Converting people with type 2 diabetes to insulin

Type 2 diabetes has commonly been viewed as more benign than type 1, partly because it was once rare to use insulin in its management. With the recognition of the importance of tight control of blood glucose, it is now the case that most people with type 2 diabetes will require insulin at some point. This article discusses the reasons why insulin treatment should be used in type 2 diabetes, and some of the practicalities of insulin initiation and management.     

Immune responses to insulin aspart and biphasic insulin aspart in people with type 1 and type 2 diabetes

OBJECTIVE: The antibody responses to a novel rapid-acting insulin analog, insulin aspart (IAsp), and their potential clinical correlates were studied with a specifically developed method in 2,420 people with diabetes treated for up to 1 year with preprandial subcutaneous injections of IAsp. RESEARCH DESIGN AND METHODS: Circulating insulin antibodies were analyzed by radioimmunoassay with (125)I insulin or IAsp tracers and polyethylene glycol precipitation. Four multinational, open, parallel group studies were conducted in Europe and North America, with a total of 1,534 people with diabetes exposed to IAsp and 886 people exposed to human insulin (HI) as meal-related insulin for 6-12 months. RESULTS: Insulin antibodies specific to HI or IAsp were absent in a majority of patients throughout the 6- to 12-month study periods. A majority of the patients (64-68%) had antibodies cross-reacting between HI and IAsp when entering the studies, with baseline levels (means +/- SD of percent bound/total) of 16.6 +/- 16.3% in study 1 and 10.3 +/- 14.0% in study 4. In all four studies, cross-reactive antibodies increased in patients exposed to IAsp, with a maximum at 3 months, and thereafter there was a decline toward baseline levels at 9-12 months (levels at 3 and 12 months: 22.3 +/- 19.7 and 16.8 +/- 16.5% in study 1 and 21.5 +/- 21.9 and 16.9 +/- 17.4% in study 4). Antibody levels showed similar changes in people with type 1 and type 2 diabetes, and there was no consistent relationship between antibody formation and glycemic control or between antibody formation and safety in terms of adverse events. CONCLUSIONS: Treatment with IAsp is associated with an increase in cross-reactive insulin antibodies, with a subsequent fall toward baseline values, without any indication of clinical relevance because no effect on efficacy or safety could be identified.     

An RCT into calculating insulin start dose in type 2 diabetes

AIMS: This trial compares to methods used to find the insulin dose when starting insulin in people with type 2 diabetes in whom maximal tolerated oral hypoglycaemic agents have failed to control glycaemia. One method of initiating insulin (based on height, weight, and fasting blood plasma glucose and insulin resistance) was compared with a conventional method of initiating 10 units of isophane insulin twice daily. METHOD: Sixty subjects were randomised to calculated (CALC) or conventional (C). Follow-up was at three, six and 12 months with diabetes specialist nurse (DSN) support. The outcomes that were compared were glycated haemoglobin levels (HbA1c), hypoglycaemia, weight gain, insulin dose, quality of life, treatment satisfaction, blood pressure, and frequency of DSN contact. RESULTS: HbA1c levels values were reduced significantly in the CALC group during the first three months after starting insulin (p = 0.0001) and improved by one per cent overall during 12 months (p = 0.03). No difference was found in rates of hypoglycaemia, blood pressure, quality of life, and treatment satisfaction. Weight gain was seen in both groups but was significantly higher in the CALC group. People in the CALC group needed significantly less DSN time (p = 0.01). CONCLUSIONS: HbA1c target values were achieved more quickly and with less DSN contact using the CALC method. The difference in weight gain with the CALC method needs further investigation.     

Setting up a fast-track insulin start clinic for type 2 diabetes

When people with established type 2 diabetes first need insulin therapy there is often a delay in accessing services. Since the report of the UK Prospective Diabetes Study was published it has been recognised that people with type 2 diabetes have a progressive disease and a need for increasing treatment. The authors set up a fast-track service to enable GPs and practice nurses to refer to a nurse-led service at the diabetes centre.     

