Targeted insulin-adherence intervention may improve glycemic control
medwireNews: Targeting specific populations of individuals with type 2 diabetes for intensive interventions to optimize their insulin use may result in better glycemic control than an untargeted approach, findings from the TARGIT-Diabetes trial suggest.
However, the pharmacist-led, telephone- and text-based intervention did not improve the primary outcome of insulin persistence, say Niteesh Choudhry, from Harvard Medical School in Boston, Massachusetts, USA, and co-investigators.
The trial included 5596 participants with type 2 diabetes treated with basal insulin who were allocated to take part in a highly targeted high-intensity, partially targeted moderate-intensity, or untargeted low-intensity intervention.
As reported in JAMA Network Open, the proportion of participants categorized as insulin nonpersistent – those who did not refill their basal insulin prescription within a set timeframe – was comparable among the highly, partially, and untargeted groups, at rates of 4.9%, 4.7%, and 5.4%, respectively.
Nevertheless, patients given the highly targeted high-intensity intervention experienced a significantly greater reduction in glycated hemoglobin (HbA1c) levels over an average follow-up of 287 days compared with those in the untargeted low-intensity group, with mean decreases of 0.31% versus 0.06%. Individuals given the partially targeted, moderate-intensity intervention had a comparable average reduction in HbA1c levels to those in the highly targeted group, at 0.21%.
Glycemic control is “ultimately a more meaningful outcome in diabetes care” than insulin nonpersistence, say the TARGIT-Diabetes (Targeted Adherence Intervention to Reach Glycemic Control With Insulin Therapy for Patients With Diabetes) investigators.
They add that “[a]lthough the levels of glycemic control achieved were modest, the improvements were roughly equivalent to those anticipated from the addition of an oral hypoglycemic medication.”
Choudhry and colleagues explain that their intervention targeted individuals most likely to benefit, so excluded people with very high insulin adherence, and assumed that those with very low adherence were likely to have “completely stopped the therapy for clinically appropriate reasons.”
Among participants who were randomly assigned to the highly targeted group, those with a predicted risk for insulin nonadherence of 20–80% and elevated HbA1c (≥8%) were given the high-intensity intervention, whereas those randomized to the partially targeted arm were given the moderate-intensity intervention if they had a predicted nonadherence risk of 10–90%. Patients in these groups who were not assigned to the interventions were given usual care. And all individuals allocated to the untargeted group received the low-intensity intervention.
All interventions involved a tailored telephone- and text message-based program, with the frequency of follow-up calls ranging from two in the low-intensity group to as many as 12 in the high-intensity group.
Taken together, the TARGIT-Diabetes results “suggest that targeting patient populations for more intensive interventions based both on predicted risk of nonadherence and level of glycemic control has the potential to be more effective than untargeted approaches,” conclude the researchers.
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