A Behavioral Perspective of Therapeutic Inertia: A Look at the Transition to Insulin Therapy

Insulin initiation for patients with poorly controlled type 2 diabetes mellitus

BACKGROUND

We examined the initiation of insulin therapy in patients with poorly controlled type 2 diabetes mellitus (T2DM), analyzed their glycemic responses, and compared patient profiles based on glycemic outcomes.

METHODS

Patients with T2DM initiated on insulin therapy were retrospectively analyzed. Data were collected from endocrinology clinic before and 3 and 6 months after insulin initiation. The primary outcome was hemoglobin A1c (HbA1c) level 6 months after commencing insulin treatment. Secondary outcomes included HbA1c levels at 3 months after insulin treatment and fasting blood glucose levels at 3 and 6 months after treatment. We analyzed the effects of insulin initiation and categorized patients based on their 6-month HbA1c levels: below the median of 7.8% (better response) and above 7.8% (worse response). Additionally, we evaluated patients based on HbA1c changes at 6 months, with greater or lesser changes defined by the cohort's median change of -1.4%.

RESULTS

Insulin therapy significantly reduced HbA1c (from 9.8% to 8.2%) and fasting blood glucose levels (from 221.4 to 147.2 mg/dL) within 3 months. After 6 months, HbA1c and fasting blood glucose levels decreased by 2.1% (9.8%-7.7%) and 77.2 mg/dL (221.4-144.2 mg/dL), respectively. Patients who responded better to insulin treatment showed lower fasting blood glucose levels by 6 months after insulin initiation and lower HbA1c levels as soon as 3 months after initiation. Patients with higher baseline glycemic profiles experienced significantly greater HbA1c reductions at 6 months post-treatment.

CONCLUSION

Insulin therapy significantly improved glycemic control in patients with T2DM within 3 months after initiation. Patients with higher baseline glycemic profiles experienced greater responses to insulin therapy.

Pharmacokinetic and Pharmacodynamic Properties of Once-Weekly Insulin Efsitora Alfa in Japanese Patients with Type 2 Diabetes

INTRODUCTION

This analysis aimed to assess the safety and tolerability of insulin efsitora alfa (efsitora, basal insulin Fc, LY3209590) and characterize the pharmacokinetic and pharmacodynamic profiles of efsitora in Japanese patients with type 2 diabetes.

METHODS

The single-dose escalation study assessed once-weekly efsitora administration in three patient cohorts: 5 mg for cohort 1; 10 mg for cohort 2 or placebo under double-blind conditions; and 20 mg for cohort 3 under open-label conditions. In the 6-week, multiple-dose study, patients started or continued using insulin degludec during the lead-in period, followed by randomization to efsitora (individualized fixed weekly dose) or insulin degludec (individualized fixed daily dose). Pharmacokinetics, pharmacodynamics, and safety were examined.

RESULTS

The mean age was 58.3 and 58.4 years, and mean body mass index was 25.6 and 26.8 kg/m2 in the single-dose escalation (n = 31) and multiple-dose studies (n = 28), respectively. The pharmacokinetic profile showed a prolonged half-life of 15 to 16 days, with a low peak-to-trough ratio of 1.13 after the last dose with little fluctuation. All doses of efsitora (5, 10, and 20 mg) decreased mean fasting glucose levels from baseline to day 15 (single-dose study), with no notable changes observed after switching from insulin degludec (multiple-dose study). All treatment-emergent adverse events were mild and unrelated to the study drug. No severe hypoglycemic events were reported.

CONCLUSIONS

Efsitora was well tolerated, and the pharmacokinetic and pharmacodynamic profiles were consistent with findings in prior global studies, supporting the participation of Japanese patients in phase 3 studies.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03603704; NCT04276428.

The Use of Rescue Insulin in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE)

OBJECTIVE

To describe rescue insulin use and associated factors in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE).

RESEARCH DESIGN AND METHODS

GRADE participants (type 2 diabetes duration <10 years, baseline A1C 6.8%-8.5% on metformin monotherapy, N = 5,047) were randomly assigned to insulin glargine U-100, glimepiride, liraglutide, or sitagliptin and followed quarterly for a mean of 5 years. Rescue insulin (glargine or aspart) was to be started within 6 weeks of A1C >7.5%, confirmed. Reasons for delaying rescue insulin were reported by staff-completed survey.

RESULTS

Nearly one-half of GRADE participants (N = 2,387 [47.3%]) met the threshold for rescue insulin. Among participants assigned to glimepiride, liraglutide, or sitagliptin, rescue glargine was added by 69% (39% within 6 weeks). Rescue aspart was added by 44% of glargine-assigned participants (19% within 6 weeks) and by 30% of non-glargine-assigned participants (14% within 6 weeks). Higher A1C values were associated with adding rescue insulin. Intention to change health behaviors (diet/lifestyle, adherence to current treatment) and not wanting to take insulin were among the most common reasons reported for not adding rescue insulin within 6 weeks.

CONCLUSIONS

Proportionately, rescue glargine, when required, was more often used than rescue aspart, and higher A1C values were associated with greater rescue insulin use. Wanting to use noninsulin strategies to improve glycemia was commonly reported, although multiple factors likely contributed to not using rescue insulin. These findings highlight the persistent challenge of intensifying type 2 diabetes treatment with insulin, even in a clinical trial.

