Are patients on basal insulin attaining glycemic targets? Characteristics and goal achievement of patients with type 2 diabetes mellitus treated with basal insulin and physician-perceived barriers to achieving glycemic targets

Dalal, Mehul; Grabner, Michael; Bonine, Nicole; Stephenson, Judith J.; Digenio, Andrés; Bieszk, Nella

doi:10.1016/j.diabres.2016.08.004

Cited by 54 publications

(58 citation statements)

References 23 publications

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“…It should be noted that glycaemic goal attainment was quite poor (12%-30%) in all cohorts in the current study-this is in line with a previous US claims database analysis by Dalal et al,18 in which 27% of patients who initiated BI reached A1C <7.0%. It is also in line with National Health and Nutrition Examination Surveys (NHANES) data, in which 30% of diabetes patients on insulin attained A1C <7.0%.…”

Section: Discussionsupporting

confidence: 90%

Clinical implications of prolonged hyperglycaemia before basal insulin initiation in type 2 diabetes patients: An electronic medical record database analysis

Raccah

Guerci

Ajmera

et al. 2019

Endocrino Diabet & Metabol

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Summary Aims To assess the effect of duration of hyperglycaemia before basal insulin (BI) initiation on clinical outcomes in type 2 diabetes (T2D). Materials and methods Patients with T2D who initiated BI during 2009‐2013, had continuous enrolment for ≥2 years preceding and ≥1 year following BI initiation (“index date”), and had ≥1 glycated haemoglobin (A1C) measure not at target (ie, ≥7.0%) within 6 months preindex date were included in the study. Patients were stratified by preindex‐date duration of A1C ≥7.0%. Longitudinal A1C, weight, BMI, and diabetes medication were compared between cohorts for up to 15‐month follow‐up. Results Of 37 053 patients who initiated BI, 40.7%, 15.3%, 16.0%, and 28.0%, respectively, had uncontrolled A1C for <6, 6‐<12, 12‐<18 and 18‐24 months preindex date. Baseline characteristics were similar between cohorts. Baseline A1C values were similar across cohorts (9.2%‐9.6%). Mean follow‐up A1C values were higher with longer preindex‐date duration of uncontrolled A1C (8.0 ± 1.7%, 8.2 ± 1.6%, 8.5 ± 1.7%, and 8.6 ± 1.7% for <6, 6‐<12, 12‐<18, and 18‐24 months); attainment of A1C <7.0% worsened with increasing preindex‐date duration of A1C ≥7.0% (29.6%, 20.0%, 14.6%, and 11.5% for <6, 6‐<12, 12‐<18, and 18‐24 months). Conclusions These data suggest that longer duration of uncontrolled A1C before BI initiation increases the risk of not reaching glycaemic targets. However, target attainment was poor in all cohorts, highlighting inadequate glycaemic control as an important unmet need in US patients with T2D.

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Section: Discussionsupporting

confidence: 90%

Clinical implications of prolonged hyperglycaemia before basal insulin initiation in type 2 diabetes patients: An electronic medical record database analysis

Raccah

Guerci

Ajmera

et al. 2019

Endocrino Diabet & Metabol

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“…34,35 This probably reflects real-world clinical practice, where clinical inertia and concern about body weight gain and increased hypoglycaemia with insulin uptitration may result in physician/patient reluctance to adhere to strict algorithms. 20,21 In summary, in patients with T2DM who were inadequately controlled despite titrated IG AE metformin, adding exenatide QW improved glycaemic measures and reduced body weight without major hypoglycaemia or unexpected safety findings. This suggests that exenatide QW represents a well-tolerated treatmentintensification option for patients with uncontrolled basal insulintreated T2DM.…”

Section: Discussionmentioning

confidence: 98%

Effect of exenatide QW or placebo, both added to titrated insulin glargine, in uncontrolled type 2 diabetes: The DURATION‐7 randomized study

Guja

Frías

Somogyi

et al. 2018

Diabetes Obesity Metabolism

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AimsTo compare the efficacy and safety of adding the glucagon‐like peptide‐1 receptor agonist exenatide once weekly (QW) 2 mg or placebo among patients with type 2 diabetes who were inadequately controlled despite titrated insulin glargine (IG) ± metformin.MethodsThis multicentre, double‐blind study (http://clinicaltrials.gov identifier: NCT02229383) randomized (1:1) patients with persistent hyperglycaemia after an 8‐week titration phase (glycated haemoglobin [HbA1c] 7.0%‐10.5% [53‐91 mmol/mol]) to exenatide QW or placebo. The primary endpoint was HbA1c change from baseline to week 28. Secondary endpoints included body weight, 2‐hour postprandial glucose, and mean daily IG dose.ResultsOf 464 randomized patients (mean: age, 58 years; HbA1c, 8.5% [69 mmol/mol]; diabetes duration, 11.3 years), 91% completed 28 weeks. Exenatide QW + IG vs placebo + IG significantly reduced HbA1c (least‐squares mean difference, −0.73% [−8.0 mmol/mol]; 95% confidence interval, −0.93%, −0.53% [−10.2, −5.8 mmol/mol]; P < .001; final HbA1c, 7.55% [59 mmol/mol] and 8.24% [67 mmol/mol], respectively); body weight (−1.50 kg; −2.17, −0.84; P < .001); and 2‐hour postprandial glucose (−1.52 mmol/L [−27.5 mg/dL]; −2.15, −0.90 [−38.7, −16.2]; P < .001). Significantly more exenatide QW + IG‐treated patients vs placebo + IG‐treated patients reached HbA1c <7.0% (<53 mmol/mol) (32.5% vs 7.4%; P < .001); daily IG dose increased by 2 and 4 units, respectively. Gastrointestinal and injection‐site adverse events were more frequent with exenatide QW + IG (15.1% and 7.8%, respectively) than with placebo + IG (10.8% and 3.0%, respectively); hypoglycaemia incidence was similar between the exenatide QW + IG (29.7%) and placebo + IG (29.0%) groups, with no major hypoglycaemic events.ConclusionsAmong patients with inadequate glycaemic control, exenatide QW significantly improved glucose control and decreased body weight, without increased hypoglycaemia or unexpected safety findings.

