | - Ran Duan
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | - Haoda Fu
- Eli Lilly and Company, Indianapolis, IN, USA
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13
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Su Q, Liu C, Zheng H, Zhu J, Li PF, Qian L, Yang WY. Comparison of insulin lispro mix 25 with insulin lispro mix 50 as insulin starter in Chinese patients with type 2 diabetes mellitus (CLASSIFY study): Subgroup analysis of a Phase 4 open-label randomized trial. J Diabetes 2017; 9:575-585. [PMID: 27371341 DOI: 10.1111/1753-0407.12442] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 05/19/2016] [Accepted: 06/26/2016] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Premixed insulins are recommended starter insulins in Chinese patients after oral antihyperglycemic medication (OAM) failure. In the present study, we compared the efficacy and safety of insulin lispro mix 25 (LM25) twice daily (b.i.d.) and insulin lispro mix 50 (LM50) b.i.d. as a starter insulin regimen in Chinese patients with type 2 diabetes mellitus (T2DM) who had inadequate glycemic control with OAMs. METHODS The primary efficacy outcome in the present open-label parallel randomized clinical trial was change in HbA1c from baseline to 26 weeks. Patients were randomized in a ratio of 1: 1 to LM25 (n = 80) or LM50 (n = 76). A mixed-effects model with repeated measures was used to analyze continuous variables. The Cochran-Mantel-Haenszel test with stratification factor was used to analyze categorical variables. RESULTS At the end of the study, LM50 was more efficacious than LM25 in reducing mean HbA1c levels (least-squares [LS] mean difference 0.48; 95 % confidence interval [CI] 0.22, 0.74; P < 0.001). More subjects in the LM50 than LM25 group achieved HbA1c targets of <7.0 % (72.4 % vs 45.0 %; P = 0.001) or ≤6.5 % (52.6 % vs 20.0 %; P < 0.001). Furthermore, LM50 was more effective than LM25 at reducing HbA1c in patients with baseline HbA1c, blood glucose excursion, and postprandial glucose greater than or equal to median levels (P ≤ 0.001). The rate and incidence of hypoglycemic episodes and increase in weight at the end of the study were similar between treatment groups. CONCLUSIONS In Chinese patients with T2DM, LM50 was more efficacious than LM25 as a starter insulin.
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Affiliation(s)
- Qing Su
- Department of Endocrinology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Chao Liu
- Department of Endocrinology, Affiliated Hospital on Integration of Chinese and Western Medicine, Nanjing University of Chinese Medicine, Jiangsu Province Academy of Traditional Chinese Medicine, Nanjing, China
| | - Hongting Zheng
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Jun Zhu
- Xinjiang Key Laboratory of Metabolic Disease Research, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Peng Fei Li
- Medical Department, Lilly Suzhou Pharmaceutical Co. Ltd, Shanghai, China
| | - Lei Qian
- Medical Department, Lilly Suzhou Pharmaceutical Co. Ltd, Shanghai, China
| | - Wen Ying Yang
- Department of Endocrinology and Metabolism, China-Japan Friendship Hospital, Beijing, China
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14
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Liebl A. Management of postprandial glucose: Recommended targets and treatment with biphasic insulin. Prim Care Diabetes 2016; 10:391-397. [PMID: 27427307 DOI: 10.1016/j.pcd.2016.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 05/11/2016] [Accepted: 06/14/2016] [Indexed: 01/03/2023]
Abstract
Increases in glycaemia, particularly following meals, have been independently associated with diabetes complications, most notably cardiovascular disease. Control of postprandial plasma glucose (PPG) therefore plays an important role in diabetes management. International diabetes guidelines acknowledge the value of PPG monitoring yet place relatively little emphasis on PPG control. This article considers the impact of suboptimal PPG control and current recommendations with regard to management of PPG. Specific consideration is given to the role of biphasic insulins, one of the treatment options recognised by the International Diabetes Federation as preferentially lowering PPG levels.
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Affiliation(s)
- Andreas Liebl
- Department of Internal Medicine, Centre for Diabetes and Metabolism, Fachklinik Bad Heilbrunn, Bad Heilbrunn, Germany.
