Bolus Insulin Therapy Research Articles

Effect of basal insulin therapy with glargine U300 versus basal bolus insulin therapy in hospitalized patients with type 2 diabetes. Real-world study from India

Background. Basal-bolus insulin therapy is the most widely accepted method of glycemic control in non-critically ill patients with T2DM. In this regimen glargine U100 is the most commonly used basal insulin. American Diabetes Association recommends either basal or basal bolus therapy for patients with type 2 diabetes mellitus admitted in general medical and surgical ward with ideal glycemic target ranging between 140–180 mg/dL by estimating four or 6 hourly capillary blood glucose per day. Insulin glargine U300 is a second generation long acting insulin analogue, which has a prolonged pharmacokinetic /pharmacodynamic profile compared to insulin glargine U100 resulting in glucose lowering activity exceeding 24 hours. Aim. To assess the efficacy and safety of basal insulin regimen (glargine U300) compared to a basal-bolus insulin regimen in patients with type 2 diabetes. Methods. A prospective single centred parallel group study comparing the efficacy and safety of basal insulin regimen with basal-bolus insulin regimen. A total of 60 patients with type 2 diabetes mellitus admitted in general medical and surgical ward for elective surgery and medical emergency were randomized to either of the two regimens. The baseline glycaemic parameters were assessed by capillary blood glucose testing thrice before meal and at bedtime with a target capillary blood glucose (CBG) between 140–180 mg/dL. All pa-tients were followed up for seven days. Results. The number of CBG readings within the target range were higher in basal insulin monotherapy (glargine U300) compared to basal-bolus regimen using (glargine U100 and regular human insulin) which was statistically significant. The incidence of hypoglycaemia was lower in the basal insulin regimen. Fewer units of insulin were required in the basal insulin regimen with lower glycaemic variability as compared to basal-bolus regimen. Conclusion. Glargine U 300 monotherapy as a basal insulin is non-inferior to basal- bolus therapy in non-critically ill hospitalised patients in glycaemic control, with fewer incidences of hypoglycaemia, less amount of insulin requirement to achieve target capillary blood glucose level and lower glycaemic variability.

Morphometric characteristics of the brain in patients with type 1 diabetes mellitus on diff erent modes of basic bolus insulin therapy

Objective— to study the morphometric characteristics of the brain in patients with type 1 diabetes mellitus (DM) receiving insulin therapy in diff erent modes, taking into account the variability of glycemia.Material and methods.120 patients with type 1 diabetes, living in Tomsk and the Tomsk Region, were examined. All patients were divided into 2 groups: group 1 — patients receiving insulin in the base-bolus regimen of multiple insulin injections (MII), group 2 — using pump insulin therapy by continuous subcutaneous infusion of insulin using a wearable dispenser (CSII). Patients took this therapy for at least 6 months before inclusion in the study. All patients underwent a general clinical examination, testing of cognitive functions using the Montreal scale (MoCA test), continuous monitoring of blood glycemia (CMG) using iPro™ 2 Professional Continuous Glucose Monitoring (Medtronic, USA), FreeStyle Libre (Abbot, USA) in for 14 days, standard magnetic resonance imaging (MRI) on a 1.5 Tesla apparatus in axial, sagittal and coronal projections using T2, TE, T1, and using programs that suppress the signal of free water. We processed the results of MRI using Free Surfer (USA) and recon-all segmentation algorithm. Statistical analysis was performed using the R-system software package.Results.It was found that in both groups with type 1 diabetes there was a decrease in cognitive functions. It has been shown that CSII is associated with the best completion of the MoCA test. In addition, it has been reported that more frequent episodes of diabetic ketoacidosis and increased glycated hemoglobin (HbA1c) are the main causes of cognitive impairment in this group of patients. Changes in the morphometric parameters of the brain are interconnected with glycemic variability.Conclusion.In patients with type 1 diabetes, cognitive impairment associated with acute and chronic hyperglycemia was verifi ed. Morphometric features of brain changes are more dependent on glycemic variability. CSII helps improve cognitive function.

Effect of the FreeStyle Libre™ flash glucose monitoring system on glycemic control in individuals with type2 diabetes treated with basal-bolus insulin therapy: An open label, prospective, multicenter trial in Japan.