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“…8 The inclusion of 4000 patients allowed this percentage to be estimated with a precision of at least 1.5%, assuming that 15% of participants would be non-evaluable. 8 The inclusion of 4000 patients allowed this percentage to be estimated with a precision of at least 1.5%, assuming that 15% of participants would be non-evaluable.…”

Section: Data Analysis and Statisticsmentioning

confidence: 99%

“…Compared with participants who did not experience any events, those who experienced one, two to four or more than four events were significantly more likely (P < 0.05) to achieve target HbA1c ( While there were substantial reductions in HbA1c during the 12-week study in both newly and previously initiated patients, most participants failed to achieve their individualized HbA1c target, set at <7.5% (<58.5 mmol/mol) for 76% of patients. 8,25 By comparison, in treat-to-target trials with defined titration algorithms, close follow-up and careful monitoring, the proportion of participants achieving HbA1c targets of less than 7.0% (<53 mmol/mol) with BIs has been reported to be as much as 40% to 50%. 25 Notably, 63% of participants in this study were reportedly self-titrating their insulin, whereas, in wider clinical practice settings, it is likely that titration is largely determined by physicians.…”

Section: Hba1c Target Achievement At 12 Weeksmultivariate Modelmentioning

confidence: 99%

“…[8][9][10][11] For example, in two international real-world studies, only 27% to 33% of individuals with T2DM achieved HbA1c less than 7.0% (<53 mmol/mol) after initiating BI therapy. [8][9][10][11] For example, in two international real-world studies, only 27% to 33% of individuals with T2DM achieved HbA1c less than 7.0% (<53 mmol/mol) after initiating BI therapy.…”

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confidence: 99%

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The Diabetes Unmet Need with Basal Insulin Evaluation (DUNE) study in type 2 diabetes: Achieving HbA1c targets with basal insulin in a real‐world setting

Meneghini

Mauricio

Orsi

et al. 2019

Diabetes Obesity Metabolism

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Aims To describe in a real‐world setting the achievement of physician‐selected individualized HbA1c targets in individuals with type 2 diabetes, newly or recently initiated with basal insulin, and the association of hypoglycaemia with target achievement. Materials and methods A 12‐week, prospective, single‐arm, observational study of adults with type 2 diabetes, either newly initiated with any basal insulin or start on basal insulin within the preceding 12 months. At enrollment, eligible participants from 28 countries were treated with or without oral antihyperglycaemic drugs and/or GLP‐1 receptor agonists. Results Individualized targets for almost all of the 3139 evaluable participants (99.7%) had been set by their physicians, with 57% of participants having HbA1c targets between 7.0% and <7.5% (53 and <58 mmol/mol). By week 12, 28% and 27% of newly and previously initiated participants, respectively, achieved individualized HbA1c targets with modest average increases in daily insulin dose of 9 and 5 U (0.10 and 0.06 U/kg), respectively, from baseline (14 and 23 U [0.17 and 0.29 U/kg], respectively). Overall, 16% of participants experienced at least one episode of hypoglycaemia. Both the incidence and frequency of hypoglycaemia, but not the severity, were positively associated with a higher likelihood of achieving individualized HbA1c targets (P < 0.05). Conclusions In this prospective real‐world study, most participants using basal insulin did not achieve the individualized HbA1c targets set by their physicians. Participants who experienced symptomatic hypoglycaemia were more likely to achieve HbA1c targets than those who did not.

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Are patients on basal insulin attaining glycemic targets? Characteristics and goal achievement of patients with type 2 diabetes mellitus treated with basal insulin and physician-perceived barriers to achieving glycemic targets

Abstract: A large proportion of patients on insulin-based therapy fail to reach glycemic goals. More education of clinicians may improve insulin intensification rates and increase the proportion of patients reaching glycemic targets.

Cited by 54 publications

References 23 publications

Clinical implications of prolonged hyperglycaemia before basal insulin initiation in type 2 diabetes patients: An electronic medical record database analysis

Clinical implications of prolonged hyperglycaemia before basal insulin initiation in type 2 diabetes patients: An electronic medical record database analysis

Effect of exenatide QW or placebo, both added to titrated insulin glargine, in uncontrolled type 2 diabetes: The DURATION‐7 randomized study

The Diabetes Unmet Need with Basal Insulin Evaluation (DUNE) study in type 2 diabetes: Achieving HbA1c targets with basal insulin in a real‐world setting

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