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15
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Gracia-Ramos AE, Cruz-Domínguez MDP, Madrigal-Santillán EO, Morales-González JA, Madrigal-Bujaidar E, Aguilar-Faisal JL. Premixed Insulin Analogue Compared with Basal-Plus Regimen for Inpatient Glycemic Control. Diabetes Technol Ther 2016; 18:705-712. [PMID: 27860499 DOI: 10.1089/dia.2016.0176] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND No previous studies have investigated the use of a premixed insulin analogue in a hospital setting. OBJECTIVE To compare the efficacy and safety of treatment with premixed insulin analogue (insulin lispro mix 75/25, LM75/25) with the basal-plus regimen with insulin glargine in hospitalized patients with type 2 diabetes (T2D). MATERIALS AND METHODS A randomized clinical trial in hospitalized patients with T2D and glucose >140 mg/dL on admission was performed. A total of 54 patients were randomized to receive insulin LM75/25 or glargine. In both groups, a correction dose of lispro was administered before meals. Insulin dose was adjusted to obtain a mean blood glucose (BG) between 100 and 140 mg/dL. RESULTS Improvement in the mean BG after the first day of treatment was similar in both groups (P = 0.470). Glycemic control at the end of follow-up was similar between the group with insulin LM75/25 (131.3 ± 28.4 mg/dL) and insulin glargine (143.8 ± 32.5 mg/dL, P = 0.153). The aim of a BG concentration of <140 mg/dL was obtained in 72% of the patients in the premixed insulin analogue group and 56% of patients in the basal-plus group (P = 0.239). There was no difference in the frequency of hypoglycemia between groups (7 vs. 10, P = 0.529). CONCLUSION Results of this trial indicate that the use of a premixed insulin analogue is as effective and safe as the basal-plus regimen to achieve glycemic control.
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Affiliation(s)
- Abraham Edgar Gracia-Ramos
- 1 Departamento de Medicina Interna, Hospital de Especialidades , Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - María Del Pilar Cruz-Domínguez
- 2 División de Investigación en Salud, Hospital de Especialidades , Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | | | - José Antonio Morales-González
- 3 Laboratorio de Medicina de Conservación, Escuela Superior de Medicina, Instituto Politécnico Nacional , Mexico City, Mexico
| | | | - José Leopoldo Aguilar-Faisal
- 3 Laboratorio de Medicina de Conservación, Escuela Superior de Medicina, Instituto Politécnico Nacional , Mexico City, Mexico
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16
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Chow W, Miyasato G, Kokkotos FK, Bailey RA, Buysman EK, Henk HJ. Real-world Canagliflozin Utilization: Glycemic Control Among Patients With Type 2 Diabetes Mellitus—A Multi-Database Synthesis. Clin Ther 2016; 38:2071-82. [DOI: 10.1016/j.clinthera.2016.07.168] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 07/22/2016] [Indexed: 01/29/2023]
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17
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Kumar A. Efficacy and safety of biphasic insulin aspart and biphasic insulin lispro mix in patients with type 2 diabetes: A review of the literature. Indian J Endocrinol Metab 2016; 20:288-299. [PMID: 27186543 PMCID: PMC4855954 DOI: 10.4103/2230-8210.179993] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Type 2 diabetes (T2D) represents an escalating burden worldwide, particularly in China and India. Compared with Caucasians, Asian people with diabetes have lower body mass index, increased visceral adiposity, and postprandial glucose (PPG)/insulin resistance. Since postprandial hyperglycemia contributes significantly to total glycemic burden and is associated with heightened cardiovascular risk, targeting PPG early in T2D is paramount. Premixed insulin regimens are widely used in Asia due to their convenience and effectiveness. Data from randomized controlled trials and observational studies comparing efficacy and safety of biphasic insulin aspart 30 (BIAsp 30) with biphasic insulin lispro mix (LM 25/50) and versus other insulin therapies or oral antidiabetic drugs (OADs) in T2D demonstrated that BIAsp 30 and LM 25/50 were associated with similar or greater improvements in glycemic control versus comparator regimens, such as basal-bolus insulin, in insulin-naÏve, and prior insulin users. Studies directly comparing BIAsp 30 and LM 25 provided conflicting glycemic control results. Safety data generally showed increased hypoglycemia and weight gain with premixed insulins versus basal-bolus insulin or OADs. However, large observational trials documented improvements in glycated hemoglobin, PPG, and hypoglycemia with BIAsp 30 in multi-ethnic patient populations. In summary, this literature review demonstrates that premixed insulin regimens are an appropriate and effective treatment choice in T2D.
