Insulin initiation and intensification in patients with T2DM for the primary care physician

Unger, Jeffrey

doi:10.2147/dmso.s14653

Cited by 22 publications

(33 citation statements)

References 42 publications

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“…Ultimately, the most important goal is for all primary care physicians to recognize that every patient treated with antihyperglycemic medications is at risk of iatrogenic hypoglycemia, and to ask patients about hypoglycemia at each and every visit. Table 5 lists questions the primary care physician can ask at each visit in order to highlight all hypoglycemic episodes that may have occurred since the last visit 33. Information gathered about hypoglycemic events will help primary care physicians to assess patient understanding of hypoglycemia and to understand more about potential causes, severity, and frequency of hypoglycemia.…”

Section: Detecting and Uncovering Hypoglycemiamentioning

confidence: 99%

Uncovering undetected hypoglycemic events

Unger¹

2012

DMSO

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Hypoglycemia is the rate-limiting factor that often prevents patients with diabetes from safely and effectively achieving their glycemic goals. Recent studies have reported that severe hypoglycemia is associated with a significant increase in the adjusted risks of major macrovascular events, major microvascular events, and mortality. Minor hypoglycemic episodes can also have serious implications for patient health, psychological well being, and adherence to treatment regimens. Hypoglycemic events can impact the health economics of the patient, their employer, and third-party payers. Insulin treatment is a key predictor of hypoglycemia, with one large population-based study reporting an overall prevalence of 7.1% (type 1 diabetes mellitus) and 7.3% (type 2 diabetes mellitus) in insulin-treated patients, compared with 0.8% in patients with type 2 diabetes treated with an oral sulfonylurea. Patients with type 1 diabetes typically experience symptomatic hypoglycemia on average twice weekly and severe hypoglycemia once annually. The progressive loss of islet cell function in patients with type 2 diabetes results in a higher risk of both symptomatic and unrecognized hypoglycemia over time. Patients with diabetes who become hypoglycemic are also more susceptible to developing defective counter-regulation, also known as hypoglycemia awareness autonomic failure, which is life-threatening and must be aggressively addressed. In patients unable to recognize hypoglycemia symptoms, frequent home monitoring or use of continuous glucose sensors are critical. Primary care physicians play a key role in the prevention and management of hypoglycemia in patients with diabetes, particularly in those requiring intensive insulin therapy, yet physicians are often unaware of the multitude of consequences of hypoglycemia or how to deal with them. Careful monitoring, adherence to guidelines, and use of optimal treatment combinations are all important steps toward improving care in patients with diabetes. The most important goals are for primary care physicians to recognize that every patient treated with antihyperglycemic medications is at risk of iatrogenic hypoglycemia and to ask patients about hypoglycemia at every visit.

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Section: Detecting and Uncovering Hypoglycemiamentioning

confidence: 99%

Uncovering undetected hypoglycemic events

Unger¹

2012

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“…A common approach for initiating insulin therapy is the addition of basal insulin to oral agent therapy (1). Clinical trials have demonstrated that basal insulin analogs can effectively treat glycemic targets when structured insulin adjustment algorithms are systematically used (2).…”

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confidence: 99%

Advancing Basal Insulin Replacement in Type 2 Diabetes Inadequately Controlled With Insulin Glargine Plus Oral Agents: A Comparison of Adding Albiglutide, a Weekly GLP-1 Receptor Agonist, Versus Thrice-Daily Prandial Insulin Lispro

et al. 2014

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OBJECTIVEGLP-1 receptor agonists may provide an alternative to prandial insulin for advancing basal insulin therapy. Harmony 6 was a randomized, open-label, activecontrolled trial testing once-weekly albiglutide vs. thrice-daily prandial insulin lispro as an add-on to titrated once-daily insulin glargine. RESEARCH DESIGN AND METHODSPatients taking basal insulin (with or without oral agents) with HbA 1c 7-10.5% (53-91 mmol/mol) entered a glargine standardization period, followed by randomization to albiglutide, 30 mg weekly (n = 282), subsequently uptitrated to 50 mg, if necessary, or thrice-daily prandial lispro (n = 281) while continuing metformin and/or pioglitazone. Glargine was titrated to fasting plasma glucose of <5.6 mmol/L, and lispro was adjusted based on glucose monitoring. The primary end point was the difference in the HbA 1c change from baseline at week 26. RESULTSAt week 26, HbA 1c decreased from baseline by 20.82 6 SE 0.06% (9.0 mmol/mol) with albiglutide and 20.66 6 0.06% (7.2 mmol/mol) with lispro; treatment difference, 20.16% (95% CI 20.32 to 0.00; 1.8 mmol/mol; P < 0.0001), meeting the noninferiority end point (margin, 0.4%). Weight decreased with albiglutide but increased with lispro (20.73 6 0.19 kg vs. +0.81 6 0.19 kg). The mean glargine dose increased from 47 to 53 IU (albiglutide) and from 44 to 51 IU (lispro). Adverse events for albiglutide versus lispro included severe hypoglycemia (0 vs. 2 events), documented symptomatic hypoglycemia (15.8% vs. 29.9%), nausea (11.2% vs. 1.4%), vomiting (6.7% vs. 1.4%), and injection site reactions (9.5% vs. 5.3%). CONCLUSIONSWeekly albiglutide is a simpler therapeutic option than thrice-daily lispro for advancing basal insulin glargine therapy, resulting in comparable HbA 1c reduction with weight loss and lower hypoglycemia risk.

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“…In a meta-analysis, comparing the efficacy of add-on anti-hyperglycemic drugs in pa tients with T2DM that were not controlled with metformin and sulfonylurea, a weight increase was seen with insulin (2.8 kg) [34]. Commonly, the achievement and maintenance of glycemic control over time is associated with weight gain [35][36][37]. However, in our study mean weight decreased significantly, even in the insulin cohort.…”

Section: Discussionmentioning

confidence: 50%

Observational Study of Patients in Morocco With Uncontrolled Type 2 Diabetes Treated With Metformin and/or Sulfonylurea With or Without Insulin

Ansari

Chadli²,

Aziz³

et al. 2015

J Endocrinol Metab

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Background: Several types of oral antidiabetic drugs (OADs), with or without insulin, may be used to achieve glycemic control in patients with type 2 diabetes mellitus (T2DM). However, real-life studies assessing diabetes treatments in Morocco are rare. Our aim was to assess the efficacy of various antidiabetic treatment regimens to achieve glycemic control in patients with uncontrolled T2DM, to determine the factors associated with a lack of glycemic control and to compare the clinical outcome after 26 weeks of treatment in a real-life setting.

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Insulin initiation and intensification in patients with T2DM for the primary care physician

Cited by 22 publications

References 42 publications

Uncovering undetected hypoglycemic events

Uncovering undetected hypoglycemic events

Advancing Basal Insulin Replacement in Type 2 Diabetes Inadequately Controlled With Insulin Glargine Plus Oral Agents: A Comparison of Adding Albiglutide, a Weekly GLP-1 Receptor Agonist, Versus Thrice-Daily Prandial Insulin Lispro

Observational Study of Patients in Morocco With Uncontrolled Type 2 Diabetes Treated With Metformin and/or Sulfonylurea With or Without Insulin

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