Basal Insulin Titration Research Articles

Patient-led rapid titration of basal insulin in gestational diabetes is associated with improved glycaemic control and lower birthweight.

AimsElevated fasting blood glucose in gestational diabetes (GDM) is a key predictor of high birthweight babies and adverse pregnancy outcomes but is hard to treat. We implemented a simple, patient‐led, insulin dose titration algorithm aiming to improve fasting glycaemic control in GDM.MethodsIn women with GDM, initiating basal insulin, we recommended a daily four‐unit dose increase after every fasting glucose value ≥5.0 mmol/mol (90 mg/dl). This approach augmented our pre‐existing intensive (weekly) specialist nursing input. Using a before‐and‐after retrospective observational study design, we examined insulin doses and glucose values at 36 weeks gestation and maternal and neonatal outcomes in 105 women completing pregnancy before and 93 women after the intervention.ResultsThe baseline characteristics of women in the before and after groups were the same. Women initiated on insulin after implementation (n = 30 before, n = 43 after) achieved substantially higher doses at 36 weeks (53 vs. 36 units/day; 0.56 vs. 0.37 units/kg/day; p = 0.027). 36‐week mean fasting glucose was lower in those on insulin after implementation (4.6 vs. 5.1 mmol/L [83 vs. 92 mg/dl]; p = 0.031). Birthweight was significantly reduced (birthweight Z‐scores 0.34 vs. 0.92; p = 0.005). There was no significant difference in macrosomia (after; 2% vs. before; 17% p = 0.078) or caesarean sections (after; 33% vs. before; 47%; p = 0.116). No women experienced severe hypoglycaemia. There were no outcome differences before versus after intervention in women not treated with insulin.ConclusionsPatient‐led daily insulin titration in gestational diabetes leads to higher insulin dose use lower fasting glucose and is associated with lower birthweight without causing significant hypoglycaemia.

Impact of the Fasting Plasma Glucose Titration Target on the Success of Basal Insulin Titration in Insulin-Naïve Patients with Type 2 Diabetes: A Systematic Analysis

Background/Aim We aimed to examine beneficial and adverse outcomes of basal insulin titration performed with different fasting plasma glucose (FPG) titration targets (TT). Methods A PubMed literature search retrieved 43 reported prospective clinical trials introducing basal insulin in 17643 insulin-naïve patients with type 2 diabetes reporting fasting plasma glucose (FPG), HbA1c, target achievement, hypoglycemic events, and insulin doses. 61 individual study arms were grouped by fasting plasma glucose titration target (TT; 1: ≤5.0 mmol/l/90 mg/dl; 2: 5.01-5.6 mmol/l/90-100 mg/dl; and 3: ≥5.61 mmol/l/101 mg/dl). Weighted means and their standard deviations were calculated for baseline and end-of-treatment FPG (primary endpoint), HbA1c, target achievement, hypoglycemic events, insulin doses, and body weight gain and compared over a duration of 31 ± 10 weeks. Results Achieved FPG and HbA1c at the end of the study were significantly lower (by up to 0.8 mmol/l or 0.23%, respectively) with more ambitious TTs (p < 0.0001), leading to better HbA1c target achievement with more ambitious TTs (by up to 14.6% for HbA1c ≤ 6.5%), without increasing the risk for hypoglycemic episodes. Conclusions Aiming for a lower FPG TT improves glycemic control without increasing the risk for hypoglycemia.

Practical Guidance on Basal Insulin Initiation and Titration in Asia: A Delphi-Based Consensus.

The global health burden of diabetes is on the rise and has affected more than half a billion people worldwide, particularly in Southeast Asia, North Africa, Africa, and the Western Pacific, Middle East, and South and Central America regions of the International Diabetes Federation (IDF). Despite many new treatments being available for the management of diabetes, glycemic control remains suboptimal in Asia, compared to the rest of the world. Delay in timely insulin initiation and inadequate titration of insulin are regarded to be some of the important reasons for inadequate glycemic control. Additionally, Asian populations have a distinct phenotype, including a younger age of onset and higher glycemic excursions, suggestive of a lower beta-cell function, as compared to non-Asians. Although there are multiple local and international guidelines on insulin initiation and titration, some of these guidelines can be complex. There is an unmet need for guideline recommendations on basal insulin initiation and titration to be simplified and customized for the Asian population with type 2 diabetes mellitus (T2DM). A unified approach would increase adoption of basal insulin initiation by primary care and family medicine physicians, which in turn would help reduce the inertia to insulin initiation. With this background, a consensus-seeking meeting was conducted with 14 experts from seven Asian countries to delineate appropriate practices for insulin initiation and titration in the Asian context. The key objective was to propose a simple insulin titration algorithm, specific for the Asian population, to improve glycemic control and optimize therapeutic outcomes of people with T2DM on basal insulin. Following a detailed review of literature and current guidelines, and potential barriers to insulin initiation and titration, the experts proposed a simplified insulin titration algorithm based on both physician- and patient-led components. The consensus recommendations of the experts related to basal insulin initiation and titration have been summarized in this article, along with the proposed titration algorithm for optimizing glycemic control in the Asian population with T2DM.