Aims/IntroductionWe investigated the effect of FreeStyle LibreTM on glycemic control in Japanese type 2 diabetes patients treated with basal–bolus insulin therapy.Materials and MethodsThis prospective, 90‐day single‐arm study enrolled 94 adults with type 2 diabetes treated with insulin. A 14‐day masked baseline phase was followed by an 11‐week treatment phase during which participants used the device to monitor glucose levels. The primary end‐point was time spent in hypoglycemia (<70 mg/dL) for baseline versus study end (days 76–90). Secondary end‐points included other measures of glycemic control, along with patient satisfaction using the Japanese Diabetes Treatment and Satisfaction Questionnaire.ResultsTime spent in hypoglycemia was low at baseline (0.51 ± 0.93 h/day) and did not significantly decrease at study end (0.47 ± 0.63 h/day, P = 0.6354). Time in range, time in hyperglycemia and estimated A1c all improved versus baseline (by +1.7 ± 3.0 h/day, −1.6 ± .4 h/day and −0.4 ± 0.8%, respectively, P < 0.0001 in each). Finger stick tests fell from 2.9 ± 1.3 to 1.9 ± 1.4/day, and mean scanning frequency during the intervention phase was 11.3/day. The mean treatment satisfaction score increased by 11.8 ± 5.3 (P < 0.0001). Two severe hypoglycemia‐related adverse events were reported; one of which was possibly related to the device. Three participants reported mild device‐related skin trauma, site discomfort or subcutaneous bleeding.ConclusionsUse of FreeStyle Libre by Japanese type 2 patients diabetes treated with basal–bolus insulin therapy showed a low baseline of hypoglycemia, and enabled improved glycemic control and treatment satisfaction.

78-LB: HbA1c Reduction Associated with a FreeStyle Libre System in People with Type 2 Diabetes Not on Bolus Insulin Therapy

Continuous glucose monitoring (CGM) in patients with diabetes using intensive insulin therapy has been well established, but there are limited data for CGM in other diabetes populations. We assessed HbA1c changes following a FreeStyle Libre prescription in people with type 2 diabetes (T2D) with poor glycemic control not using bolus insulin. IBM Explorys, a U.S. electronic health record database, was used in this retrospective, observational study. Cohort requirements included: FreeStyle Libre prescription in 2017 Q4-2020 Q1, de novo to CGM, T2D diagnosis, lack of rapid-/short-acting insulin, age &amp;lt;65 years, baseline HbA1c ≥ 8%, and presence of HbA1c data before and after FreeStyle Libre prescription. Baseline HbA1c was defined as the value within 180 days pre-index closest to CGM prescription date and post-CGM HbA1c as the value closest to 180 days post-index and within 60-300 days after CGM prescription. The outcome of the study was change in HbA1c from baseline to post-FreeStyle Libre prescription. The cohort (n=1,183, age 52 (SD 9.2) years, 52% male) had a reduction in HbA1c from 10.16 (SD 1.75) to 8.78 (SD 1.92) (p&amp;lt;0.001). Those starting with higher HbA1c and those on non-insulin therapy saw the greatest reduction. After receiving a prescription for a FreeStyle Libre system, people with T2D, poor glycemic control, and not using bolus insulin had a significant reduction in HbA1c. Disclosure E. Wright: Advisory Panel; Self; Abbott, Sanofi. Consultant; Self; Abbott, AstraZeneca, Bayer U.S., Boehringer Ingelheim Pharmaceuticals, Inc., MannKind Corporation, Merck &amp; Co., Inc., Voluntis France. Speaker’s Bureau; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Lilly Diabetes. M.S.D. Kerr: Employee; Self; Abbott. I.J. Reyes: None. Y. Nabutovsky: Employee; Self; Abbott. E. Miller: None.

883-P: Utility of CGM Technology in the Inpatient Setting

Effective inpatient insulin management is an important safety issue for our patients. Barriers to appropriate insulin use include incorrect timing of prandial insulin administration, failure to administer basal insulin to persons with type 1 DM, and insulin dosage overtreatment resulting in severe hypoglycemia. We studied the use of Abbott professional (blinded) Libre sensor in patients either on basal bolus insulin therapy (n=20) or on IV insulin (n=20) as a potential aide in minimizing insulin errors. The Wake Forest Baptist Health IRB approved the study and all subjects studied signed informed consent. Continuous BG data were aggregated for each subject and compared to point of care blood glucose (BG), iStat, or lab chemistry values. BG results were assessed for comparability (CGM versus Standard BG testing) and in ability to detect hypoglycemia early in those subjects experiencing hypoglycemia. Analysis of the basal bolus insulin arm revealed that an average difference of standard of care versus CGM glucose reading of 44.80 mg/dL. Differences in basal bolus arm BG comparing 24-hour average CGM glucometric data to standard of care was similar at 43.56 mg/dL. One third of participants in the basal bolus arm had at least one episode of hypoglycemia (BG &amp;lt; 70 mg/dL.) The average BG value in those experiencing a hypoglycemic event in our study group was 59 mg/dL on Standard BG testing. In retrospective review, all episodes of hypoglycemia were detected earlier on CGM technology. In one occurrence, hypoglycemia noted 6 hours sooner on CGM. CGM data consistently shows lower BG values than those using standard methods. Additional data including difference in insulin dosing based on CGM vs. Standard BG testing following completion of the IV insulin arm will be discussed. Disclosure J.A. Aloi: Consultant; Self; Medtronic. Research Support; Self; Medtronic. C.E. Price: None. Funding Wake Forest Baptist Medical Center

