BACKGROUND: Many patients with type 2 diabetes eventually require insulin, yet little is known about the patterns and quality of pharmacologic care received following insulin initiation. Guidelines from the American Diabetes Association and the European Association for the Study of Diabetes recommend that insulin secretagogues such as sulfonylureas be discontinued at the time of insulin initiation to reduce the risk of hypoglycemia, and that treatment be intensified if HbA1c levels remain above-target 3 months after insulin initiation. OBJECTIVE: To describe pharmacologic treatment patterns over time among adults initiating insulin and/or intensifying insulin treatment. DESIGN: Observational study. SUBJECTS: A large commercially insured population of adult patients without recorded type 1 diabetes who initiated insulin. MAIN MEASURES: We evaluated changes in non-insulin antidiabetic medication use during the 120 days immediately following insulin initiation, rates of increase in insulin dose and/or dosing frequency during the 270 days following an insulin initiation treatment period of 90 days, and rates of insulin discontinuation. KEY RESULTS: Seven thousand, nine hundred and thirty-two patients initiated insulin during 2003-2008, with the majority (61 %) initiating basal insulin only. Metformin (55 %), sulfonylureas (39 %), and thiazolidinediones (30 %) were commonly used prior to insulin initiation. Metformin was continued by 64 % of patients following mixed or mealtime insulin initiation; the continuation rate was nearly as high for sulfonylureas (58 %). Insulin dose and/or dosing frequency increased among 22.9 % of patients. Insulin was discontinued by 27 % of patients. CONCLUSIONS: We found evidence of substantial departures from guideline-recommended pharmacotherapy. Insulin secretagogues were frequently co-prescribed with insulin. The majority of patients had no evidence of treatment intensification following insulin initiation, although this finding is difficult to interpret without HbA1c levels. While each patient's care should be individualized, our data suggest that the quality of care following insulin initiation can be improved.
BACKGROUND: Many patients with type 2 diabetes eventually require insulin, yet little is known about the patterns and quality of pharmacologic care received following insulin initiation. Guidelines from the American Diabetes Association and the European Association for the Study of Diabetes recommend that insulin secretagogues such as sulfonylureas be discontinued at the time of insulin initiation to reduce the risk of hypoglycemia, and that treatment be intensified if HbA1c levels remain above-target 3 months after insulin initiation. OBJECTIVE: To describe pharmacologic treatment patterns over time among adults initiating insulin and/or intensifying insulin treatment. DESIGN: Observational study. SUBJECTS: A large commercially insured population of adult patients without recorded type 1 diabetes who initiated insulin. MAIN MEASURES: We evaluated changes in non-insulin antidiabetic medication use during the 120 days immediately following insulin initiation, rates of increase in insulin dose and/or dosing frequency during the 270 days following an insulin initiation treatment period of 90 days, and rates of insulin discontinuation. KEY RESULTS: Seven thousand, nine hundred and thirty-two patients initiated insulin during 2003-2008, with the majority (61 %) initiating basal insulin only. Metformin (55 %), sulfonylureas (39 %), and thiazolidinediones (30 %) were commonly used prior to insulin initiation. Metformin was continued by 64 % of patients following mixed or mealtime insulin initiation; the continuation rate was nearly as high for sulfonylureas (58 %). Insulin dose and/or dosing frequency increased among 22.9 % of patients. Insulin was discontinued by 27 % of patients. CONCLUSIONS: We found evidence of substantial departures from guideline-recommended pharmacotherapy. Insulin secretagogues were frequently co-prescribed with insulin. The majority of patients had no evidence of treatment intensification following insulin initiation, although this finding is difficult to interpret without HbA1c levels. While each patient's care should be individualized, our data suggest that the quality of care following insulin initiation can be improved.
Authors: Sebastian Schneeweiss; Amanda R Patrick; Til Stürmer; M Alan Brookhart; Jerry Avorn; Malcolm Maclure; Kenneth J Rothman; Robert J Glynn Journal: Med Care Date: 2007-10 Impact factor: 2.983
Authors: Anushka Patel; Stephen MacMahon; John Chalmers; Bruce Neal; Laurent Billot; Mark Woodward; Michel Marre; Mark Cooper; Paul Glasziou; Diederick Grobbee; Pavel Hamet; Stephen Harrap; Simon Heller; Lisheng Liu; Giuseppe Mancia; Carl Erik Mogensen; Changyu Pan; Neil Poulter; Anthony Rodgers; Bryan Williams; Severine Bompoint; Bastiaan E de Galan; Rohina Joshi; Florence Travert Journal: N Engl J Med Date: 2008-06-06 Impact factor: 91.245
Authors: David M Nathan; John B Buse; Mayer B Davidson; Robert J Heine; Rury R Holman; Robert Sherwin; Bernard Zinman Journal: Diabetes Care Date: 2006-08 Impact factor: 19.112
Authors: Mark Peyrot; Richard R Rubin; Torsten Lauritzen; Soren E Skovlund; Frank J Snoek; David R Matthews; Rüdiger Landgraf; Line Kleinebreil Journal: Diabetes Care Date: 2005-11 Impact factor: 19.112
Authors: Philip Raskin; Elsie Allen; Priscilla Hollander; Andrew Lewin; Robert A Gabbay; Peter Hu; Bruce Bode; Alan Garber Journal: Diabetes Care Date: 2005-02 Impact factor: 19.112
Authors: Rury R Holman; Kerensa I Thorne; Andrew J Farmer; Melanie J Davies; Joanne F Keenan; Sanjoy Paul; Jonathan C Levy Journal: N Engl J Med Date: 2007-09-21 Impact factor: 91.245
Authors: Shari Bolen; Leonard Feldman; Jason Vassy; Lisa Wilson; Hsin-Chieh Yeh; Spyridon Marinopoulos; Crystal Wiley; Elizabeth Selvin; Renee Wilson; Eric B Bass; Frederick L Brancati Journal: Ann Intern Med Date: 2007-07-16 Impact factor: 25.391