379-P: Patient and Physician Experience of Hypoglycemia during Basal Insulin (BI) Titration in Type 2 Diabetes (T2D) in the U.S.

Introduction: Hypoglycemia after BI initiation can negatively impact patient adherence to titration and glycemic target achievement. We report on 2 surveys to better understand patient and physician perspectives/experiences of hypoglycemia during BI titration. Methods: Adults with T2D and ≥2 claims (≥30 days apart in last 12 months) in the Optum Research Database who initiated BI (February-April 2021) , and physicians who treated ≥30 patients with T2D, ≥1 initiating BI (October 2020-March 2021) , completed a mailed survey. Results: Responders were 416 patients (51% male, 71% white, mean age 70 years, 72% &amp;gt;years T2D duration) and 386 physicians (45% general practice) . Most physicians reported discussing hypoglycemia signs/symptoms (93%) and how to titrate BI in response to blood glucose (BG) levels (81%) with patients. Among patients who experienced hypoglycemia (49%; Table) , 57% felt very/extremely confident titrating BI during hypoglycemia. Only 35% met fasting BG (FBG) targets. Diabetes Treatment Satisfaction Questionnaire hypoglycemia score (1.34/6) suggests patients felt hypoglycemia was infrequent. Conclusion: While physicians educate patients on hypoglycemia awareness and BI titration, nearly half of patients surveyed experienced hypoglycemia during titration, and only a third met FBG targets, suggesting new strategies and tools are needed for effective BI titration. Disclosure S.B.Harris: Consultant; Abbott, AstraZeneca, Eli Lilly and Company, Novo Nordisk, Sanofi, Other Relationship; Abbott, AstraZeneca, Bayer Inc., Dexcom, Eli Lilly and Company, HLS Therapeutics, Janssen Pharmaceuticals, Inc., Novo Nordisk, Sanofi, Research Support; Applied Therapeutics Inc., AstraZeneca, Canadian Institutes of Health Research, Juvenile Diabetes Research Foundation (JDRF) , Novo Nordisk, Sanofi, The Lawson Foundation. K.Mohammedi: Board Member; Lilly, Novo Nordisk, Sanofi, Research Support; Cyclerion Therapeutics, Inc., Speaker's Bureau; Abbott, AstraZeneca. M.Bertolini: Employee; Sanofi. V.Walker: Consultant; Sanofi-Aventis U.S. M.H.Carlyle: None. F.L.Zhou: Employee; Sanofi, Stock/Shareholder; Sanofi. J.Seufert: Advisory Panel; Abbott, Sanofi-Aventis Deutschland GmbH, Research Support; Boehringer Ingelheim International GmbH, Speaker's Bureau; Abbott Diabetes, AstraZeneca, Bayer AG, Boehringer Ingelheim International GmbH, Lilly, Novo Nordisk, Sanofi-Aventis Deutschland GmbH. J.E.Anderson: Advisory Panel; Abbott Diabetes, Consultant; AstraZeneca, Bayer AG, Boehringer Ingelheim International GmbH, Gelesis, Novo Nordisk, Sanofi, Speaker's Bureau; Eli Lilly and Company. Funding Sanofi

512-P: Physician Perspectives and Experiences with Basal Insulin Titration in Type 2 Diabetes: A U.S. Cross-Sectional Survey