384-P: Impact of Concurrent Use of Oral Antidiabetes Agents with Insulin in the Real-World Hospital Setting

Guidelines recommend discontinuing oral antidiabetes drugs (OADs) on admission and initiating basal bolus insulin therapy. In the real world, concurrent OAD use with insulin is common and may affect outcomes. We conducted a large, retrospective study of 4558 patients age &amp;gt;18, admission &amp;gt;48 hours, and administered insulin &amp;gt;75% of days. 847 (18.58%) were administered OADs along with insulin within the first 2 days. Insulin therapy was categorized into 3 groups based on observed prescribing practices: sliding scale (SS), basal and scheduled rapid acting bolus (BB), Basal and rapid acting as needed (B+). Each group was analyzed for glucose control by days with hypoglycemia (any &amp;lt;70 mg/dl), hyperglycemia (mean &amp;gt;180 mg/dl) or euglycemia (no hypo- or hyperglycemia). Clinical outcomes included length of stay, 30/60 day readmission, and hospital mortality. Previously identified patient and provider factors that influence the choice of therapy were controlled using propensity score adjusted models. There were no statistical significant differences in hyperglycemia, euglycemia or clinical outcomes between BB or B+ compared to SS. However, hypoglycemia occurred 2 times more in BB compared to SS. B+ also had a higher trend of hypoglycemia. In our hospital system, basal insulin along with OADs resulted in more hypoglycemia. Further investigation is needed on optimizing these choices of therapy. Disclosure B. Patham: None. S. Chikermane: None. A. Vadhariya: None. M.L. Johnson: None. A.R. Sadhu: None.

Perioperative glycemic control in patients with coronary artery disease and diabetes mellitus type 2 undergoing coronary artery bypass grafting: results of pilot study

BACKGROUND: According to different studies, diabetes mellitus type 2 (DM2) is associated with higher mortality after undergoing coronary artery bypass grafting (CABG). Perioperative hyperglycaemia, even in non-DM2 patients, is associated with adverse outcomes after CABG. Thus, successful perioperative blood glucose control (BGC) is mandatory to reduce the risk of death and postoperative complications. Nowadays, the most effective method for BGC in the operating room is still unknown.&#x0D; AIMS: To assess the continuous glucose monitoring (CGM) efficacy in association with insulin pump therapy in patients with coronary artery disease (CAD) and DM2 undergoing CABG in intra- and early postoperative periods.&#x0D; METHODS: The study involved 97 patients undergoing isolated CABG. Patients were divided into two groups: 48 patients with DM2 and 49 patients without DM2. In both groups of patients, we used CGM in intra- and early postoperative periods (72 hours). In some patients with DM2, CGM was associated with insulin pump therapy (MiniMed Paradigm Veo 554/754) to successfully control postoperative glucose level. Besides commonly used tests (such as HbA1C and lipid profile), we analysed high sensitive C-reactive protein (hs-CRP) levels before surgery, and then at 1 hour, 12 hours and 7 days after CABG in order to estimate their prognostic value.&#x0D; RESULTS: During the 48 hours after CABG, there was a trend towards having higher glucose levels in both groups of patients with and without DM2 according to CGM. In patients with DM2, the glucose level was significantly increased (р0,05). Insulin pump therapy resulted in glycemic control improvement in early follow-up (72 hours). Moreover, there were no hypoglycaemic episodes in patients on insulin pump therapy and also in patients prescribed bolus insulin therapy. We revealed the trend towards lower rate of postpericardiotomy syndrome (PCTS) in patients on insulin pump therapy compared to patients prescribed bolus insulin therapy in the early postoperative period (p=0,1). Hs-CRP level was lower in patients with DM2 who were on insulin pump therapy compared to patients prescribed bolus insulin therapy in the early postoperative period (р0,05). This most likely confirms that insulin pump therapy decreases systemic inflammatory response.&#x0D; CONCLUSIONS: Thus, we demonstrated the CGM feasibility, safety and efficacy in association with insulin pump therapy in patients with DM2 undergoing CABG.