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Affiliation(s)
- Ajay Kumar
- Diabetes Care and Research Centre, Patna, Bihar, India
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18
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Elliott L, Fidler C, Ditchfield A, Stissing T. Hypoglycemia Event Rates: A Comparison Between Real-World Data and Randomized Controlled Trial Populations in Insulin-Treated Diabetes. Diabetes Ther 2016; 7:45-60. [PMID: 26886441 PMCID: PMC4801820 DOI: 10.1007/s13300-016-0157-z] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Hypoglycemia is the most common adverse effect of diabetes therapy, particularly insulin treatment. Hypoglycemia is associated with considerable clinical and economic burden, and may be under-reported. The aim of this study was to com pare the frequency of hypoglycemic events reported in real-world settings with those reported in clinical trials. METHODS We conducted a structured literature review in PubMed to identify hypoglycemic event rates in patients with type 1 diabetes mellitus (T1DM) and insulin-treated type 2 diabetes mellitus (T2DM) from real-world data (RWD) and randomized controlled trials (RCTs). The search was restricted to English language, full-text publications from 2010 onwards, reporting on treatment of T1DM or T2DM with basal only, basal-bolus, or premix insulin. RESULTS The final dataset included 30 studies (11 RWD studies and 19 RCTs). Six studies (RWD, n = 2; RCT, n = 4) reported hypoglycemia event rates in people with T1DM. For all reported categories of hypoglycemia (severe, non-severe, and nocturnal), rates were consistently higher in RWD studies compared with RCTs. Twenty-five studies (RWD, n = 10; RCT, n = 15) reported hypoglycemia event rates in people with insulin-treated T2DM. For T2DM basal-oral therapy; the highest rates were observed in RWD studies, although there was an overlap with RCT rates. For basal-bolus therapy, there was considerable between-study variability but higher rates of severe and non-severe hypoglycemia were generally observed in RWD studies. For T2DM premix insulin, reported rates of hypoglycemia in RWD studies and RCTs were similar. CONCLUSION We found that higher rates of hypoglycemia are observed in real-world settings compared with clinical trial settings, although there is a large degree of overlap. Due to the inherent constraints of RCTs, they are likely to underestimate the burden of hypoglycemia in clinical practice. Further, high-quality RWD are needed to determine a more accurate incidence of hypoglycemia in clinical practice.
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Affiliation(s)
| | - Carrie Fidler
- DRG Abacus, 6 Talisman Business Centre, Bicester, Oxfordshire UK
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19
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Wu T, Betty B, Downie M, Khanolkar M, Kilov G, Orr-Walker B, Senator G, Fulcher G. Practical Guidance on the Use of Premix Insulin Analogs in Initiating, Intensifying, or Switching Insulin Regimens in Type 2 Diabetes. Diabetes Ther 2015; 6:273-87. [PMID: 26104878 PMCID: PMC4575300 DOI: 10.1007/s13300-015-0116-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Premix insulin analogs are a well-established treatment for type 2 diabetes (T2D). However, there is a lack of simple, clear guidance on some aspects of their use. These include choosing a regimen for insulin initiation, recognizing when patients need intensification of therapy, and switching from basal-bolus to a premix insulin analog when appropriate. METHODS An independent expert panel formulated recommendations on the use in T2D of the premix insulin analog formulations widely available in Australasia, based on the available evidence and their own experience. RESULTS Results from trials in both initiation and intensification of insulin show that no single insulin or regimen is best on all endpoints, and that improved glycemic control can be expected regardless of which regimen is used. Thus, individual patient factors and preferences become more important. Guidance is presented to help the clinician choose between a premix insulin analog or basal analog for insulin initiation, and to intensify insulin therapy using premix insulin analogs. Recommendations are made on dosing, titration, the concomitant use of non-insulin glucose-lowering drugs, and other practical issues, and on the special case of switching from basal-bolus to premix insulin analog therapy. CONCLUSION This guidance is intended to help both general and specialist practitioners make informed choices and provide optimal care for patients with T2D. It emphasizes the importance of taking into account individual patient factors and preferences so that the choice of insulin regimen is individualized to the patient in the same way that glycemic targets are now individualized. FUNDING Novo Nordisk Region IO A/S.
