Insulin Treatment of Fasting or Postprandial Glucose in Type 2 Diabetes. Does It Matter? The South Danish Diabetes Study
Heinrikson JE, et al.
There are 3 main defects observed in type 2 diabetes: decreased insulin secretion, increased insulin resistance, and increased hepatic glucose output. In this study, patients were randomized to receive insulin aspart delivered three times daily to bedtime NPH. Within each of the 2 groups, patients were further randomized to receive placebo, metformin, or rosiglitazone. Over 2 years of treatment, A1C showed a greater improvement in the aspart group. Further, there was a significant effect for both metformin and rosiglitazone. Body weight increased more with insulin aspart than with NPH. Metformin treatment was associated with weight loss, and rosiglitazone was associated with a significant weight gain. Daytime hypoglycemia was higher during the day with aspart, but higher nocturnally with NPH. Metformin therapy decreased risk of hypoglycemia, but rosiglitazone did not affect hypoglycemia. Triple therapy with insulin plus metformin and rosiglitazone was shown to give best glycemic control.
Intensive Insulin Therapy in Type 2 Diabetes Patients Previously Treated with Glargine Plus Oral Agents: Prandial NPL/Lispro Mixtures vs Glargine/Lispro Basal/Bolus
Rosenstock J, et al.
This study examined the efficacy of intensive mixture therapy compared with basal/bolus therapy in patients with type 2 diabetes previously treated with insulin glargine and oral agents. Patients were randomized to receive lispro mix 50/50 3-times with meals or basal/bolus therapy with glargine and lispro. Patients with elevated fasting glucose on intensive mixture therapy were given the option to switch to 75/25 lispro mixture. Sulfonylurea therapy was discontinued because patients were going to be given prandial insulin. Results showed that A1C was lower with basal/bolus therapy than with intensive mixture therapy, and noninferiority was not met. Significantly more basal/bolus patients achieved A1C <6.5% and an A1C <7%. Weight gain and hypoglycemia were similar between the 2 groups. Clinically meaningful glycemic improvements can be achieved in patients treated with basal insulin. When basal insulin needs to be advanced, this study can guide choice of therapy.
Efficacy and Safety of Insulin Detemir in a Large Cohort of Patients With Type 2 Diabetes Using a Simplified Self-Adjusted Dosing Guideline: Results of the PREDICTIVE 303 Study
Menegini L, et al.
Basal insulin is a simple, effective, and safe option in patients poorly controlled with oral agents. Many people with type 2 diabetes are managed in primary care. Compared with NPH, basal insulin analogs have similar efficacy with less hypoglycemia. Insulin detemir, in particular, is associated with less weight gain than insulin glargine or NPH insulin. The use of a simplified patient-adjusted algorithm (303 group) was compared with physician-adjusted insulin therapy (standard of care) in this 26-week prospective and randomized. Patients added detemir to ongoing therapy or as replacement to other therapies. Data were collected at baseline, 12 weeks, and 26 weeks, and approximately 3000 patients were in each arm of the study. Patients assigned to the 303 algorithm were instructed to take the mean of last 3 plasma glucose values every 3 days. If plasma glucose <80 mg/dL, they were to reduce insulin by 3 units. If their average was between 80 mg/dL and110 mg/dL, no change was to be made. For patients with plasma glucose of >110 mg/dL, an increase of 3 U was recommended. By contrast, healthcare providers adjusting insulin dose for patients in the standard of care group could use any adjustment they desired. Mean A1C decreased in both groups, as did fasting plasma glucose. Patients in the 303 group were using significantly more insulin at study end. Weight also decreased in both groups. When patients were stratified based on BMI, the data demonstrated that patients with a higher BMI lost weight, while patients with a lower BMI gained weight. The rates of hypoglycemia were low in both groups, but slightly higher in the self-directed group. At study end, 93% of patients were using insulin detemir once daily. This study demonstrated that basal insulin titration can be safely completed by patients. It is a safe and effective alternative to physician directed adjustments in primary care setting.
Basal Insulin and Oral Antidiabetic Therapy (BOT) Plus a Single Dose of Insulin Glulisine (BOT+) reduces A1C and Blood Glucose Values in Patients With Type 2 Diabetes
Lankisch ML, et al.
The goal of this study was to show 2-sided equivalence of basal insulin plus insulin glulisine either given at breakfast or with the main meal. This is the first study to assess the efficacy of adding a single prandial injection to basal insulin and oral therapy. The group receiving prandial insulin at breakfast had significantly higher A1C than did patients taking prandial insulin with the main meal. How ever, there was no difference in the percentage of patients meeting glycemic targets. A single bolus of insulin glulisine results in improvement of A1C and PPG, and that change is independent of time of administration, although responder rates were slightly higher in main meal. Hypoglycemia was low in both groups. |