Introduction: Appropriate titration of basal insulin (BI) is essential to achieve glycemic control in patients with type 2 diabetes (T2D) . However, optimal glucose control is often unattained due to challenges with BI titration. This survey study reports physician experiences with BI titration. Methods: Physicians in the Optum Research Database who treated ≥30 patients with T2D, with ≥1 who initiated BI from 10/01/20 to 03/31/21, were asked to complete a one-time mailed survey. Results: Among 386 responders, 70% were male, 76% in general practice, 63% had ≥20-years’ experience, and 29% practiced in rural regions. Most (90%) physicians reported seeing &amp;gt;50 patients with T2D in the prior 6 months, and 66% treated ≥25% of them with BI. The majority (77%) expected glucose control attainment within 12 weeks, and 51% estimated &amp;lt;25% of patients were unable to reach HbA1c goal. Most (86%) physicians explained titration to all/most of their patients new to BI. Only 27% expected patients to self-manage titration; 60% managed titration for them, and 13% did both. Most (84%) physicians had in-office titration education by healthcare providers, 42% provided ongoing access to them; only 13% provided digital tools. The majority expressed concerns about patients’ abilities to follow titration algorithms (79%) , and to monitor blood glucose effectively (66%) , as well as lack of engagement in the titration process (72%) . Conclusion: Physicians reported counseling most new-to-BI patients for titration and providing ongoing clinical guidance and non-digital support tools. Despite this, the majority of physicians expressed concern about patients' abilities to manage self-titration effectively. These findings support the need for novel approaches or tools to support patients during BI titration. Disclosure S.B.Harris: Consultant; Abbott, AstraZeneca, Eli Lilly and Company, Novo Nordisk, Sanofi, Other Relationship; Abbott, AstraZeneca, Bayer Inc., Dexcom, Eli Lilly and Company, HLS Therapeutics, Janssen Pharmaceuticals, Inc., Novo Nordisk, Sanofi, Research Support; Applied Therapeutics Inc., AstraZeneca, Canadian Institutes of Health Research, Juvenile Diabetes Research Foundation (JDRF) , Novo Nordisk, Sanofi, The Lawson Foundation. J.Seufert: Advisory Panel; Abbott, Sanofi-Aventis Deutschland GmbH, Research Support; Boehringer Ingelheim International GmbH, Speaker's Bureau; Abbott Diabetes, AstraZeneca, Bayer AG, Boehringer Ingelheim International GmbH, Lilly, Novo Nordisk, Sanofi-Aventis Deutschland GmbH. M.Bertolini: Employee; Sanofi. V.Walker: Consultant; Sanofi-Aventis U.S. J.C.White: Consultant; Sanofi-Aventis U.S. F.L.Zhou: Employee; Sanofi, Stock/Shareholder; Sanofi. K.Mohammedi: Board Member; Lilly, Novo Nordisk, Sanofi, Research Support; Cyclerion Therapeutics, Inc., Speaker's Bureau; Abbott, AstraZeneca. J.E.Anderson: Advisory Panel; Abbott Diabetes, Consultant; AstraZeneca, Bayer AG, Boehringer Ingelheim International GmbH, Gelesis, Novo Nordisk, Sanofi, Speaker's Bureau; Eli Lilly and Company.

809-P: Digital-Tool-Supported Basal Insulin (BI) Titration: Real-World Effectiveness of My Dose Coach (MDC) in People with Type 2 Diabetes (T2D) in Colombia

BI therapy is recommended in people with T2D uncontrolled on oral antidiabetic agents. However, due to delay in BI initiation and titration, many people with T2D fail to achieve recommended glycemic targets. MDC, an FDA-approved digital app, helps people with T2D to adjust their BI doses based on their fasting blood glucose (FBG) readings and hypoglycemic event data. We evaluated real-world outcomes from people with T2D on BI therapy, who registered on MDC app from 08/01/2018 to 09/30/2021 and received insulin glargine 100 U/mL or 300 U/mL. FBG target achievement (≥3 consecutive measurements within the target range) , change in FBG, and hypoglycemia events were assessed. A total of 5MDC users from Colombia with mean (SD) age 56.6 (15.1) years (55.8% female) were included (Table) . Overall, 4 (80.9%) users achieved individualized FBG target, 44 (8.7%) were still titrating and 52 (10.3%) stopped using MDC. The mean (SD) time to reach FBG target was 10.3 (15.8) days. Mean (SD) FBG at baseline was 141.7 (55.0) mg/dL, which decreased to 117.3 (31.7) mg/dL and mean (SD) BI dose increased from 22.2 (11.3) U to 24.2 (12.4) U. Hypoglycemia events were reported in 72 (14%) participants overall. These results show that people with T2D from Colombia using MDC were able to successfully titrate their BI doses and achieve FBG target with low risk of hypoglycemia. Disclosure A.Gomez: Advisory Panel; AstraZeneca, Research Support; Abbott Diabetes, Speaker's Bureau; Eli Lilly and Company, Medtronic, Novo Nordisk, Sanofi. A.Rincon: Advisory Panel; AstraZeneca, Medtronic, Sanofi, Consultant; Abbott, Medtronic, Novo Nordisk, Novo Nordisk, Sanofi, Other Relationship; Boehringer Ingelheim International GmbH, Novo Nordisk, Sanofi. K.Feriz: Other Relationship; Abbott, Boehringer Ingelheim International GmbH, Novo Nordisk, Sanofi, Speaker's Bureau; AstraZeneca, Lilly Diabetes, Medtronic, Merck Sharp &amp; Dohme Corp. C.F.Salamanca: Employee; Sanofi. L.P.Silva: Employee; Merck KGaA, Sanofi. Funding Sanofi