Optimizing insulin regimens in type 1 diabetes. How to help patients get control of their life

The advances in insulin therapy in the past 5 years, including the introduction of insulin analogues, have made blood glucose control in patients with type 1 diabetes much more attainable. Diabetic patients can now achieve a better quality of life, including spontaneity and flexibility in lifestyle, than was possible with earlier insulin products. Here, Dr Bohannon discusses the latest improvements in acute and basal insulin therapy and presents three algorithms she has developed to help patients individualize their insulin regimens in relation to their eating and exercise patterns.     

Insulin non-persistence among people with type 2 diabetes: how to get your patients to stay on insulin therapy

Continuing use of medication is key to effective treatment and positive health outcomes, particularly in chronic conditions such as diabetes. However, in primary care, non-persistence (i.e. discontinuing or interrupting treatment) with insulin therapy is a common problem among patients with type 2 diabetes. To help primary care physicians manage patients who are non-persistent or likely not to be persistent, this review aimed to provide an overview of modifiable and non-modifiable factors associated with insulin non-persistence as well as practical strategies to address them. Data were extracted from published studies evaluating factors associated with non-persistence among patients with type 2 diabetes. A targeted literature review was performed using PubMed to identify recent studies (2000–2016) reporting measures of non-persistence with insulin therapy. Practical strategies to identify and prevent non-persistence were based on the authors’ direct experience in primary care. Non-modifiable factors associated with non-persistence included gender, age, prior treatments, and cost of therapy. Before/at insulin initiation, modifiable factors included patients’ perception of diabetes, preference for oral medication, and concerns/expectations about treatment complexity, inconvenience, or side effects. After initiation, modifiable factors included syringe use, difficulties during the first week of therapy, side effects, and insufficient glycemic control. Open-ended and patient-centered questions and a blame-free environment can help physicians identify, prevent, and reduce non-persistence behaviors. Possible questions to start a conversation with patients are provided. Effective physician-patient communication is essential to the management of diabetes. Primary care physicians should be familiar with the most common reasons for insulin non-persistence.     

Instruments to tailor care of people with type 2 diabetes

Title.  Instruments to tailor care of people with type 2 diabetes.
Aim.  This paper is a report of a study conducted to assess the effectiveness of an educational intervention for people with type 2 diabetes based on self-completed instruments to identify particular areas of self-care needs.
Background.  Diabetes is a demanding disease which requires self-care. Instruments that identify self-care needs or factors affecting self-care can be helpful to detect level of self-care, distress or knowledge among individuals with diabetes.
Methods.  Participants were randomized into intervention ( n  = 28) or control groups ( n  = 25). Both groups answered five validated instruments three times, at baseline and after 3 and 6 months, and biological measurements were conducted simultaneously. The intervention was based on an empowerment approach. The study started in November 2005 and lasted until March 2007.
Findings.  There was no statistically significant difference between groups in level of glycated haemoglobin postintervention as it reduced statistically significantly in both groups between baseline and 3 months but increased again after 6 months. There was no statistically significant difference between groups in body mass index reduction; the intervention group achieved a statistically significant body mass index reduction but this was unchanged in the control group. No statistically significant differences between groups were found in scores for empowerment, well-being and distress. There was a statistically significant difference between groups in knowledge postintervention.
Conclusion.  Use of instruments to identify self-care needs can enable patient-tailored care as it allows direct focusing on issues that are challenging and of relevance for each individual. It seems to be feasible to use the telephone to conduct an empowering educational intervention after one meeting.     

Battling insulin resistance in elderly obese people with type 2 diabetes: bring on the heavy weights

Exercise improves insulin resistance and has beneficial effects in preventing and treating type 2 diabetes. However, aerobic exercise is hindered in many type 2 diabetic patients because of advancing age, obesity, and other comorbid conditions. Weight lifting or progressive resistance training (PRT) offers a safe and effective exercise alternative for these people. PRT promotes favorable energy balance and reduced visceral fat deposition through enhanced basal metabolism and activity levels while counteracting age- and disease-related muscle wasting. PRT improves insulin sensitivity and glycemic control; increases muscle mass, strength, and endurance; and has positive effects on bone density, osteoarthritic symptoms, mobility impairment, self-efficacy, hypertension, and lipid profiles. PRT also alleviates symptoms of anxiety, depression, and insomnia in individuals with clinical depression and improves exercise tolerance in individuals with cardiac ischemic disease and congestive heart failure; all of these aspects are relevant to the care of diabetic elders. Moreover, PRT is safe and well accepted in many complex patient populations, including very frail elderly individuals and those with cardiovascular disease. The greater feasibility of using PRT over aerobic exercise in elderly obese type 2 diabetic individuals because of concomitant cardiovascular, arthritic, and other disease provides a solid rationale for investigating the global benefits of PRT in the management of diabetes.     

