Starting Insulin in Type 2 Diabetes: Real-World Outcomes After the First 12 Months of Insulin Therapy in a New Zealand Cohort

Abstract

AimsCurrently, there is no consensus on which form of insulin to use when initiating insulin in type 2 diabetes (T2D). Our aim was to compare glycated hemoglobin (HbA1C) reduction, weight change and severe hypoglycemia rates during the first year after initiation of intermediate-acting insulin isophane, insulin glargine and pre-mixed insulin in patients with T2D.MethodsElectronic clinical records of patients with T2D, starting insulin at a tertiary referral center in Auckland, New Zealand, from January 1 to December 31, 2012, were retrospectively evaluated. Primary outcomes were HbA1C reduction at 12 months and number of hospital admissions for hypoglycemia.ResultsOf 339 eligible patients, 273 (80.5%) started on intermediate insulin, 24 started on insulin glargine and 42 started on pre-mixed insulin. The mean HbA1C at insulin initiation was 89–95 mmol/mol, but had decreased at 12 months by 26.6 mmol/mol with insulin glargine, 23.4 mmol/mol with pre-mixed insulin and 16.6 mmol/mol with insulin isophane (p < 0.05 vs. baseline for all groups). Patients on insulin glargine were more likely to achieve the HbA1C target of <55 mmol/mol compared with patients on insulin isophane (16.7% vs. 4.8%; p = 0.04). Persistence rates were higher in patients initiated on pre-mixed insulin vs. insulin isophane (90.5% vs. 69.6%; p = 0.01). After controlling for confounding variables, glargine was more likely to achieve an HbA1C target of <55 (p = 0.05).ConclusionsAll insulin types caused a significant reduction in HbA1C, but very few met HbA1C targets. Insulin isophane was the most common type of insulin prescribed at initiation, with comparable outcomes to other types of insulin. More observational studies are needed to explore the possible impact of using other insulin types at initiation.Electronic supplementary materialThe online version of this article (doi:10.1007/s13300-015-0100-8) contains supplementary material, which is available to authorized users.

Identification of barriers to insulin therapy and approaches to overcoming them

“…57 Ideally, these discussions would Studies indicate that once treatment with basal insulin has been initiated, glycaemic control is still not achieved in the majority of cases 78,79 and that this is partly attributable to insufficient titration of insulin. 33,44 A study by Blak et al, 78 Germany, 80 New Zealand 81 and China. 82 This is in contrast to data from the plethora of clinical trials 74,75 that entail close monitoring by trial staff of motivated participants following strict titration algorithms.…”

“…A study by Blak et al, in 2012, revealed that only 17.3% of participants achieved HbA1c <7% (53 mmol/mol) after a mean follow‐up of 2.9 years, while 141 (41%) participants in a study by Dale et al, in 2010, achieved the pre‐2006/2007 UK Quality and Outcomes Framework target of ≤7.4% (57 mmol/mol) after 36 months of basal insulin therapy. In addition, modest titration of basal insulin in a real‐world setting has been observed in studies from Germany, New Zealand and China . This is in contrast to data from the plethora of clinical trials that entail close monitoring by trial staff of motivated participants following strict titration algorithms .…”

“…In addition, HCPs might not adequately direct or encourage aggressive titration in patients for whom this would be beneficial, either because of a lack of resources or in response to patient concerns. It is not always clear whether the lack of titration observed in real‐world studies is as a result of reluctance/inaction by the HCP or the patient, or both . A recent systematic review of real‐world factors affecting adherence to insulin therapy in people with diabetes identified predictive factors for adherence vs non‐adherence.…”

“…It is not always clear whether the lack of titration observed in real-world studies is as a result of reluctance/inaction by the HCP or the patient, or both. [80][81][82] A recent systematic review of real-world factors affecting adherence to insulin therapy in people with diabetes identified predictive factors for adherence vs non-adherence. Negative predictors of adherence included being a student, needing a large number of injections, diagnosis of T2D vs type 1 diabetes, and lower HbA1c level.…”

Higher versus standard starting dose of insulin glargine 100 U/mL in overweight or obese Chinese patients with type 2 diabetes: Results of a multicentre, open‐label, randomized controlled trial (BEYOND VII)

“…ORBIT was the largest observational study of basal insulin utility in China, which showed that the dose of basal insulin among patients with uncontrolled T2D increased by only 0.034 U/kg/d during 6 months after treatment initiation, with a mean starting dose of 0.18 ± 0.07 U/kg/d . Observational studies from other countries have also reported that, 1 year after treatment initiation, basal insulin only increased by 0.1 U/kg/d.…”