Advancing Health Equity in Diabetes: Tools to Help Remove Barriers to Health

People living with diabetes and their health care teams face an endless number of care decisions that are often compounded by limited access to needed resources, especially adequate food, medications, and monitoring tools.1 Registered dietitians, as diabetes care and education specialists and as members of care teams, can help assess what barriers exist and how they can best be mitigated both in the short- and long term.2 Examples of health equity challenges and tools to support efforts in type 2 diabetes (T2D) prevention and diabetes management are presented.

Pharmacokinetic and pharmacodynamic properties of the novel basal insulin Fc (insulin efsitora alfa), an insulin fusion protein in development for once-weekly dosing for the treatment of patients with diabetes

AIM

To assess the safety, tolerability, pharmacokinetics (PK) and pharmacodynamics (PD) of basal insulin Fc (BIF; LY3209590), a fusion protein combining a novel single-chain insulin variant together with human IgG2 Fc domain, following single and multiple once-weekly BIF administration.

MATERIALS AND METHODS

The single ascending dose, 15-day study assessed four BIF doses (5-35 mg) in healthy participants and people with type 2 diabetes (T2D). In the 6-week multiple ascending dose study, people with T2D, previously treated with basal insulin, received insulin glargine daily or a one-time loading dose of BIF followed by 5 weeks of once-weekly dosing (1-10 mg). Safety, tolerability and PK and glucose PD were examined.

RESULTS

Mean ages of people with T2D (N = 57) and healthy participants (N = 16) in the single-dose study were 58.4 and 35.8 years, respectively; mean body mass index values were 29.5 and 26.1 kg/m² . BIF had a PK half-life of approximately 17 days, which led to a sustained, dose-dependent decrease in fasting blood glucose for 5 days or longer. No severe hypoglycaemia was observed. The 6-week ascending dose study included 33 people with T2D aged 40-69 years. BIF showed a low peak-to-trough ratio of 1.14 after the last dose at week 6 (steady state). Over 6 weeks, BIF seven-point glucose profiles remained constant and were similar to insulin glargine. Rates and duration of BIF hypoglycaemic events were similar to insulin glargine.

CONCLUSIONS

BIF was well tolerated and the PK/PD profile enabled once-weekly dosing with minimal variation in exposure in a treatment interval of 1 week. The findings suggest BIF is suitable for further development as a weekly basal insulin in people with diabetes.

Basal weekly insulins: the way of the future!

Basal insulin treatment is indispensable for patients with type 1 diabetes and often required by many with type 2 diabetes. Incremental advances lengthening the duration of action of insulin analogs and reducing pharmacodynamic variability have resulted in truly once-daily, long-acting basal insulin analogs. In the quest for better basal insulins to facilitate improvements in glycemic control and long-term outcomes, the driving need is to remove barriers delaying timely initiation of basal insulin, to maximize treatment adherence and persistence and reduce treatment burden without increasing risk of hypoglycemia. We review the range of investigational once-weekly insulins and their molecular strategies and profiles. Currently, the two most advanced clinical development programs are: (1) basal insulin icodec, an insulin analog acylated with a C20 fatty diacid (icosanedioic acid) side chain (Novo Nordisk) and (2) basal insulin Fc, a fusion protein that combines a single-chain insulin variant with a human immunoglobulin G fragment crystallizable domain (Eli Lilly). Available phase 2 data for these two once-weekly agents show comparable glycemic control to existing once-daily insulin analogs, with no greater risk of hypoglycemia. While phase 3 data are awaited to confirm efficacy and safety, we provide future clinical perspectives on practical considerations for the potential use of once-weekly insulins.

Patient-physician interpersonal processes of care at the time of diabetes treatment intensification and their links to patient outcomes

OBJECTIVE

To investigate how patient-physician interpersonal processes of care are related to levels of diabetes-related distress, diabetes medication-taking behavior, and HbA1c during conversations with patients about intensifying medication.

METHODS

We randomly recruited 1270 patients from diabetes specialty clinics in Tehran, Iran who were taking an additional oral diabetes medication or starting insulin during the prior 3 months. This interviewer-administered cross-sectional survey assessed multiple aspects of patient-physician interpersonal processes, diabetes-related distress, and diabetes medication-taking. Clinical history and HbA1c were collected from electronic medical records. Regression estimates and Structural Equation Modeling were used to test associations.

RESULTS

Some communication scales indicated a significant relationship with total diabetes distress (P < 0.001). Diabetes medication-taking was associated with less diabetes distress (adjusted odds ratio [aOR]=0.45, P < 0.001), lower Hurried Communication (aOR=0.72, P = 0.013), higher Elicited Concerns (aOR=1.30, P = 0.012), and higher Explained Results (aOR=1.41, P < 0.001) scores. SEM analyses showed medication-taking behavior was associated with a 0.68 decrease in HbA1c. Hurried Communication and diabetes distress were directly associated with HbA1c.

CONCLUSION

Aspects of patient-physician interpersonal processes at the time of intensifying diabetes treatment may be related to experiencing less distress, effective medication-taking, and improved HbA1c.

PRACTICE IMPLICATIONS

The results are intended to inform communication strategies that physicians might incorporate into practice.