Initiating insulin therapy in type 2 Diabetes: a comparison of biphasic and basal insulin analogs

OBJECTIVE: Safety and efficacy of biphasic insulin aspart 70/30 (BIAsp 70/30, prebreakfast and presupper) were compared with once-daily insulin glargine in type 2 diabetic subjects inadequately controlled on oral antidiabetic drugs (OADs). RESEARCH DESIGN AND METHODS: This 28-week parallel-group study randomized 233 insulin-naive patients with HbA(1c) values >/=8.0% on >1,000 mg/day metformin alone or in combination with other OADs. Metformin was adjusted up to 2,550 mg/day before insulin therapy was initiated with 5-6 units BIAsp 70/30 twice daily or 10-12 units glargine at bedtime and titrated to target blood glucose (80-110 mg/dl) by algorithm-directed titration. RESULTS: A total of 209 subjects completed the study. At study end, the mean HbA(1c) value was lower in the BIAsp 70/30 group than in the glargine group (6.91 +/- 1.17 vs. 7.41 +/- 1.24%, P < 0.01). The HbA(1c) reduction was greater in the BIAsp 70/30 group than in the glargine group (-2.79 +/- 0.11 vs. -2.36 +/- 0.11%, respectively; P < 0.01), especially for subjects with baseline HbA(1c) >8.5% (-3.13 +/- 1.63 vs. -2.60 +/- 1.50%, respectively; P < 0.05). More BIAsp 70/30-treated subjects reached target HbA(1c) values than glargine-treated subjects (HbA(1c) 8.5%.     

Insulin treatment for type 2 diabetes: when to start, which to use

In type 2 diabetes mellitus, oral hypoglycemic agents and analogues of glucagon-like peptide-1 provide adequate glycemic control early in the disease. Insulin therapy becomes necessary for those with advanced disease. Further, some experts recommend electively starting insulin therapy in early diabetes. This review addresses practical approaches to insulin therapy, particularly when it is indicated and which regimen to use.     

Weight management in people with type 2 diabetes

This article sets out a comprehensive outline of the mechanism for the development of Type 2 diabetes and the importance of weight reduction in Type 2 diabetes management. Current weight reduction strategies are reviewed. Lifestyle modifications form the frontline strategy for targeted weight loss in diabetes care. However, there is a lack of knowledge regarding effective and safe interventions to promote weight management for those who have already developed Type 2 diabetes.     

Self-management skills for people with type 2 diabetes

This article discusses type 2 diabetes, including the underlying causes and the treatment algorithm needed to manage this condition. The article also explores the educational opportunities available to encourage self-management of this chronic life long condition.     

Factors influencing diabetes self-management in Chinese people with type 2 diabetes

Patients with diabetes must incorporate a complicated regimen of self-management into their daily lives (e.g., taking medication, diet, exercise). Diabetes self-management (DSM) is the cornerstone for controlling diabetes and preventing diabetic complications. The purpose of this study was to test a model describing the effects of individual and environmental factors on DSM in a sample of patients with diabetes in Beijing, China. Survey data were gathered from a convenience sample of 201 Chinese adults with type 2 diabetes during outpatient visits. Data were analyzed using structural equation modeling. Model fit indices indicated a good fit to the data. In the final model, belief in treatment effectiveness and diabetes self-efficacy were proximate factors affecting DSM. Knowledge, social support, and provider-patient communication affected self-management indirectly via beliefs and self-efficacy. The findings provide a theoretical basis to direct the development of interventions for improving DSM in Chinese individuals with diabetes.     