Аналіз циркадної динаміки та тренду частоти серцевих скорочень при холтерівському моніторуванні у дітей з цукровим діабетом 1 типу

Aim. To determine the diagnostic value of the analysis of circadian dynamics and heart rate trend during Holter monitoring in children with type 1 diabetes mellitus. Material and Methods. Holter electrocardiogram monitoring was performed in 53 children with type 1 diabetes mellitus (DM) (17 boys and 36 girls) who were in the endocrinology department of the Children's Clinical Hospital №6 of the Shevchenkivskyi district of Kyiv. The patients were divided into two groups depending on the duration of diabetes. The first group included 28 children aged 9-17 years with duration of diabetes ranging from 9 months to 5 years. The second group included 25 children aged 12-17 years, with history of diabetes varying from 5 to 15 years. All children received basal bolus insulin therapy, which was documented (time, dose, and name of insulin administered) in their Holter monitoring diaries, as well as the blood glucose levels. Holter monitoring system DiaCard-2 with recorder 03100 (JSC "Solvaig", Kyiv) was used for ECG monitoring. In addition to the standard parameters of daily recording, the circadian dynamics of heart rate (HR), and circadian index (CI) were evaluated; the trend of heart rate was analyzed in relation to the patients' activity, glycemic level, and insulin administration. Results and Discussion. In children with disease duration of 5-15 years (2nd group), the average day time heart rate exceeded both the rates in children with disease duration of up to 5 years (1st group) and normal ranges; a positive correlation was revealed (r=0.53 at p&lt;0.05) between diabetes duration and the average night heart rate in children. In addition, the progressive decrease in CI with the duration of the disease (1.33±0.16 in group 1 against 1.28±0.14 in group 2) indicated a progressive increase of the sympathetic and weakening of the parasympathetic influence on the heart rhythm. Signs of paroxysmal heart rate readiness, presented as increased duration (more than 50% of night sleep time) and/or number of periods of increased heart rate dispersion (more than 5) in combination with hyperreactivity of heart rate on waking, were found in 11 children (20.7%). Correlations between supraventricular tachycardia paroxysms (STP) and reactivity of the cardiovascular system during awakening (r=0.35 at p&lt;0.05), and STP and the percentage of periods of increased heart rate dispersion on the heart rate trend during night sleep (r=0.33 at p&lt;0.05) were revealed. These data may be useful for the early detection of patients with active heterotopic arrhythmias (eg, paroxysms of supraventricular tachycardia), which may not always be detected during Holter monitoring. During analyzing the heart rate dynamics according to the trend and comparing it with the patients' activity, insulin therapy and glycemic levels, an increase in heart rate of 15-25% in average was detected in 38 children (71.6%) 20-30 minutes after injections of short-acting insulin, which corresponds to the onset of their effect, and, after 60-120 minutes - to its maximum. Conclusions. Comprehensive analysis of the results of daily ECG monitoring with analysis of the heart rate trend revealed the effect of basic bolus insulin therapy on heart rate at the onset and maximum of short and ultrashort insulin drugs in 71.6% of patients with type 1 diabetes. Detection of signs of paroxysmal readiness on the heart rate trend may be useful for early detection of patients with active heterotopic arrhythmias that are not always detected during monitoring. Analysis of circadian dynamics of heart rate and circadian index allows to determine the condition of cardiac activity autonomic regulation even in the absence of technical feasibility of analyzing heart rate variability, and is available when using Holter systems of any level. Key words: type 1 diabetes mellitus, Holter monitoring, heart rate trend, circadian index, circadian heart rate dynamics

Three European Retrospective Real-World Chart Review Studies to Determine the Effectiveness of Flash Glucose Monitoring on HbA1c in Adults with Type2 Diabetes.

IntroductionThe impact of flash glucose monitoring technology on HbA1c in type 2 diabetes managed by basal bolus insulin is uncertain. Three parallel European retrospective non-interventional chart review studies collected data reported in medical records. Each country’s study aim was to determine the effectiveness of the device on HbA1c when used by their population for 3–6 months as their standard of care for management of glycaemia in a real-world setting.MethodsMedical records were eligible for adult patients with type 2 diabetes, on a basal bolus insulin regimen for 1 year or more, device use for 3 months or more before the start of the study, an HbA1c concentration up to 3 months prior to starting device use (patients were using blood glucose monitoring for self-management) between 64 and 108 mmol/mol (8.0–12.0%) plus an HbA1c determination 3–6 months after commencing flash glucose monitoring use.ResultsRecords were analysed from 18 medical centres in Austria (n = 92), France (n = 88) and Germany (n = 183). Baseline HbA1c results, recorded up to 90 days before the start of device use, were comparable across the three countries and were reduced significantly by 9.6 ± 8.8 mmol/mol mean ± SD (Austria [0.9 ± 0.8%], p < 0.0001), 8.9 ± 12.5 mmol/mol (France [0.8% ± 1.1], p < 0.0001) and 10.1 ± 12.2 mmol/mol (Germany [0.9% ± 1.1], p < 0.0001). No significant differences were detected between age group, sex, BMI or duration of insulin use.ConclusionsThree European real-world, chart review studies in people with type 2 diabetes managed using basal bolus insulin therapy each concluded that HbA1c was significantly reduced after changing to use of flash glucose monitoring for 3–6 months in a real-world setting.Electronic supplementary materialThe online version of this article (10.1007/s13300-019-00741-9) contains supplementary material, which is available to authorized users.