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Affiliation(s)
- Ted Wu
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia.
| | - Bryan Betty
- Porirua Union and Community Health Service, Cannons Creek, Porirua City, New Zealand
| | | | - Manish Khanolkar
- Auckland District Health Board Diabetes Centre, Greenlane Clinical Centre, Auckland, New Zealand
| | - Gary Kilov
- The Seaport Practice, Launceston, TAS, Australia
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20
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Fu H, Cao D, Boye KS, Curtis B, Schuster DL, Kendall DM, Ascher-Svanum H. Early Glycemic Response Predicts Achievement of Subsequent Treatment Targets in the Treatment of Type 2 Diabetes: A Post hoc Analysis. Diabetes Ther 2015; 6:317-28. [PMID: 26142890 PMCID: PMC4575302 DOI: 10.1007/s13300-015-0119-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION American Diabetes Association consensus guidelines emphasize individualized treatment in the management of type 2 diabetes mellitus (T2DM). Early glycemic response is a clinical marker that may predict longer term efficacy for individual patients and provide a clinical tool to enhance personalized treatment. This analysis evaluated whether glycemic response measured at week 12 ("early") could serve as a reliable predictor of glycemic control at weeks 24 and 52 of therapy in patients with T2DM. METHODS We used data from 3 randomized, controlled clinical trials that evaluated patients with T2DM treated with 3 commonly prescribed glucose-lowering medications: metformin (n = 597), sulfonylurea (n = 626), and insulin glargine (n = 1046). The gradient boosting method was used to identify predictors of subsequent response; predictive accuracy was represented by sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Treatment success at weeks 24 and 52 was assessed for each patient and defined as achieving a glycated hemoglobin (HbA1c) level of <7.0% or a reduction from baseline of ≥1.0%. RESULTS The predictive parameters (sensitivity, specificity, PPV, and NPV) for improvements in HbA1c at week 24 for metformin were 0.83, 0.81, 0.44, and 0.96; for sulfonylurea, 0.79, 0.94, 0.71, and 0.96; and for insulin glargine, 0.67, 0.89, 0.65, and 0.90. The predictive parameters for improvements in HbA1c at week 52 for metformin were 0.73, 0.84, 0.56, and 0.92 and for sulfonylurea, 0.45, 0.94, 0.74, and 0.82. CONCLUSION High predictive values identified in this analysis support "early" response as an appropriate tool for predicting treatment success at weeks 24 and 52. The high NPV (lack of early glycemic response) appears to be an effective indicator of the likely need for change in (or intensification of) therapy. These data support the current guideline recommendations that clinicians evaluate therapeutic responses to pharmacologic interventions with metformin, sulfonylureas, or insulin glargine as early as week 12.
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Affiliation(s)
- Haoda Fu
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA.
| | - Dachuang Cao
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA
| | - Kristina S Boye
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA
| | - Bradley Curtis
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA
| | - Dara L Schuster
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA
| | - David M Kendall
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA
| | - Haya Ascher-Svanum
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA
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21
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Lin SD, Tsai ST, Tu ST, Su CC, Chen JF, Lu CH, Wang CH, Yu NC, Hsu SR, Hsieh MC. Glycosylated hemoglobin level and number of oral antidiabetic drugs predict whether or not glycemic target is achieved in insulin-requiring type 2 diabetes. Prim Care Diabetes 2015; 9:135-141. [PMID: 25266893 DOI: 10.1016/j.pcd.2014.05.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Revised: 03/19/2014] [Accepted: 05/27/2014] [Indexed: 01/10/2023]
Abstract
AIMS Factors predicting success (glycosylated hemoglobin (A1C)<7%) with insulin therapy in patients with insulin-requiring type 2 diabetes need to be identified. METHODS A retrospective, multi-center, observational study was conducted for outpatients with oral antidiabetic drug (OAD)-treated type 2 diabetes whose A1C levels remained above 7%. Patients were begun on basal insulin between January 2005 and December 2006. Biochemical variables and demographic data were collected before and after 52 weeks of insulin therapy. RESULTS A total of 565 patients (age, 60.4±11.9 years; A1C levels, 10.11 ±1.81%; duration of diabetes, 11.5±6.8 years) were studied. By study end, 63 patients (11.2%) had achieved the glycemic goal (A1C<7%). The glycemic goal attainment rate was only 9.1% in patients with A1C>8.8% and who were taking >2 OADs at baseline. The highest rate (32.7%) of successful glycemic control was observed in the group of patients with A1C ≤ 8.8% and who used ≤ 2 OADs at baseline. CONCLUSIONS Insulin-naïve diabetic patients with A1C>8.8%, especially those who are taking >2 OADs, have small chance to achieve good glycemic control with adding only basal insulin therapy.
