Clinical inertia with regard to intensifying therapy in people with type 2 diabetes treated with basal insulin

There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

Abstract

Aim

To investigate whether clinical inertia, the failure to intensify treatment regimens when required, exists in people with type 2 diabetes treated with basal insulin.

Methods

This was a retrospective cohort study involving patients with type 2 diabetes in the UK Clinical Practice Research Datalink database between January 2004 and December 2011, with follow‐up until December 2013.

Results

A total of 11 696 patients were included in the analysis. Among all patients, 36.5% had their treatment intensified during the study period; of these, the treatment of 50.0, 42.5 and 7.4% was intensified with bolus or premix insulin or glucagon‐like peptide‐1 receptor agonists, respectively. The median time from initiation of basal insulin to treatment intensification was 4.3 years [95% confidence interval ( CI) 4.1, 4.6]. Among patients clinically eligible for treatment intensification [glycated haemoglobin ( HbA1c) ≥7.5% (58 mmol/mol)], 30.9% had their treatment regimen intensified. The median time to intensification in this group was 3.7 years (95% CI 3.4, 4.0). Increasing age, duration of diabetes, oral antihyperglycaemic agent usage and Charlson comorbidity index score were associated with a significant delay in the time to intensification (p < 0.05). Among patients with HbA1c ≥7.5% (58 mmol/mol), 32.1% stopped basal insulin therapy.

Conclusions

Strategies should be developed to increase the number of patients undergoing therapy intensification and to reduce the delay in intensifying therapy for suitable patients on basal insulin. Initiatives to support patients continuing on insulin are also required.

Related collections

Most cited references 25

Record: found
Abstract: found
Article: not found

Validity of diagnostic coding within the General Practice Research Database: a systematic review.

Nada F. Khan, Sian Harrison, Peter W Rose (2010)

The UK-based General Practice Research Database (GPRD) is a valuable source of longitudinal primary care records and is increasingly used for epidemiological research. To conduct a systematic review of the literature on accuracy and completeness of diagnostic coding in the GPRD. Systematic review. Six electronic databases were searched using search terms relating to the GPRD, in association with terms synonymous with validity, accuracy, concordance, and recording. A positive predictive value was calculated for each diagnosis that considered a comparison with a gold standard. Studies were also considered that compared the GPRD with other databases and national statistics. A total of 49 papers are included in this review. Forty papers conducted validation of a clinical diagnosis in the GPRD. When assessed against a gold standard (validation using GP questionnaire, primary care medical records, or hospital correspondence), most of the diagnoses were accurately recorded in the patient electronic record. Acute conditions were not as well recorded, with positive predictive values lower than 50%. Twelve papers compared prevalence or consultation rates in the GPRD against other primary care databases or national statistics. Generally, there was good agreement between disease prevalence and consultation rates between the GPRD and other datasets; however, rates of diabetes and musculoskeletal conditions were underestimated in the GPRD. Most of the diagnoses coded in the GPRD are well recorded. Researchers using the GPRD may want to consider how well the disease of interest is recorded before planning research, and consider how to optimise the identification of clinical events.

0 comments Cited 289 times – based on 0 reviews      Review now

Bookmark

Record: found
Abstract: found
Article: not found

Three-year efficacy of complex insulin regimens in type 2 diabetes.

Rury R Holman, Andrew J Farmer, Melanie Davies … (2009)

Evidence supporting the addition of specific insulin regimens to oral therapy in patients with type 2 diabetes mellitus is limited. In this 3-year open-label, multicenter trial, we evaluated 708 patients who had suboptimal glycated hemoglobin levels while taking metformin and sulfonylurea therapy. Patients were randomly assigned to receive biphasic insulin aspart twice daily, prandial insulin aspart three times daily, or basal insulin detemir once daily (twice if required). Sulfonylurea therapy was replaced by a second type of insulin if hyperglycemia became unacceptable during the first year of the study or subsequently if glycated hemoglobin levels were more than 6.5%. Outcome measures were glycated hemoglobin levels, the proportion of patients with a glycated hemoglobin level of 6.5% or less, the rate of hypoglycemia, and weight gain. Median glycated hemoglobin levels were similar for patients receiving biphasic (7.1%), prandial (6.8%), and basal (6.9%) insulin-based regimens (P=0.28). However, fewer patients had a level of 6.5% or less in the biphasic group (31.9%) than in the prandial group (44.7%, P=0.006) or in the basal group (43.2%, P=0.03), with 67.7%, 73.6%, and 81.6%, respectively, taking a second type of insulin (P=0.002). [corrected] Median rates of hypoglycemia per patient per year were lowest in the basal group (1.7), higher in the biphasic group (3.0), and highest in the prandial group (5.7) (P<0.001 for the overall comparison). The mean weight gain was higher in the prandial group than in either the biphasic group or the basal group. Other adverse event rates were similar in the three groups. Patients who added a basal or prandial insulin-based regimen to oral therapy had better glycated hemoglobin control than patients who added a biphasic insulin-based regimen. Fewer hypoglycemic episodes and less weight gain occurred in patients adding basal insulin. (Current Controlled Trials number, ISRCTN51125379.) 2009 Massachusetts Medical Society

0 comments Cited 180 times – based on 0 reviews      Review now

Bookmark

Record: found
Abstract: found
Article: not found

Addition of biphasic, prandial, or basal insulin to oral therapy in type 2 diabetes.