Persistence with Basal-Bolus Insulin Therapy in Patients with Type 2 Diabetes Mellitus and Effect on Clinical and Economic Outcomes: A Retrospective Claims Database Study.

Persistence with multiple daily insulin injections (MDI) may be challenging for patients with type 2 diabetes (T2DM). However, limited information is available regarding the effect of persistence with MDI on outcomes. To evaluate persistence with basal and bolus insulin therapy and assess its relationship with clinical and economic outcomes in a real-world setting. This retrospective matched cohort study used 2012-2015 data from multiple U.S. commercial health plans (IBM MarketScan). Patients with T2DM aged 18-64 years with ≥ 2 basal and ≥ 2 bolus insulin claims during a 12-month period were eligible for inclusion if they had 18 months of continuous health plan enrollment (6-month baseline and 12-month post-index). Persistence during 12 months post-index was defined using 2 methods: (a) method 1, ≤ 90-day gaps in both basal and bolus insulin claims and (b) method 2, ≥ 1 basal and ≥ 1 bolus insulin claim every quarter (every 90 days) for 4 consecutive quarters after index bolus claim. Propensity score matching was used to match persistent and nonpersistent method 2 cohorts. Mean per-patient all-cause and diabetes-related medical costs (2015 U.S. dollars, excluding outpatient drugs) and health care resource use (HCRU) were calculated. For patients with hemoglobin A1c (A1c) values during baseline and post-index months 10-12, treatment success was defined as (a) A1c decrease from baseline of ≥ 1% and/or (b) baseline A1c ≥ 7% with post-index A1c < 7%. Baseline characteristics of matched cohorts were compared using standardized mean differences (SMDs). Outcome variables were compared using t-tests, chi-square tests, and generalized linear models. Characteristics of 12,882 eligible patients and 12-month persistence rates were similar as defined by method 1 (22.4%) and method 2 (21.1%). After matching, the method 2 cohorts included 2,723 and 8,169 persistent and nonpersistent patients, respectively, with well-balanced baseline characteristics (mean age 53 years; 58% men; all SMDs < 0.1). All-cause annual medical costs were lower for the persistent cohort (mean $13,499 vs. $17,362; P < 0.0001), as were annual diabetes-related costs (mean $6,392 vs. $8,376; P < 0.0001). In persistent versus nonpersistent cohorts, 11% versus 15% of patients, respectively, experienced ≥ 1 hospitalization; 21% versus 24%, respectively, had ≥ 1 ED visit; 9% versus 12%, respectively, experienced ≥ 1 diabetes-related hospitalization; and 13% versus 15%, respectively, had ≥ 1 diabetes-related ED visit (P ≤ 0.005 for all). Mean baseline A1c was similar in persistent and nonpersistent cohorts (9.7% vs. 9.6%, respectively; P = 0.63). Persistence with MDI was associated with greater mean reduction in A1c (-1.3% vs. -0.8%, respectively; P = 0.006) and greater percentages of patients achieving treatment success (55% vs. 39%, respectively, for nonpersistent; P = 0.009). Poor persistence with basal-bolus insulin therapy over 12 months of follow-up was prevalent and was associated with greater medical costs, greater HCRU, and poorer glycemic control than for patients who were persistent. Interventions are needed to improve persistence with insulin therapy and aid patients with T2DM to achieve glycemic control. Funding for this study was provided by Becton, Dickinson and Company (BD). All authors except Edelman are employees and stockholders of BD. Edelman reports board membership at Senseonics and participation in advisory board/speakers bureau at Lilly USA, MannKind, Novo Nordisk, Sanofi-Aventis U.S., Merck, and AstraZeneca, all unrelated to this study. A poster for this study was presented at the AMCP Managed Care & Specialty Pharmacy Annual Meeting 2018; April 23-26, 2018; Boston MA.

