Appropriate insulin initiation delayed in diabetes patients
MedWire News: The appropriate initiation of insulin treatment in patients with Type 2 diabetes is considerably delayed in routine clinical practice, show study findings.
Nearly half of patients had a glycated hemoglobin (HbA1c) level of 9.0% or more, despite prolonged treatment with multiple oral antidiabetic drugs, report Kamlesh Khunti (University of Leicester) and colleagues.
As reported in Diabetes, Obesity and Metabolism, the team conducted a subanalysis of the Study of Once Daily Levemir (SOLVE), a 24-week investigation of the initiation of once-daily insulin detemir in patients with diabetes uncontrolled by diet, exercise and one or more oral antidiabetics (OADs).
The study was conducted in 10 countries (Canada, China, Germany, Israel, Italy, Poland, Portugal, Spain, Turkey, and the UK) and comprised 17,374 participants aged a mean of 62 years, with a mean diabetes duration of 10 years, and mean body mass index of 29.3 kg/m2.
The researchers report that the mean HbA1c of participants initiating therapy was 8.9%, with a significant 41.0% and 22.0% of patients having HbA1c values of more than 9.0% and 10.0%, respectively. Only 7.0% of participants initiating insulin therapy had an HbA1c level within the recommended target of less than 7.0%.
Mean pre-insulin HbA1c was highest in the UK, at 9.8%, and lowest in China, at 8.3%. The proportion of patients with an HbA1c of 9.0% or more was highest in the UK and Turkey at 64.0% and lowest in Poland, at 23.0%.
The pre-insulin duration of OADs also varied substantially by country, ranging from 11.4 years in Italy to 6.3 years in China. With the exception of Germany, most patients received at least two OADs at the time of insulin initiation, with the highest proportions of patients on more than two OADs found in Portugal, Turkey, and Canada, at 39%, 29%, and 24%, respectively.
The mean starting dose of insulin detemir was 0.16 U/kg and, again, varied significantly by country, ranging from 0.12 U/kg in the UK and Canada to 0.21 U/kg in Spain and Turkey.
At the time of initiation, no changes were made to the existing OAD regimen in 81% of metformin-only users, 65% of sulfonyurea-only users, and 71% of patients using a combination of sulfonylurea and metformin. The largest proportional changes in OAD prescription at insulin initiation were seen with glinides (+15%), sulfonylureas (-19%), thiazolidinediones (-31%), and dipetidyl peptidase-IV inhibitors (-28%).
The team says the findings show that the majority of Type 2 diabetes patients were poorly controlled when the decision was taken to initiate basal insulin treatment, and reinforce the need to educate physicians on the importance of early and appropriate treatment intensification to maintain glycemic control.
"SOLVE provides an opportunity to better understand global and regional trends in the intensification of treatment in patients with Type 2 diabetes mellitus," write Khunti et al. "These findings should facilitate the development of targeted strategies in order to achieve improved glycemic control earlier in the course of Type 2 diabetes mellitus."
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By Sally Robertson