Rury R Holman, Kerensa I. Thorne, Andrew J Farmer … (2007)

Adding insulin to oral therapy in type 2 diabetes mellitus is customary when glycemic control is suboptimal, though evidence supporting specific insulin regimens is limited. In an open-label, controlled, multicenter trial, we randomly assigned 708 patients with a suboptimal glycated hemoglobin level (7.0 to 10.0%) who were receiving maximally tolerated doses of metformin and sulfonylurea to receive biphasic insulin aspart twice daily, prandial insulin aspart three times daily, or basal insulin detemir once daily (twice if required). Outcome measures at 1 year were the mean glycated hemoglobin level, the proportion of patients with a glycated hemoglobin level of 6.5% or less, the rate of hypoglycemia, and weight gain. At 1 year, mean glycated hemoglobin levels were similar in the biphasic group (7.3%) and the prandial group (7.2%) (P=0.08) but higher in the basal group (7.6%, P<0.001 for both comparisons). The respective proportions of patients with a glycated hemoglobin level of 6.5% or less were 17.0%, 23.9%, and 8.1%; respective mean numbers of hypoglycemic events per patient per year were 5.7, 12.0, and 2.3; and respective mean weight gains were 4.7 kg, 5.7 kg, and 1.9 kg. Rates of adverse events were similar among the three groups. A single analogue-insulin formulation added to metformin and sulfonylurea resulted in a glycated hemoglobin level of 6.5% or less in a minority of patients at 1 year. The addition of biphasic or prandial insulin aspart reduced levels more than the addition of basal insulin detemir but was associated with greater risks of hypoglycemia and weight gain. (Current Controlled Trials number, ISRCTN51125379 [controlled-trials.com].). Copyright 2007 Massachusetts Medical Society.

0 comments Cited 173 times – based on 0 reviews      Review now

Bookmark

All references

Author and article information

Journal

Journal ID (nlm-ta): Diabetes Obes Metab

Journal ID (iso-abbrev): Diabetes Obes Metab

Journal ID (doi): 10.1111/(ISSN)1463-1326

Journal ID (publisher-id): DOM

Title: Diabetes, Obesity & Metabolism

Publisher: Blackwell Publishing Ltd (Oxford, UK )

ISSN (Print): 1462-8902

ISSN (Electronic): 1463-1326

Publication date (Electronic): 09 February 2016

Publication date (Print): April 2016

Volume: 18

Issue: 4 ( doiID: 10.1111/dom.2016.18.issue-4 )

Pages: 401-409

Affiliations

[ ¹ ] Diabetes Research CentreUniversity of Leicester LeicesterUK

[ ² ]Novo Nordisk A/S SøborgDenmark

[ ³ ]StatGroup ApS CopenhagenDenmark

[ ⁴ ] Clinical Trials & Biostatistics UnitQIMR Berghofer Medical Research Institute BrisbaneAustralia

Author notes

[*] [* ] Correspondence to: K. Khunti, Diabetes Research Centre, College of Medicine, Biological Sciences and Psychology, University of Leicester, Leicester Diabetes Centre, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK.

E‐mail: kk22@ 123456leicester.ac.uk

[†]

K. K. and S. P. contributed equally to the study design, statistical analysis plan, data interpretation and writing of this manuscript.

Article

Publisher ID: DOM12626

DOI: 10.1111/dom.12626

PMC ID: 5067688

PubMed ID: 26743666

SO-VID: 1c7bb72d-006d-4f20-a370-e048cfedce42

License:

This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

History

Date received : 03 November 2015

Date revision received : 30 November 2015

Date accepted : 29 December 2015

Page count

Pages: 9

Funding

Funded by: Novo Nordisk

Custom metadata

source-schema-version-number 2.0

component-id dom12626

cover-date April 2016

details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_NLMPMC version:4.9.5 mode:remove_FC converted:18.10.2016

ScienceOpen disciplines: Endocrinology & Diabetes

Keywords: basal,glucagon‐like peptide‐1,glycaemic control,intensive insulin therapy,type 2 diabetes

Data availability:

ScienceOpen disciplines: Endocrinology & Diabetes

Keywords: basal, glucagon‐like peptide‐1, glycaemic control, intensive insulin therapy, type 2 diabetes

Clinical inertia with regard to intensifying therapy in people with type 2 diabetes treated with basal insulin

Read this article at

Abstract

Aim

Methods

Results

Conclusions

Related collections

GLUT4 biology

Most cited references 25

Validity of diagnostic coding within the General Practice Research Database: a systematic review.

Three-year efficacy of complex insulin regimens in type 2 diabetes.

Addition of biphasic, prandial, or basal insulin to oral therapy in type 2 diabetes.

Author and article information

Journal

Affiliations

Author notes

Article

History

Page count

Funding

Categories

Custom metadata

Comments

Comment on this article

Similar content 218

Cited by 107

Most referenced authors 760