674-P: Glycemic Management Practice Guideline Combined with a Multidisciplinary Champion Team Approach Increased the Use of Basal Bolus Insulin Regimen and Reduced the Use of Sliding Scale Insulin

Basal-bolus insulin (BBI) therapy is recommended for treatment of hyperglycemia in the inpatient setting, but many patients still receive sliding scale insulin (SSI) that has been shown to be less effective. To evaluate the transition from insulin drip to subcutaneous insulin therapy we performed a retrospective chart review spanning four months in the cardiothoracic intensive care unit (CTICU) at our institution. Of the patients in the unit who were transitioned from insulin drip, 84% (n=63) were transitioned to sliding scale insulin, while only 16% (n=12) were transitioned to basal bolus insulin therapy. Of those patients treated with basal bolus insulin, 33% (n=4) had a delay in basal insulin administration, while 17% (n=2) of patients experienced interrupted basal insulin therapy. In order to increase the use of basal bolus insulin and reduce the use of sliding scale, we developed a glycemic practice guideline which focused on when and how to transition from insulin drip to basal bolus insulin therapy. We launched a multidisciplinary champion team who assisted with the implementation of the guideline in the CTICU. After implementing the guideline for one year, we found the use of basal bolus therapy increased from 16% (n=12) to 68% (n=50), and use of sliding scale decreased from 84% (n=63) to 22% (n=16), (p=0.008). Furthermore, patients who were treated with basal bolus insulin therapy had less delay and interruption of basal insulin by 21% and 7%, respectively, although the difference was not statistically significant (p=0.10). Additional studies are necessary to determine whether our guideline, combined with a multidisciplinary team approach, would affect clinical outcomes. Disclosure M.M. Bogun: None. E. Zagoren: None. K. Ackerman: None. A.M. Ciolek: None.

PDB45 EVALUATING THE SHORT-TERM COST-UTILITY OF INSULIN DEGLUDEC VERSUS INSULIN GLARGINE U100 IN BASAL-BOLUS REGIMENS FOR TYPE 2 DIABETES IN CHINA

Insulin degludec (degludec) is an insulin analog with an ultra-long duration of action, low risk of hypoglycaemia and confirmed cardiovascular safety demonstrated in DEVOTE trial (NCT01959529). The study aimed to evaluate the short-term cost-utility of degludec versus insulin glargine 100 units/mL (glargine) for the treatment of type 2 diabetes (T2DM) receiving basal–bolus insulin therapy in China based on data from subgroup results of the DEVOTE trial. A short-term health economic model programmed in Microsoft Excel was conducted to compare costs in patients receiving once daily degludec or glargine over a 2-year time horizon. Clinical inputs and patient characteristics were taken exclusively from DEVOTE trial, whilst China-specific costs (the most current drug provincial biding price in china) were obtained from the literature. Both costs and health effects had not been discounted annually for such a short time horizon. Sensitivity analyses were conducted to assess the robustness of the results. Degludec was associated with a mean improvement of 0.00649 quality-adjusted life-years (QALYs) compared with glargine, with improvements driven predominantly by lower rates of severe hypoglycaemia with degludec versus glargine. degludec was associated with mean cost savings of 289.35 CNY per patient relative to glargine in patients with type 2 diabetes. Cost savings were primarily driven by the reduction in risk of diabetes-related complications with degludec, which offset the higher treatment costs relative to glargine. Insulin relative cost of degludec was 1040.36 CNY (16.98%) more than glargine. However, the costs of Non-fatal myocardial infarction, Non-fatal stroke, severe hypoglycaemia, and self-monitoring of blood glucose were reduced by 764.56 CNY (28.51%), 119.71 CNY (19.47%), 195.06 CNY (21.35%), and 210.13 CNY (36.94%), respectively. Sensitivity analyses demonstrated that the results were stable to variations in biding price. Among T2DM receiving basal–bolus insulin therapy in China, degludec is a cost saving treatment option compared with glargine.

SUN-131 Improving the Glycemic Control of Women Veterans with Poorly Controlled Diabetes with a Telephone Encounter