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Affiliation(s)
- Shi-Dou Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Shih-Tzer Tsai
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Te Tu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Ching-Chieh Su
- Department of Medicine, Cardinal Tien Hospital, New Taipei city, Taiwan; The Graduate Institute of Applied Science and Engineering, Fu-Jen Catholic University, New Taipei City, Taiwan
| | - Jung-Fu Chen
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chieh-Hsiang Lu
- Department of Internal Medicine, Chiayi Christian Hospital, Chiayi, Taiwan; Department of Business Administration, National Chung Cheng University, Tainan, Taiwan
| | - Chao-Hung Wang
- Department of Endocrinology and Metabolism, Mackay Memorial Hospital, Taipei, Taiwan
| | - Neng-Chun Yu
- Yu Neng-Chun Diabetes Clinic, I-Lan County, Taiwan
| | - Shang-Ren Hsu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Ming-Chia Hsieh
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan; College of Medicine, Chung Shan Medical University, Taichung, Taiwan; Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan.
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22
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Fu H, Luo J, Qu Y. Hypoglycemic events analysis via recurrent time-to-event (HEART) models. J Biopharm Stat 2014; 26:280-98. [DOI: 10.1080/10543406.2014.992524] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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23
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Jovanovič L, Peters AL, Jiang HH, Hardin DS. Durability of glycemic control with insulin lispro mix 75/25 versus insulin glargine for older patients with type 2 diabetes. Aging Clin Exp Res 2014; 26:115-21. [PMID: 24092662 PMCID: PMC3955127 DOI: 10.1007/s40520-013-0140-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 09/02/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Few studies have evaluated long-term durability of glycemic control in older patients. The aim of this study was to compare durability of glycemic control of twice-daily insulin lispro mix 75/25 (LM75/25; 75 % insulin lispro protamine suspension, 25 % insulin lispro) and once-daily insulin glargine (GL) added to oral antihyperglycemic medications in older patients (≥65 years of age). METHODS Patients were participants in the maintenance phase of the DURABLE trial. During the initiation phase, patients with type 2 diabetes were randomized to LM75/25 or GL. After 6 months, patients with hemoglobin A1c (HbA1c) ≤7.0 % advanced to the 24-month maintenance phase. The primary objective was between-group comparison of duration of maintaining the HbA1c goal in older patients (≥65 years of age). A similar analysis was conducted for older patients achieving HbA1c ≤6.5 % in the initiation phase. RESULTS Median time of maintaining HbA1c goal was longer in LM75/25 versus GL (19.6 versus 15.4 months, p = 0.007) and more LM75/25 patients maintained goal versus GL (49.2 versus 30.4 %; p = 0.003). HbA1c reduction from baseline was greater in LM75/25 versus GL (-1.56 ± 0.10 versus -1.24 ± 0.11 %; p = 0.003). Post-meal glucose was significantly lower in LM75/25 versus GL (158.86 ± 3.42 versus 171.67 ± 4.51 mg/dL; p = 0.017). No differences were observed in overall and severe hypoglycemia. LM75/25 patients had higher daily insulin doses (0.41 ± 0.02 versus 0.32 ± 0.02 units/kg/day; p < 0.001) and more weight gain (5.47 ± 0.49 versus 3.10 ± 0.53 kg; p = 0.001). Similar results were generally obtained in older patients with HbA1c ≤6.5 %. CONCLUSIONS In our evaluation of older patients from a larger trial, LM75/25 appeared to provide longer durability of glycemic control, as well as a greater number of patients maintaining HbA1c goal versus GL.