A comparison of intermediate and long-acting insulins in people with type 2 diabetes starting insulin: an observational database study

Aims: Insulin is normally added to oral glucose‐lowering drugs in people with type 2 diabetes when glycaemic control becomes suboptimal. We evaluated outcomes in people starting insulin therapy with neutral protamine Hagedorn (NPH), detemir, glargine or premixed insulins. Methods: Insulin‐naïve people with type 2 diabetes (n = 8009), ≥ 35 years old, HbA_1c≥ 6.5% and begun on NPH (n = 1463), detemir (n = 357), glargine (n = 2197) or premix (n = 3992), were identified from a UK database of primary care records (The Health Improvement Network). Unadjusted and multivariate‐adjusted analyses were conducted, with persistence of insulin therapy assessed by survival analysis. Results: In the study population (n = 4337), baseline HbA_1c was 9.5 ± 1.6%, falling to 8.4 ± 1.5% over 12 months (change ?1.1 ± 1.8%, p < 0.001). Compared with NPH, people taking detemir, glargine and premix had an adjusted reduction in HbA_1c from baseline, of 0.00% (p = 0.99), 0.19% (p < 0.001) and 0.03% (p = 0.51). Body weight increased by 2.8 kg overall (p < 0.001), and by 2.3, 1.7, 1.9, and 3.3 kg on NPH, detemir, glargine and premix (p < 0.001 for all groups); insulin dose at 12 months was 0.70 (overall), 0.64, 0.61, 0.56 and 0.76 U/kg/day. After 36 months, 57% of people on NPH, 67% on glargine and 83% on premix remained on their initially prescribed insulin. Discussion and Conclusion: In routine clinical practice, people with type 2 diabetes commenced on NPH experienced a modest disadvantage in glycaemic control after 12 months compared with other insulins. When comparing the insulins, glargine achieved best HbA_1c reduction, while premix showed greatest weight gain and the highest dose requirement, but had the best persistence of therapy.     

The distress experienced by people with type 2 diabetes

With diabetes an ever-increasing problem across the developed world, a great deal of research has been carried out into the effects of the disease on the patient. Yet despite the fact that type 1 diabetes accounts for only a relatively small proportion of worldwide cases, it has been the focus of research attention. This study aimed to investigate the distress associated with type 2 diabetes, whether gender differences existed in the impact of type 2 diabetes and how men and women viewed dietary management. A multi-method, two-stage research approach was taken. Quantitative data were obtained using the Problem Areas in Diabetes (PAID) questionnaire, and no statistically significant gender difference was identified. Worrying about the future, the possibility of complications and feelings of guilt or anxiety when 'off-track' with diabetes management were sources of significant distress. Treatment mode, length of time diagnosed with diabetes and age were significant factors which impacted on the emotional distress experienced by the individual. A subsample of respondents took part in the survey. Behavioural impact, emotional impact and fear of complications were major themes identified in the interviews. Views of the dietary management of diabetes were also explored within the focus groups and three broad categories identified: dietary restrictions, value judgements and the influence of others. Awareness by health-care professionals of factors influencing adaptation to diabetes is recommended.     

Increasing physical activity in people with type 2 diabetes

OBJECTIVE: To evaluate effect of exercise consultation on physical activity and resultant physiological and biochemical variables at 6 months in people with type 2 diabetes. RESEARCH DESIGN AND METHODS: A total of 70 inactive people with type 2 diabetes were given standard exercise information and were randomized to receive an exercise consultation (n = 35) or not (n = 35). Exercise consultation, based on the transtheoretical model, combines motivational theory and cognitive behavioral strategies into an individualized intervention to promote physical activity. Changes from baseline to 6 months were assessed in 1) physical activity (7-day recall, accelerometer, cardiorespiratory fitness, stage, and processes of change), 2) physiological variables (blood pressure and BMI), and 3) biochemical variables (HbA(1c), lipid profile, and fibrinogen). RESULTS: Between-group differences were recorded for the change in minutes of moderate activity (P < 0.001) and activity counts (P < 0.001) per week. Experimental participants recorded an increase in activity counts per week and minutes of moderate activity per week (P < 0.001). The control group recorded no significant changes. More experimental participants increased stage of change (chi(2) = 22.6, P < 0.001). Between-group differences were recorded for the change in total exercise duration and peak gradient (P < 0.005), HbA(1c) (P = 0.02), systolic BP (P = 0.02), and fibrinogen (P = 0.03). CONCLUSIONS: Exercise consultation increased physical activity and improved glycemic control and cardiovascular risk factors in people with type 2 diabetes.