Introduction: Despite having a broad range of services available at the Veterans Affairs Healthcare System (VAHS), veterans struggle to control their chronic diseases. At the Miami VAHS, 30% of veterans have diabetes, and of those, 30% are poorly controlled. Women represent a growing number of veterans at the Miami VAHS who face many of the challenges posed by having a diabetes diagnosis. Objective: To improve HbA1c measurements in women veterans (WV) with poorly controlled diabetes following a phone encounter with an endocrinologist addressing diabetes management. Method: This was a prospective intervention study of WV with HbA1c levels ≥ 9%. An endocrinologist attempted up to three telephone calls to reach WV. The phone intervention involved a chart review of co-morbidities to establish a HbA1c target, and management included lifestyle modification counseling, insulin dose adjustment, introduction and/or discontinuation of diabetes medications, and a plan for follow-up. During the following 3-4 months, results of follow-up HbA1c were collected regardless of having had an initial telephone encounter. WV who did not have follow-up HbA1c were excluded from the study. The remaining WV were further divided into 1) those that answered the phone and participated in the assessment (intervention group) and 2) those who did not answer the phone to have an initial encounter (control group). Other variables included BMI, eGFR, type of diabetes, diabetes medication, presence of hypertension, dyslipidemia, coronary artery disease (CAD), smoking, and psychiatric illness. Results: Of 77 WV who were called, 36 WV were assessed by the endocrinologist; 41 did not answer the phone and were regarded as the control. 8 WV from the intervention group and 16 WV from the control group did not have a follow-up HbA1c, and were excluded. 28 intervention and 25 control WV were included in the final analysis. In the intervention group: mean age 55.0 ± 10.3 years, BMI 29.8 ± 5.5, eGFR 57.9 ± 4.5, 86% type 2 diabetes, 61% on basal bolus insulin therapy, 68% HTN, 93% dyslipidemia, 71% smokers, 4% CAD, and 68% psychiatric diagnosis. In the control group: mean age 55.6 ± 9.9 years, BMI 32.5 ± 6.1, eGFR 58.9 ± 4.5, 96% type 2 diabetes, 44% on basal bolus insulin therapy, 80% HTN, 84% dyslipidemia, 16% smokers, 4% CAD, and 68% psychiatric diagnosis. Mean baseline HbA1c was 10.9 ± 1.5 for the intervention and 10.8 ± 1.8 for the control group. After 3-4 months, mean HbA1c was 9.9 ± 2.3 in the intervention group, and 10.6 ± 1.7 in the control group. HbA1c decrease in the intervention group was statistically significant (p = 0.03). Conclusion: This preliminary study demonstrates that a telephone intervention from a diabetes specialist has a positive impact on decreasing HbA1c in WV with poorly controlled diabetes. Findings from this study suggest that this approach should be considered in management of other chronic diseases.

Assessment of diabetic patients' adherence to insulin injections on basal-bolus regimen in diabetic care center in Saudi Arabia 2018: Cross sectional survey.

Background:Since insulin became a focal point of diabetes management, several studies have been carried out to monitor and improve patient outcomes. Adherence insulin therapy is an important part of diabetes management.Aim:This study reviews the responses of patients being managed in a diabetic care setting in monitoring their adherence to basal bolus insulin therapy.Method:A pre-validated questionnaire containing 18 questions was administered to patients in the diabetic care unit of the Security Forces Hospital, Riyadh, Saudi Arabia.Results:The levels of adherence with basal bolus insulin therapy was 61.9%. There is no considerable difference in adherence levels of male and female respondents with 31.62% and 31.58% respectively. The younger age groups (14-29) had the highest adherence levels at 65.75%. Higher levels of patient literacy and the location also have a positive relationship with adherence.Conclusion:To improve adherence levels, dosing should be made with consideration for patient convenience, and patients should be encouraged to build positive psychological relationships. Further studies should look to studying outcomes of therapy, and markers should be developed to monitor patient progress on therapy regimen regularly. The aspect of short clinic visits is another major consideration that needs to be look into properly to understand and monitor patients’ proper adherence toward the basal bolus insulin.

Sustained Implementation Success Following Targeted Knowledge Translation Intervention to Improve Glycemic Outcomes with Basal Bolus Insulin Therapy

Purpose: To evaluate the long-term impact of a targeted knowledge translation intervention to address recognized barriers to basal bolus insulin therapy (BBIT) use in a moderate-sized acute care facility staffed predominantly by non-diabetes care providers.

Mobile-Based Artificial Intelligence Significantly Improves Type 1 Diabetes Management