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Affiliation(s)
- Lois Jovanovič
- Sansum Diabetes Research Institute, Santa Barbara, CA USA
| | - Anne L. Peters
- University of Southern California Keck School of Medicine, Los Angeles, CA USA
| | - Honghua H. Jiang
- Eli Lilly and Company, Lilly Corporate Center, Drop Code 223, Indianapolis, IN 46285 USA
| | - Dana S. Hardin
- Eli Lilly and Company, Lilly Corporate Center, Drop Code 223, Indianapolis, IN 46285 USA
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24
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Elizarova S, Galstyan GR, Wolffenbuttel BHR. Role of premixed insulin analogues in the treatment of patients with type 2 diabetes mellitus: a narrative review. J Diabetes 2014; 6:100-10. [PMID: 24127999 PMCID: PMC4285786 DOI: 10.1111/1753-0407.12096] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 09/30/2013] [Accepted: 10/09/2013] [Indexed: 01/10/2023] Open
Abstract
Because of the progressive nature of type 2 diabetes mellitus (T2DM), insulin therapy will eventually become necessary in most patients. Recent evidence suggests that maintaining optimal glycemic control by early insulin therapy can reduce the risk of microvascular and macrovascular complications in patients with T2DM. The present review focuses on relevant clinical evidence supporting the use of premixed insulin analogues in T2DM when intensifying therapy, and as starter insulins in insulin-naïve patients. Our aim is to provide relevant facts and clinical evidence useful in the decision-making process of treatment selection and individualized treatment goal setting to obtain sustained blood glucose control.
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Affiliation(s)
- Svetlana Elizarova
- Department of Endocrinology, Eli Lilly Vostok S.A.Moscow, Russian Federation
| | | | - Bruce HR Wolffenbuttel
- Department of Endocrinology, University of Groningen, University Medical Center GroningenThe Netherlands
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25
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Tambascia MA, Nery M, Gross JL, Ermetice MN, de Oliveira CP. Evidence-based clinical use of insulin premixtures. Diabetol Metab Syndr 2013; 5:50. [PMID: 24011173 PMCID: PMC4016222 DOI: 10.1186/1758-5996-5-50] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 05/17/2013] [Indexed: 01/04/2023] Open
Abstract
Brazil is expected to have 19.6 million patients with diabetes by the year 2030. A key concept in the treatment of type 2 diabetes mellitus (T2DM) is establishing individualized glycemic goals based on each patient's clinical characteristics, which impact the choice of antihyperglycemic therapy. Targets for glycemic control, including fasting blood glucose, postprandial blood glucose, and glycated hemoglobin (A1C), are often not reached solely with antihyperglycemic therapy, and insulin therapy is often required. Basal insulin is considered an initial strategy; however, premixed insulins are convenient and are equally or more effective, especially for patients who require both basal and prandial control but desire a more simplified strategy involving fewer daily injections than a basal-bolus regimen. Most physicians are reluctant to transition patients to insulin treatment due to inappropriate assumptions and insufficient information. We conducted a nonsystematic review in PubMed and identified the most relevant and recently published articles that compared the use of premixed insulin versus basal insulin analogues used alone or in combination with rapid-acting insulin analogues before meals in patients with T2DM. These studies suggest that premixed insulin analogues are equally or more effective in reducing A1C compared to basal insulin analogues alone in spite of the small increase in the risk of nonsevere hypoglycemic events and nonclinically significant weight gain. Premixed insulin analogues can be used in insulin-naïve patients, in patients already on basal insulin therapy, and those using basal-bolus therapy who are noncompliant with blood glucose self-monitoring and titration of multiple insulin doses. We additionally provide practical aspects related to titration for the specific premixed insulin analogue formulations commercially available in Brazil.
