Related news story: Real-world HbA1c targets usually individualized, rarely achieved
We continue to let inertia get in our way.
Insulin is one of the safest and most potent medications for treating hyperglycemia. The American Diabetes Association recommends that providers should assess and intensify treatment every 3 months if a patient is not at goal , but we know this has not happened. Less than half of people with diabetes are at goal and there is lots of evidence that steps to treatment intensification take too long [2, 3].
The authors of “The Diabetes Unmet Need with basal insulin Evaluation (DUNE) study in type 2 diabetes: Achieving HbA1c targets with basal insulin in a real world setting” set out to explore if the addition of basal insulin improved glucose targets, as determined by individualized glycated hemoglobin (HbA1c) goals, and if rates of hypoglycemia were increased. This was a prospective real-world observational multicenter trial in more than 3000 adults with type 2 diabetes. Providers were asked to set an individualized glucose target when they were planning to start insulin. Patients were then monitored for 12 weeks to determine if the HbA1c target was met and if hypoglycemia occurred.
The authors found that about one-quarter of patients (28% of new insulin starters, and 27% of previous insulin starters) actually got to the prespecified goal at 12 weeks. The providers used small doses of insulin (14–23 U/kg per day of basal insulin) and had little dose increase over the time of the study (5–9 U/kg). Providers reported that lack of patient adherence to lifestyle (60%) and lack of adherence to titration (44%) were the leading causes of patients not achieving the target. The great majority of patients did not experience any hypoglycemic episodes over the study period (84%); only 10% of patients experienced two or more episodes, and less than 1% experienced a severe hypoglycemic episode (0.8%). Those with hypoglycemia were more likely to achieve the HbA1c target.
This study is important in that the medication we rely on to treat the most hyperglycemic patients is still not being optimized. We are starting at too low a dose and still not titrating to an effective dose quick enough. There is ample evidence that a weight-based approach is advisable for starting insulin, and patient-driven titrations are more effective than provider-driven titrations. In this study, 63% of participants were instructed to self-titrate their insulin while the rest had provider-driven titration regimens. In this study, who drove the titration did not affect the achieved outcomes. Patients who were started on a basal insulin analog were more likely to get to goal than those who used NPH insulin (Neutral Protamine Hagedorn; p<0.05).
So it is clear that when we turn to insulin we can do better. We need to start at higher doses (weight-based is preferred) and we need a strategy to ensure that titrations are occurring on schedule. In this study, those who had higher HbA1c and were heavier were even less likely to get to goal, further highlighting the need for a strategic approach to helping patients titrate. When we turn to insulin we need to use it effectively in type 2 diabetes and this may need a team approach in which your staff or diabetes educators or clinical pharmacists can be called in to help patients achieve their target and stick to the treatment plan. Future real-world studies will need to explore which of those effective protocols in clinical trials can be replicated in the community setting.