64-LB: Long-Term Effectiveness of the My Dose Coach Application on the Maintenance of Glycemic Control in Patients with Type 2 Diabetes Mellitus in Uncontrolled

Introduction: My Dose Coach (MDC) is an app designed for basal insulin dose titration that has demonstrated its versatility in several clinical studies. We evaluated its effect on the maintenance of glycemic control for 28 weeks in patients with type 2 Diabetes. Objective: Compare the efficacy of 2 basal insulin titration strategies: MDC vs. Conventional Titration (CT) to maintain glycemic control (HbA1c &amp;lt; 7% and fasting plasma glucose -FPG- between 90-130 mg/dL) . Research Design and Methods: We design controlled and randomized clinical trial lasting 28 weeks, we included 80 patients with uncontrolled type 2 Diabetes (HbA1c between 8-10%) and without previous treatment with insulin. They were randomized into 2 groups: online insulin dose titration using the MDC app vs. CT in person every 2 weeks. At week 25, all enrolled patients titrated their dose in a conventional manner to assess the effect of discontinuing use of the app. Results: We included 40 patients per group, with a mean age of 52.7 years and a duration of type 2 Diabetes of 8.1 years. A total of 36 subjects (90%) vs. 33 (82.5%) completed the study, p 0.215. In the initial evaluation the following results were obtained: baseline FPG 172 vs. 167 mg/dL, p 0.98, HbA1c 9 vs. 8.9%, p 0.497, initial dose of insulin Glargine (U-100/U-300) 16.9 vs. 17.6 IU, p 0.122, MDC vs. CT respectively. Evaluation at 24 weeks, glucose 106 vs. 110 mg/dL, p 0.69, HbA1c 6.87 vs. 7.08 %, p 0.016, mean HbA1c reduction -2.10 vs. -1.83 %, p 0.015. Final insulin dose 29.9 vs. 34.1 IU, p 0.004, mean time to FPG goal 18 vs. 26 days, p 0.001. When suspending the titration by means of the application in the week 25 to 28 average glucose increased 138.5 vs. 142 mg/dL p 0.605, MDC vs. CT respectively. Conclusions: My Dose Coach app is an effective digital insulin glargine titration tool in real-world patients with uncontrolled type 2 Diabetes, as the number of participants achieving established control goals was higher and lasted longer. Fulfilling the objective of the study with lower doses of insulin and achieving stability in FPG in a considerably shorter time. Disclosure M. A. Polanco: None.

Effect of Digital-Tool-Supported Basal Insulin Titration Algorithm in Reaching Glycemic Control in Patients with Type 2 Diabetes in Mexico.

My Dose Coach (MDC) is a mobile application combined with a web portal that can suggest optimized basal insulin (BI) injection doses using Self-Measured Plasma Glucose (SMPG) and hypoglycemia data. This study aimed to evaluate its efficacy on patients reaching SMPG and Fasting blood glucose (FBG) target range 90-130 mg/dl (5-7.2 mmol/L) goals without severe hypoglycemic episodes. We also addressed the mean reduction in glycated hemoglobin (A1C), FBG, and SMPG and the improvement in the WHO's Five Well Being Index (WBI). This prospective pilot study involved the use of MDC in outpatients with type 2 diabetes (T2DM) from a Hospital in Northern Mexico. Patients on treatment with any BI were included in the study. The follow-up was of 16 weeks. Student t-tests or McNemar test were used for effect comparisons. We included 158 patients (46.8% women), mean (SD) age 51 (10.3) years. We achieved SMPG target range in 58.9% [mean (95CI) reduction of 30.9 mg/dl (22.5-37.7; P < .001)] of the patients [66(28) days], with no severe hypoglycemia events. FBG goal was reached in 55.7% [mean (95CI) reduction of 63.4 mg/dl (49.6-77.2; P < .001)]. The mean (95CI) reduction of A1C was 1.78% (1.47-2, P < .01) with the last observation carried forward. There was a mean (95CI) increase of 2.23 (-3, -1.4, P < .01) points in WBI scale. MDC successfully helped to achieve FBG and SMPG goals, reduced A1C, and increased WBI with no severe hypoglycemia events.