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Affiliation(s)
- Marcos Antônio Tambascia
- Faculty of Medical Sciences, State University of Campinas, Brazil Rua Frei Manoel da Ressurreição 965, Campinas, SP, Brazil
| | - Márcia Nery
- Diabetes Unit - Endocrinology and Metabolism Service, Clinical Hospital of Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Jorge Luiz Gross
- Department of Internal Medicine, Faculty of Medicine of Federal University of Rio Grande do Sul, Rio Grande do Sul, Brazil
| | - Mariana Narbot Ermetice
- Diabetes Group, Eli Lilly do Brazil São Paulo, São Paulo, Brazil
- Currently at Novo Nordisk Brazil, São Paulo, Brazil
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26
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Zhao Y, Shen W, Fu H. Joint modeling of clinical efficacy and safety with an application to diabetes studies. J Biopharm Stat 2013; 23:1155-71. [PMID: 23957521 DOI: 10.1080/10543406.2013.813520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The purpose of drug development is to evaluate a drug's efficacy and safety profile. For a personalized medicine, it is important for patients and health care providers to understand the efficacy and safety trade-off when selecting a dose for a patient. In this article, we propose three different methods for jointly modeling the clinical safety and efficacy endpoints. These three methods model the correlation relationship in three different ways: modeling the joint distribution by a copula method, modeling conditional distributions, and modeling their correlations through individual means by a hierarchical model. We compare these three methods through simulations and apply these methods to a data set from a diabetes study.
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Affiliation(s)
- Yang Zhao
- Department of Statistics, University of Wisconsin-Madison, Madison, Wisconsin, USA
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27
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Meneghini L, Kesavadev J, Demissie M, Nazeri A, Hollander P. Once-daily initiation of basal insulin as add-on to metformin: a 26-week, randomized, treat-to-target trial comparing insulin detemir with insulin glargine in patients with type 2 diabetes. Diabetes Obes Metab 2013; 15:729-36. [PMID: 23421331 DOI: 10.1111/dom.12083] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 07/05/2012] [Accepted: 02/12/2013] [Indexed: 11/29/2022]
Abstract
AIMS This study assessed the efficacy and safety of once-daily insulin initiation using insulin detemir (detemir) or insulin glargine (glargine) added to existing metformin in type 2 diabetes (T2D). METHODS This 26-week, multinational, randomized, treat-to-target trial involved 457 insulin-naïve adults with T2D (HbA1c 7-9%). Detemir or glargine was added to current metformin therapy [any second oral antidiabetic drug (OAD) discontinued] and titrated to a target fasting plasma glucose (FPG) ≤90 mg/dl (≤5.0 mmol/l). Primary efficacy endpoint was change in HbA1c. RESULTS Mean (s.d.) HbA1c decreased with detemir and glargine by 0.48 and 0.74%-points, respectively, to 7.48% (0.91%) and 7.13% (0.72%) [estimated between-treatment difference, 0.30 (95% CI: 0.14-0.46)]. Non-inferiority for detemir at the a priori level of 0.4%-points was not established. The proportions of patients reaching HbA1c ≤ 7% at 26 weeks were 38% and 53% (p = 0.026) with detemir and glargine, respectively. FPG decreased ∼43.2 mg/dl (∼2.4 mmol/l) in both groups [non-significant (NS)]. Treatment satisfaction was good for both insulins. Hypoglycaemia, which occurred infrequently, was observed less with detemir than glargine [rate ratio 0.73 (95% CI 0.54-0.98)]. The proportions of patients reaching HbA1c ≤ 7% without hypoglycaemia in the detemir and glargine groups were 32% and 38% (NS), respectively. Weight decreased with detemir [-0.49 (3.3) kg] and increased with glargine [+1.0 (3.1) kg] (95% CI for difference: -2.17 to -0.89 kg). CONCLUSION While both detemir and glargine, when added to metformin therapy, improved glycaemic control, glargine resulted in greater reductions in HbA1c, while detemir demonstrated less weight gain and hypoglycaemia.
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Affiliation(s)
- L Meneghini
- Division of Endocrinology, Diabetes & Metabolism, University of Miami Miller School of Medicine, Miami, FL, USA.
