J Manski-Nankervis1, C J Yates2,3, I Blackberry1,4, J Furler1, L Ginnivan1, N Cohen5, A Jenkins6, S Vasanthakumar7, A Gorelik8, D Young1, J Best9, D O'Neal10. 1. Department of General Practice, University of Melbourne, Carlton, Vic., Australia. 2. Department of Medicine, University of Melbourne, Melbourne, Vic., Australia. 3. Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Vic., Australia. 4. La Trobe University, Wodonga, Vic., Australia. 5. Baker IDI Heart and Diabetes Institute, Melbourne, Vic., Australia. 6. NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia. 7. Monash Medical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Vic., Australia. 8. Melbourne EpiCentre, Royal Melbourne Hospital, University of Melbourne, Parkville, Vic., Australia. 9. Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore. 10. Department of Medicine, St Vincent's Hospital, University of Melbourne, Fitzroy, Vic., Australia.
Abstract
AIM: To use continuous glucose monitoring to examine the effects of insulin initiation with glargine, with or without glulisine, on glycaemic variability and glycaemia in a cohort of people with Type 2 diabetes receiving maximum oral hypoglycaemic agents in primary healthcare. METHODS: We conducted a post hoc analysis of continuous glucose monitoring data from 89 participants at baseline and at 24 weeks after insulin commencement. Indicators of glycaemic variability (standard deviation, J-index and mean amplitude of glycaemic excursion) and glycaemia (HbA1c , mean glucose, area under the glucose-time curve) were assessed. Multi-level regression analysis was used to identify the predictors of change. RESULTS: Complete glycaemic variability data were available for 78 participants. Of these participants, 41% were women, their mean (sd) age was 59.2 (10.4) years, the median (interquartile range) diabetes duration was 10.4 (6.5, 13.3) years and the median (interquartile range) baseline HbA1c was 82.5 (71.6, 96.7) mmol/mol [9.7 (8.7, 11.0)%]. At baseline, BMI correlated negatively with standard deviation (r = -0.30) and mean amplitude of glycaemic excursion (r = -0.26), but not with J-index; HbA1c correlated with J-index (r = 0.61) but not with mean amplitude of glycaemic excursion and standard deviation. After insulin initiation the mean (sd) glucose level decreased [from 12.0 (3.0) to 8.5 (1.6) mmol/l; P < 0.001], as did the median (interquartile range) J-index [from 66.9 (47.7, 95.1) to 36.9 (27.6, 49.8) mmol/l; P < 0.001]. Baseline HbA1c correlated with a greater J-index reduction (r = -0.45; P < 0.001). The mean amplitude of glycaemic excursion and standard deviation values were unchanged. The baseline temporal profile, showing elevated postprandial morning glucose levels, was unchanged after insulin initiation, despite an overall reduction in glycaemia. CONCLUSION:Insulin initiation reduced hyperglycaemia but did not alter glycaemic variability in adults with Type 2 diabetes receiving maximum oral hypoglycaemic agents. The most significant postprandial excursions were seen in the morning, which identifies prebreakfast as the most effective target for short-acting insulin therapy.
RCT Entities:
AIM: To use continuous glucose monitoring to examine the effects of insulin initiation with glargine, with or without glulisine, on glycaemic variability and glycaemia in a cohort of people with Type 2 diabetes receiving maximum oral hypoglycaemic agents in primary healthcare. METHODS: We conducted a post hoc analysis of continuous glucose monitoring data from 89 participants at baseline and at 24 weeks after insulin commencement. Indicators of glycaemic variability (standard deviation, J-index and mean amplitude of glycaemic excursion) and glycaemia (HbA1c , mean glucose, area under the glucose-time curve) were assessed. Multi-level regression analysis was used to identify the predictors of change. RESULTS: Complete glycaemic variability data were available for 78 participants. Of these participants, 41% were women, their mean (sd) age was 59.2 (10.4) years, the median (interquartile range) diabetes duration was 10.4 (6.5, 13.3) years and the median (interquartile range) baseline HbA1c was 82.5 (71.6, 96.7) mmol/mol [9.7 (8.7, 11.0)%]. At baseline, BMI correlated negatively with standard deviation (r = -0.30) and mean amplitude of glycaemic excursion (r = -0.26), but not with J-index; HbA1c correlated with J-index (r = 0.61) but not with mean amplitude of glycaemic excursion and standard deviation. After insulin initiation the mean (sd) glucose level decreased [from 12.0 (3.0) to 8.5 (1.6) mmol/l; P < 0.001], as did the median (interquartile range) J-index [from 66.9 (47.7, 95.1) to 36.9 (27.6, 49.8) mmol/l; P < 0.001]. Baseline HbA1c correlated with a greater J-index reduction (r = -0.45; P < 0.001). The mean amplitude of glycaemic excursion and standard deviation values were unchanged. The baseline temporal profile, showing elevated postprandial morning glucose levels, was unchanged after insulin initiation, despite an overall reduction in glycaemia. CONCLUSION:Insulininitiation reduced hyperglycaemia but did not alter glycaemic variability in adults with Type 2 diabetes receiving maximum oral hypoglycaemic agents. The most significant postprandial excursions were seen in the morning, which identifies prebreakfast as the most effective target for short-acting insulin therapy.
Authors: John Furler; David Norman O'Neal; Jane Speight; Irene Blackberry; Jo-Anne Manski-Nankervis; Sharmala Thuraisingam; Katie de La Rue; Louise Ginnivan; Jessica Lea Browne; Elizabeth Holmes-Truscott; Kamlesh Khunti; Kim Dalziel; Jason Chiang; Ralph Audehm; Mark Kennedy; Malcolm Clark; Alicia Josephine Jenkins; Danny Liew; Philip Clarke; James Best Journal: BMJ Open Date: 2018-07-17 Impact factor: 2.692