BeAM value: an indicator of the need to initiate and intensify prandial therapy in patients with type 2 diabetes mellitus receiving basal insulin

Abstract

IntroductionIn patients with type 2 diabetes mellitus (T2DM) with uncontrolled glycemia despite ongoing upward titration of basal insulin, targeting postprandial hyperglycemia may be required. Nevertheless, the point at which basal insulin is fully optimized and postprandial glucose (PPG) should be targeted with additional treatment remains unclear. We report here on the BeAM value (difference between bedtime and morning blood glucose values) as an indicator of the need to target PPG.MethodsThis study had 3 stages: exploratory, main, and proof-of-concept analyses. For the exploratory and main analyses, data were pooled from phase 3 trials in adults with T2DM adding basal insulin to oral antidiabetic drugs (OADs). The main analysis included only patients who did not reach A1C ≤7.0% (53 mmol/mol) at week 24. The proof-of-concept analysis used pooled data from phase 3 trials in adults with T2DM adding insulin glargine and a single insulin glulisine injection to OADs.ResultsIn patients undergoing basal insulin titration, BeAM value increased over 24 weeks (27.8–61.7 mg/dL, n=1188; 32.6–71.2 mg/dL, n=553; exploratory and main analyses, respectively). There were significant correlations between week 24 BeAM value and postprandial contribution to hyperglycemia (Pearson's correlation coefficient (r)=0.375, p<0.001; r=0.396, p<0.001; exploratory and main analyses, respectively). When PPG was targeted (proof-of-concept analysis), the BeAM value reduced from 77.0 to 40.4 mg/dL (n=299).ConclusionsThe BeAM value described in this study is a simple, easy-to-calculate value that may identify patients with T2DM using basal insulin that need targeting of postprandial control rather than advancing basal insulin dose.

Baseline nocturnal glucose change: A predictor of the treatment effect of bolus intensification in insulin‐treated type 2 diabetes

“…A proof‐of‐concept study, exploring the potential of the nocturnal glucose change measure, termed “BeAM”, as an indicator to intensify treatment targeting postprandial hyperglycaemia in people inadequately controlled on basal insulin, concluded that BeAM values between 2.5 and 3.1 mmol/L (45 and 55 mg/dL) should trigger the consideration of intensification . In our analysis, the median cut‐off was 3.1 mmol/L (56 mg/dL), which aligns with these observations, as only a modest improvement in HbA1c (−0.03%) was observed after 18 weeks' treatment with continued basal‐only treatment in participants with a nocturnal glucose change >3.1 mmol/L (56 mg/dL).…”

“…In our analysis, the median cut‐off was 3.1 mmol/L (56 mg/dL), which aligns with these observations, as only a modest improvement in HbA1c (−0.03%) was observed after 18 weeks' treatment with continued basal‐only treatment in participants with a nocturnal glucose change >3.1 mmol/L (56 mg/dL). Further, they reported that large BeAM values may correlate with higher incidence of hypoglycaemia . Similarly, the incidence of hypoglycaemia was numerically higher in participants treated with basal‐only insulin, with a nocturnal glucose change >3.1 mmol/L (56 mg/dL) compared with those with nocturnal glucose change readings under this cut‐off; therefore, the use of the nocturnal glucose change as an indicator for intensification may also help prevent the unnecessary uptitration of basal insulin and the corresponding increase in the risk of hypoglycaemia with no additional benefit in glycaemic control.…”

“…However, HbA1c does not provide an indication of short‐term glycaemic control, and measuring PPG increments can be time‐consuming and disrupt patients' lives . The change in nocturnal blood glucose from bedtime to pre‐breakfast (termed herein as “nocturnal glucose change”) is an SMBG‐derived measure that only requires two blood glucose readings; it is easier and quicker to calculate than PPG increments and, when elevated, indicates a need to target PPG . Moreover, calculating baseline nocturnal glucose change may provide a simple method for identifying patients who would benefit most from bolus insulin intensification.…”

“…Those with baseline HbA1c >61.7 mmol/mol (7.8%) also experienced greater benefit from basal-bolus therapy, but only in terms of reduction in PPG increment. These findings suggest, in this study population, that baseline values of nocturnal glucose change and PPG increment may be better predictors for response to intensification with bolus insulin than baseline HbA1c.A proof-of-concept study, exploring the potential of the nocturnal glucose change measure, termed "BeAM", as an indicator to intensify treatment targeting postprandial hyperglycaemia in people inadequately controlled on basal insulin, concluded that BeAM values between 2.5 and 3.1 mmol/L (45 and 55 mg/dL) should trigger the consideration of intensification 11. In our analysis, the median cut-off was 3.1 mmol/L (56 mg/dL), which aligns with these observations, as only a modest improvement in HbA1c (−0.03%) was observed after 18 weeks' treatment with continued basal-only treatment in participants with a nocturnal glucose change >3.1 mmol/L (56 mg/dL).…”

Improving postprandial hyperglycemia in patients with type 2 diabetes already on basal insulin therapy: Review of current strategies

“…In addition, a recent pooled data analysis shows that prandial therapy should be considered when basal insulin doses are >0.5 IU/kg, although this should be assessed individually because some patients may be more insulin resistant than others . Another possible indicator of the need for starting prandial therapy is the appearance of large differences (>55 mg/dL [3.1 mmol/L]) between Bedtime and morning/AM (“BeAM” factor) blood glucose levels, large glucose drops overnight or between meals, an increase in the rate of nocturnal hypoglycemia, and an increase in the variability of FPG values …”