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Rosenstock J, Shenouda SK, Bergenstal RM, Buse JB, Glass LC, Heilmann CR, Kwan AYM, MacConell LA, Hoogwerf BJ. Baseline factors associated with glycemic control and weight loss when exenatide twice daily is added to optimized insulin glargine in patients with type 2 diabetes. Diabetes Care 2012; 35:955-8. [PMID: 22432107 PMCID: PMC3329851 DOI: 10.2337/dc11-1434] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine variables associated with glycemic and body weight responses when adding exenatide to basal insulin-treated type 2 diabetes. RESEARCH DESIGN AND METHODS Exploratory subgroup analyses based on baseline A1C, disease duration, and BMI of a 30-week study comparing exenatide twice daily to placebo, added to optimized insulin glargine (intent-to-treat analysis: 137 exenatide; 122 placebo). RESULTS Exenatide participants had greater A1C reductions compared with optimized insulin glargine alone, irrespective of baseline A1C (P < 0.001). Exenatide participants with longer diabetes duration and those with lower BMI had greater A1C reductions (P < 0.01). Exenatide participants lost more weight, regardless of baseline A1C or BMI (P < 0.05). Exenatide participants with longer diabetes duration lost the most weight (P < 0.001). CONCLUSIONS Exenatide added to optimized basal insulin was associated with improved glycemic control and weight loss, irrespective of baseline A1C, diabetes duration, and BMI. Changes were evident in modestly obese patients and in those with longer diabetes duration.
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Affiliation(s)
- Julio Rosenstock
- Dallas Diabetes and Endocrine Center at Medical City, Dallas, Texas; 2Eli Lilly and Company,Indianapolis, Indiana, USA
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29
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Abstract
Type 2 diabetes is characterized by insulin resistance and impaired insulin secretion at diagnosis and by progressive β-cell dysfunction over time. Insulin therapy is thus frequently required during the course of the disease to maintain glycemic control and prevent diabetes complications. Insulin should be initiated when alternative antihyperglycemic agents have failed or when symptomatic or marked hyperglycemia is present. Recent studies demonstrate that the addition of basal, prandial, basal/bolus, or premixed insulins to existing antihyperglycemic regimens effectively lowers glycosylated hemoglobin (HbA(1c)). The long-acting insulin analogs cause less nocturnal hypoglycemia than bedtime NPH, with comparable HbA(1c) reductions. Insulin detemir confers a weight advantage over glargine or NPH. Rapid-acting insulin analogs control postprandial hyperglycemia more effectively than regular insulin and modestly lower HbA(1c). For selected patients with severe insulin resistance, U-500 is a less expensive and potentially more effective alternative to U-100 insulin. Adverse effects of insulin, including weight gain and hypoglycemia, can be minimized by initial use of basal insulins in combination with metformin, incretin mimetics, or dipeptidyl-peptidase-IV inhibitors. Although in vitro studies suggest that hyperinsulinemia may promote tumorigenesis, no currently available insulin has been shown to increase cancer rates. Targeting near-normal glucose levels in insulin-treated patients should be reserved for those of younger age with a longer life expectancy, a shorter duration of diabetes, and little or no end-organ complications. A higher HbA(1c) target of 7-8% is more appropriate for patients less likely to benefit from intensive control and in those at high risk for severe hypoglycemia.
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Affiliation(s)
- Thomas Donner
- Division of Endocrinology and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA.
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30
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Abstract
Health care providers and patients have lots of choice to treat type 2 diabetes, but the blood glucose improvement is limited. The one therapy with unlimited potential (at least theoretically) is insulin. Many studies show that glucose control is achievable with insulin safely in most patients with type 2 diabetes. Effective diabetes management at the primary care or specialty level requires a belief in the importance of insulin therapy in uncontrolled patients with type 2 diabetes. This review details the theories, observed outcomes, and how-tos regarding insulin use in type 2 diabetes.
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Affiliation(s)
- Jack L Leahy
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Vermont, Colchester Research Facility, Room 110, 208 South Park Drive, Colchester, VT 05446, USA
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31
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Intensifying Insulin Therapy in Type 2 Diabetes Mellitus: Dosing Options for Insulin Analogue Premixes. Clin Ther 2011; 33:1630-42. [DOI: 10.1016/j.clinthera.2011.09.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Revised: 09/14/2011] [Accepted: 09/15/2011] [Indexed: 01/20/2023]
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