827-P: Pioneering a Novel Inpatient Diabetes Consult Service in the COVID Era

Hospitalized patients often do not reach the ADA-recommended glucose targets, which in turn increases complications, costs, length of stay, and readmission rate. The ADA supports the availability of trained specialists and teams to improve outcomes. Partly in response to the SARS CoV-2 pandemic, we instituted an inpatient “virtual care” initiative by electronic medical record (EMR) review. The ProActive Glucose Advice Team (pGAT) utilizes specialist expertise, automated computerized detection of hyperglycemia, and feedback to the primary service. The pGAT team members consist of an endocrinologist, a nurse diabetes care and education specialist, and a clinical dietician. The team reviewed a computer-generated report of inpatients with either 2 or more blood glucose values ≥180 mg/dl within the last 24 hours, and/or a hemoglobin A1c (A1c) ≥8%. We proposed to enter a brief, structured “pGAT Note” in the EMR, followed by a “gentle reminder” note the next day, including advice for a formal diabetes education and an endocrinology consultation. This proactive approach to the management of hyperglycemia would provide a summary review of the patient’s glucose state, determine the level of patient’s self-care skills, and steps to improve inpatient glycemic control. For preliminary data during the first 4-month phase after implementation of the pGAT initiative, we examined individualized discharge management and timely outpatient follow-up with endocrinology. Of 37 patients (28 males, 9 females; average age 60.4 years), 34 were treated with intensive insulin therapy with multiple daily insulin injections, 31 were seen in f/u within 2 weeks of discharge, and 25 were begun on Continuous Glucose Monitoring. The average A1c fell from an inpatient value of 11.6% to 8.4% measured between 2-4 months later. During the next pGAT phase, we intend to study inpatient therapy parameters, notably appropriate use of computerized insulin order sets, titration of basal insulin, and prandial-correction bolus insulin use. Disclosure A. A. Rizvi: None. A. O. Rich: None. R. Eldridge: None.

Expert Opinion: A Call for Basal Insulin Titration in Patients with Type2 Diabetes in Daily Practice: Southeast European Perspective.

Therapeutic inertia related to insulin treatment, i.e. delays in initiation, especially titration of basal insulin, is a significant problem in daily practice in Southeast European countries. This phenomenon can be traced back to several patient-, physician- and health system-related factors. In recognition of the issue of inadequate insulin titration, 11 leading experts from countries in this region held a consensus-seeking meeting to review the current status of insulin initiation after non-insulin treatment and the potential barriers to insulin titration to provide an algorithm and tools for outpatient physicians and for patients aimed at optimizing basal insulin titration. The experts reached a consensus on the majority of the topics and proposed recommendations on how clinical inertia can be overcome. The outcomes of the meeting have been summarized in this paper.

Pharmacokinetic and Pharmacodynamic Head-to-Head Comparison of Clinical, Equivalent Doses of Insulin Glargine 300 units · mL−1 and Insulin Degludec 100 units · mL−1 in Type 1 Diabetes

To prove equivalence of individual, clinically titrated basal insulin doses of glargine 300 units ⋅ mL-1 (Gla-300) and degludec 100 units ⋅ mL-1 (Deg-100) under steady state conditions in a single-blind, randomized, crossover study, on the glucose pharmacodynamics (PD) in people with type 1 diabetes (T1D). Subjects with T1D (N = 22, 11 men, age 44.3 ± 12.4 years, disease duration 25.5 ± 11.7 years, A1C 7.07 ± 0.63% [53.7 ± 6.9 mmol ⋅ mL-1], BMI 22.5 ± 2.7 kg · m-2), naïve to Gla-300 and Deg-100, underwent 24-h euglycemic clamps with individual clinical doses of Gla-300 (0.34 ± 0.08 units ⋅ kg-1) and Deg-100 (0.26 ± 0.06 units ⋅ kg-1), dosing at 2000 h, after 3 months of optimal titration of basal (and bolus) insulin. At the end of 3 months, Gla-300 and Deg-100 reduced slightly and, similarly, A1C versus baseline. Clamp average plasma glucose (0-24 h) was euglycemic with both insulins. The area under curve of glucose infused (AUC-GIR[0-24 h]) was equivalent for the two insulins (ratio 1.04, 90% CI 0.91-1.18). Suppression of endogenous glucose production, free fatty acids, glycerol, and β-hydroxybutyrate was 9%, 14%, 14%, and 18% greater, respectively, with Gla-300 compared with Deg-100 during the first 12 h, while glucagon suppression was no different. Relative within-day PD variability was 23% lower with Gla-300 versus Deg-100 (ratio 0.77, 90% CI 0.63-0.92). In T1D, individualized, clinically titrated doses of Gla-300 and Deg-100 at steady state result in similar glycemic control and PD equivalence during euglycemic clamps. Clinical doses of Gla-300 compared with Deg-100 are higher and associated with quite similar even 24-h distribution of PD and antilipolytic effects.

