Insights into optimal basal insulin titration in type 2 diabetes: Results of a quantitative survey

Abstract

AimsBasal insulin (BI) treatment initiation and dose titration in type 2 diabetes (T2DM) are often delayed. Such “clinical inertia” results in poor glycaemic control and high risk of long‐term complications. This survey aimed to determine healthcare professional (HCP) and patient attitudes to BI initiation and titration.MethodsAn online survey (July–August 2015) including HCPs and patients with T2DM in the USA, France and Germany. Patients were ≥18 years old and had been on BI for 6 to 36 months, or discontinued BI within the previous 12 months.ResultsParticipants comprised 386 HCPs and 318 people with T2DM. While >75% of HCPs reported discussing titration at the initiation visit, only 16% to 28% of patients remembered such discussions, many (32%–42%) were unaware of the need to titrate BI, and only 28% to 39% recalled mention of the time needed to reach glycaemic goals. Most HCPs and patients agreed that more effective support tools to assist BI initiation/titration are needed; patients indicated that provision of such tools would increase confidence in self‐titration. HCPs identified fear of hypoglycaemia, failure to titrate in the absence of symptoms, and low patient motivation as important titration barriers. In contrast, patients identified weight gain, the perception that titration meant worsening disease, frustration over the time to reach HbA1c goals and fear of hypoglycaemia as major factors.ConclusionA disconnect exists between HCP‐ and patient‐perceived barriers to effective BI titration. To optimize titration, strategies should be targeted to improve HCP–patient communication, and provide support and educational tools.

Hypoglycaemia and treatment patterns among insulin‐treated patients with type 2 diabetes who switched to insulin glargine 300 units/mL versus other basal insulin in a real‐world setting

“…This combined with lower levels of hypoglycaemia seen in Gla‐300 switchers may contribute to better persistence, as patients who are concerned about hypoglycaemia are more likely to discontinue their insulin therapy. In addition, both patients who are not achieving their A1C targets, and their physicians, cite hypoglycaemia as a barrier to effective insulin titration …”

Take Control: A randomized trial evaluating the efficacy and safety of self‐ versus physician‐managed titration of insulin glargine 300 U/mL in patients with uncontrolled type 2 diabetes

“…Achieving glycated haemoglobin (HbA1c) targets reduces the risk of long‐term complications of diabetes, but in real‐world practice many individuals with type 2 diabetes (T2DM) fail to achieve adequate glycaemic control . Poor glycaemic control can be a result of clinical inertia, which may be contributed to by several physician‐ and patient‐related barriers including fear of hypoglycaemia and/or weight gain, burdensome treatment regimens, poor persistence to injectable therapies, lack of time for healthcare professionals to teach and difficulty for patients to understand the importance and performance of appropriate titration, frustration at time taken to achieve goals, insufficient communication between healthcare professionals and patients, and anxiety . As the disease progresses, lack of glycaemic control may also indicate the need to initiate adjunctive therapies…”

“…[2][3][4] Poor glycaemic control can be a result of clinical inertia, which may be contributed to by several physician-and patient-related barriers including fear of hypoglycaemia and/or weight gain, burdensome treatment regimens, poor persistence to injectable therapies, lack of time for healthcare professionals to teach and difficulty for patients to understand the importance and performance of appropriate titration, frustration at time taken to achieve goals, insufficient communication between healthcare professionals and patients, and anxiety. [5][6][7][8][9][10] As the disease progresses, lack of glycaemic control may also indicate the need to initiate adjunctive therapies. 11 Empowering those with T2DM to take a more active role in their own treatment may help individuals to achieve their glycaemic goals and reduce the risk of all-cause mortality, 12,13 which could reduce lifetime costs of complications and hospital admissions, 14 and might help to address the increasing burden of diabetes on healthcare systems worldwide.…”

Early hypoglycaemia and adherence after basal insulin initiation in a nationally representative sample of Medicare beneficiaries with type 2 diabetes

“…Among patients with type 2 diabetes who initiate BI, only about 30% achieve their individual glycaemic target, primarily because a fear of hypoglycaemia limits proper titration . Additionally, patients who are concerned about hypoglycaemia are more likely to discontinue their insulin therapy …”