Efficacy and safety of patient-led versus physician-led titration of basal insulin in patients with uncontrolled type 2 diabetes: a meta-analysis of randomized controlled trials

IntroductionInsulin is the most effective antihyperglycemic treatment and basal insulin is the preferred initial formulation in patients with type 2 diabetes. However, its effects are dose-dependent, so adequate titration is...

202-OR: Basal Insulin Digital Titration App vs. Enhanced Paper Titration Tool: A Randomized Control Study

Self-adjusting insulin is challenging for people with type 2 diabetes (PWT2D). Mobile health technologies (mHealth) can help PWT2D track blood glucose more easily, but it remains unclear whether an mHealth-enabled digital therapeutic tool can effectively support basal insulin (BI) titration in a large multispecialty health care setting. We randomized 242 PWT2D on BI (baseline HbA1c 7.5% - 12.5%) to use either an app-based self-titration tool [Mobile Insulin Dosing System (MIDS)] or an enhanced paper titration tool based on a stepped algorithm with diabetes educator support (control) for 16 weeks. Cohort characteristics for the intent to treat sample (MIDS n = 117; control n = 120) were: median age 61 years [IQR: 53 - 69], 41.7% female, 75.9% non-Hispanic White, 11.4% new to insulin, median duration of diabetes 11 years [IQR: 7 - 18], and median baseline HbA1c of 8.7% [IQR: 8.0 - 9.6]. Improvements in HbA1c (-1.3% [IQR: -2.2 - -.5] and -1.2% [IQR: -1.9 - -.5]; both Ps &amp;lt; .05) with increased median insulin dose (+8 IU [IQR: 2 - 22] and +10 IU [IQR: 2 - 25.5]; both Ps &amp;lt; .05) and no change in hypoglycemia were observed at 16 weeks in both the MIDS and control groups, respectively. No differences in HbA1c (P = .48) or insulin dose change (P = .34) were observed between the groups. Among SMBG readings recorded during the study, the mean proportion of readings between 70-180 mg/dL (76.8% ± 22.0; 70.0% ± 26.7; p&amp;lt;0.05) and &amp;gt;250 mg/dL (4.9% ± 9.2; 9.2% ± 18.4; p&amp;lt;0.05) both favored the MIDS group. The use of MIDS and the enhanced paper-based tool for BI self-titration both resulted in higher insulin dose and significantly improved glycemic control among PWT2D who were relatively uncontrolled despite most already being treated with insulin. An mHealth-enabled digital therapeutic tool such as MIDS may offer an effective alternative option for PWT2D and their HCPs for titrating BI to non-mHealth approaches; future RCTs will more clearly elucidate the efficacy of MIDS compared to usual care. Disclosure A. Philis-Tsimikas: Advisory Panel; Self; Lilly Diabetes, Medtronic, Novo Nordisk A/S, Sanofi. Employee; Spouse/Partner; Ionis Pharmaceuticals, Inc. Research Support; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Dexcom, Inc., Lilly Diabetes, Medtronic, Novo Nordisk A/S, Sanofi. A.L. Fortmann: None. A. Bastian: None. A. Kanchi: Employee; Self; Glooko, Inc. Stock/Shareholder; Self; Glooko, Inc. R. Abad: Employee; Self; Glooko, Inc. T. Sheng: Employee; Self; Glooko, Inc. L. Parks: Employee; Self; Glooko, Inc. M. Greenfield: Consultant; Self; Glooko, Inc. M.A. Clements: Consultant; Self; Glooko, Inc. Other Relationship; Self; Glooko, Inc.

Overbasalization: Addressing Hesitancy in Treatment Intensification Beyond Basal Insulin.

The proportion of patients with type 2 diabetes achieving recommended treatment goals remains suboptimal despite advances in diabetes care (1). Only 30% of patients with type 2 diabetes who use basal insulin achieve an A1C <7%, with the probability of doing so diminishing greatly if not achieved within 1 year of insulin initiation (2–6). Factors underlying these delays are complex and may involve therapeutic inertia, which is defined as failure to intensify or deintensify therapy when appropriate (7). The clinical course of type 2 diabetes is characterized by a progressive decline in β-cell mass and function, as well as insulin resistance (8). Early in the course of the disease, the addition of basal insulin addresses decreasing β-cell function and is an efficient step in controlling fasting blood glucose but has little effect on controlling postprandial blood glucose (9). In patients with type 2 diabetes and elevated A1C, the relative contribution of fasting hyperglycemia is dominant with higher A1C, and postprandial hyperglycemia is a larger contributor when A1C is closer to 7% (10). Thus, titration of basal insulin when A1C is close to 7% will have minimal effect on postprandial hyperglycemia or on attainment of the A1C goal (11). Basal insulin is not designed to address postprandial hyperglycemia; its role is mainly to suppress hepatic glucose production, address insulin resistance, and correct fasting hyperglycemia. In theory, the ideal basal insulin dose should allow a patient with type 2 diabetes to fast for 24 hours without hypoglycemia. Once basal insulin has been initiated, appropriate titration is necessary to avoid “overbasalization,” or titration of basal insulin beyond an appropriate dose in an attempt to achieve glycemic targets. Several evidence-based titration algorithms exist (12–14); however, no particular algorithm has been shown to provide superior clinical benefit over others (15 …

Best Practices and Tools for Titrating Basal Insulins: Expert Opinion from an Indian Panel via the Modified Delphi Consensus Method.

AimTo develop an evidence-based expert group consensus document on the best practices and simple tools for titrating basal insulins in persons with type 2 diabetes mellitus (T2DM).BackgroundGlycemic control is suboptimal in a large proportion of persons with T2DM, despite insulin therapy, thereby increasing the risk of potentially severe complications. Early initiation of insulin therapy and appropriate dose titration are crucial to achieving glycemic targets. Attitudes and practices among healthcare professionals (HCPs) and perceptions about insulin therapy among persons with diabetes contribute largely to suboptimal glycemic control. Improving HCP–patient communication, encouraging the use of additional educational tools, and providing support for the titration process to increase confidence, both at the initiation visit and at home, facilitate the optimization of dose titration. In Indian settings, specific guidelines and a consensus statement are lacking on the optimal insulin initiation dose, frequency of dose titration, and basal insulin profile needed to achieve optimal titration. In clinical practice, physicians and persons with diabetes often do not adhere to the titration algorithms that currently exist for the purpose of achieving optimal titration as they perceive these to be very cumbersome. In this context, a group of experts met at an advisory board meeting and arrived at a consensus on best practices for the titration of basal insulin in persons withT2DM in India, using the modified Delphi methodology.Review ResultsAfter a review of evidence and further discussions, the expert group provided recommendations on insulin initiation dose, ideal period for titration in practice, titration regimen for use in practice, basal insulin profile for titration, and choosing a self-monitoring blood glucose schedule for titration.ConclusionsIn the management of T2DM, insulin can be effectively titrated by following a few simple recommendations. The use of second-generation basal insulin aids in mitigating the risk of hypoglycemic events. The implementation of a simplified titration regimen is crucial to achieving glycemic targets and long-term treatment goals.

EFFICACY AND SAFETY OF BASAL INSULIN THERAPY IN ROMANIAN PATIENTS WITH TYPE 2 DIABETES IN REAL-LIFE SETTINGS: A SUB-GROUP ANALYSIS OF DUNE STUDY.

Despite the available evidence showing the vital role of glycemic control in the management of type 2 diabetes, a significant proportion of patients are not achieving a good glycemic control. Here we present the results of the Diabetes Unmet Need with basal insulin Evaluation (DUNE) study for patients enrolled in Romanian centers with the aim to describe the proportion of participants who achieved individualized HbA1c targets at 12 weeks following basal insulin therapy initiation. Prospective, observational study. 355 consecutive adults with type 2 diabetes, who were newly initiated with basal insulin therapy (Newly initiated group) or had been treated for less than 12 months with basal insulin prior to study enrollment (Previously initiated group) were enrolled and followed for 12 weeks. The individualized HbA1c target was achieved by 22.7% of the patients in the Newly initiated group and by 25.0% of the patients in the Previously initiated group. During the study period, in the Newly initiated group mean basal insulin dose increased from 16.2 U at baseline to 27.6 U at 12 weeks. In the Previously initiated group, the insulin dose increased from 27.4 U at baseline to 33.1 U at 12 weeks. In both groups, 9.7% and 12.8% of the patients reported at least 1 episode of symptomatic hypoglycemia. In real-world settings, despite insulin initiation a large number of patients fail to achieve their individualized glycemic targets. One of the reasons appeared to be linked to the insufficient basal insulin titration.

The importance of the initial period of basal insulin titration in people with diabetes.

Achieving target glycaemic control is essential in people with diabetes to minimize the risk of long‐term complications, and many people with type 2 diabetes will ultimately require basal insulin (BI) therapy to achieve their individualized glycaemic targets. Usually, the first 12 weeks following initiation of BI therapy represents the period when the greatest dose increases and glycaemic reductions occur. Effective glycaemic control combined with minimizing the risk of hypoglycaemia is important to enable the achievement of glycaemic control in the longer term. However, substantial therapeutic inertia exists in clinical practice, both in initiation and up‐titration of BI, owing to patient‐, physician‐ and healthcare system‐related barriers, including fear of hypoglycaemia and the perception of a burdensome regimen. The more prolonged duration of action, reduced glycaemic variability and lower risk of hypoglycaemia seen with second‐generation versus first‐generation BI analogues may help alleviate patients’ and physicians’ concerns and facilitate titration. In turn, optimal BI titration and subsequent metabolic benefits may help improve therapy adherence and self‐management. This review details the clinical implications of prompt titration of BI to achieve early glycaemic control, and the importance of minimizing hypoglycaemia risk within the initial titration period. Facilitation of patients’ self‐management of BI is also addressed.

Basal Insulin Dose Titration for Glycemic Control in Patients With Type 2 Diabetes Mellitus in Thailand: Results of the REWARDS Real-World Study.

This multicenter, longitudinal, descriptive, observational study of T2DM adults in Thailand aimed to assess real-world outcomes of basal insulin (BI) dose titration on glycemic control. Three-hundred and twenty-four patients were recruited and followed up over 24 weeks. Basal insulin titration was physician-driven in 58.2% of patients and patient-driven in the rest. During the 24-week study period, the total daily BI dose moved from 20.9 to 25.6 in the physician-driven group, while in the patient-driven group, it increased from 25.3 to 29.7. Thirty-five patients (11.2%) achieved their individualized HbA1c targets, with 18 patients (5.8%) achieving HbA1c ⩽ 7% without documented hypoglycemia. In summary, this study highlights that BI titration is suboptimal in the real world, and patients are unable to achieve their glycemic targets.

Effect of medication adherence on clinical outcomes in type 2 diabetes: analysis of the SIMPLE study

ObjectiveMedication adherence is impacted by regimen complexity. The SIMPLE (Simple basal Insulin titration, Metformin Plus Liraglutide for type 2 diabetes with very Elevated HbA1c) study compared GLP1RA plus basal insulin...

Effectiveness and Safety of Physician-Led Versus Patient-Led Titration of Insulin Glargine in Indian Patients with Type 2 Diabetes Mellitus: A Subanalysis of the Asian Treat to Target Lantus Study (ATLAS).

Background: Titration of basal insulin led by either the physician or the patient is not well understood in India. This analysis of Indian subset of Asian Treat to Target Lantus Study (ATLAS) compared effectiveness of patient-led with physician-led titration of once-daily insulin glargine 100 U/mL (Glargine-U-100) in patients with type 2 diabetes mellitus (T2DM) uncontrolled on oral antidiabetes drug (OAD). Methods: In this open-label parallel group study, randomized patients (either physician-led or patient-led [self-titration] group) followed the same dose titration algorithm (fasting blood glucose [FBG] target 110 mg/dL [6.1 mmol/L]). The primary endpoint was change in mean glycated hemoglobin (HbA1c) at week 24 in the patient-led group versus the physician-led group. Results: Patients (40-75 years) were randomized to either the physician-led group (n = 39) or the patient-led group (n = 36). At week 24, self-titration led to a greater decline in HbA1c than physician-led titration (-1.3% vs. -1.1%). Mean decrease in FBG was more in the patient-led group than in the physician-led group (-53.7 mg/dL vs. -35.5 mg/dL). Mean daily dose of Glargine-U-100 at week 24 was higher in the patient-led group than in the physician-led group (30.0 U vs. 23.8 U). At any time during the study, 30.6% and 7.7% of patients in the patient-led and physician-led groups, respectively, showed target HbA1c level of <7.0% without severe hypoglycemia. Treatment satisfaction and quality of life improved in both groups. Overall, treatment was safe and well tolerated, and none of the events led to treatment discontinuation. Conclusion: Patient-led adjustment of Glargine-U-100 in outpatient setting can be a safe and effective method for glycemic control in Indian patients with T2DM uncontrolled on OADs.