Background: Type 1 diabetes involves a multiple decision making process on a daily basis.Mobile technology has been widely spread not only as a mean of communication, but also as multi-usage tool involving a large variety of applications, making everyday life more convenient. “D-Partner” (Diabetes Innovations Ltd) is a mobile based application that serves as a self-management tool for type 1 diabetes, including a bolus wizard (with food database),a basal insulin titration manager, as well as, a large number of automated notifications, warnings or reward messages, according to the data imported by the patient. In addition,“D-Partner” serves as a telemedicine tool, as information of meals, insulin dosage, measurements of glucose, blood pressure, body weight, and lab values, may be monitored by the physician through an on-line, web-based platform. Aim: To investigate the efficacy of "D-Partner" mobile application, in glucose management, in patients with type 1 diabetes. Methods: 24 patients with type 1 diabetes (14 male, 10 female), with diabetes duration of 14,2±8,8 years, mean age of 37.4±11,7 years and HBA1c &amp;gt;7%, on basal bolus insulin therapy, were randomized to receive either standard care, or standard care plus the ‘D-Partner” application usage. HBA1c, somatometric data, blood pressure, heart rate and hypoglycemia frequency data, were obtained at baseline and 3 months after the intervention. Results: The intervention group presented a significantly improved glucose control as recorded by HBA1c reduction, compared to the control group (p=0.01). Additionally, hypoglycemia incidence was significantly lower in the intervention group (p=0.04). There were no significant changes in somatometric data blood pressure, and heart rate, among the 2 groups. Concusion: D-partner, is a mobile based self-management application, that may contribute to a better management of type 1 diabetes, potentially improving the life quality of the patient. Disclosure J. Doupis: Consultant; Self; Novo Nordisk Inc., Eli Lilly and Company, Sanofi, AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc.. V. Papandreopoulou: None. S. Glykofridi: None. V. Andrianesis: None.

Basal-Bolus Insulin Therapy May Not Be the Optimal Strategy in a "Real-World" Hospital Setting for Inpatient Hyperglycemia Management

Basal bolus insulin therapy (BB) is recommended for glucose control in noncritically ill inpatients based on two small RABBIT2 trails. However, BB is complex and has limited data in large scale “real world” settings. This is a retrospective analysis of 4,558 noncritical, medical-surgical admissions from 1/2013 to 9/2015 in patients ≥18 years who received SC but not IV insulin for ≥ 75% of the stay. Insulin therapy was identified within the first 2 days as BB (long + rapid, n=2319), sliding scale (SS, rapid only, n=1855) or Basal Only (BO, long only, n=384). A propensity score analysis adjusted for clinical, demographic and physician variables affecting choice of therapy. Point of care glucose (mg/dl) was used to define patient days as hypo- (any &amp;lt;70), hyper- (mean &amp;gt;180) or euglycemic (no &amp;lt;70 AND mean ≤180). Negative binomial regression analyzed glucose outcomes (number of hypo-, hyper- and euglycemic days, mean glucose); linear regression modeled log of length of stay (LOS); logistic regression modeled odds of 30 and 60 day readmission. All analyses were conducted overall and by medical or surgical DRG. BB had worse glucose control but less LOS in medical DRG. BO had better hyper-, euglycemic and mean glucose. BB and BO had more hypo- days. This suggests that BO may be superior and simpler than BB for hyperglycemia but medical patients may benefit from BB for reasons beyond glucose control. Insulin groupsOVERALL (n= 4,558)MEDICAL DRG (n =3,211)SURGICAL DRG (n= 1,347)Length of stay*BB vs SS0.97 (0.141)0.94 (0.003)1.02 (0.540)BO vs SS1.01 (0.711)0.99 (0.741)1.03 (0.665)Hyperglycemic days*BB vs SS0.99 (0.700)0.97 (0.416)1.00 (0.922)BO vs SS0.69 (&amp;lt;0.001)0.69 (&amp;lt;0.001)0.69 (&amp;lt;0.001)Hypoglycemic days*BB vs SS2.45 (&amp;lt;0.001)2.29 (&amp;lt;0.001)2.78 (&amp;lt;0.001)BO vs SS2.71 (&amp;lt;0.001)2.37 (&amp;lt;0.001)3..40 (&amp;lt;0.001)Euglycemic days*BB vs SS0.91 (0.008)0.85 (&amp;lt;0.001)1.01 (0.823)BO vs SS1.15 (0.012)1.11 (0.151)1.20 (0.063)Mean glucose*BB vs SS1.01 (0.415)1.69 (0.266)-1.18 (0.589)BO vs SS-17.27 (&amp;lt;0.001)-17.95 (&amp;lt;0.001)-15.91 (&amp;lt;0.001)1Results for 30 and 60 day readmission are not significantly different across the groups and are not presented in the table;*Results above shown as: Estimate (p-value) Disclosure A.R. Sadhu: None. B. Patham: None. A. Vadhariya: None. M.L. Johnson: None.

Basal-Bolus Insulin Therapy with Gla-300 During Hospitalization Reduces Nocturnal Hypoglycemia in Patients with Type 2 Diabetes Mellitus: A Randomized Controlled Study.

IntroductionAlthough reduction in the incidence of nocturnal hypoglycemia, as estimated by symptom or self-monitored plasma glucose, was shown to be more pronounced with 300 units/mL insulin glargine (Gla-300) than with 100 units/mL insulin glargine (Gla-100) in type 2 diabetes patients, the exact frequency of nocturnal hypoglycemia estimated with continuous glucose monitoring (CGM) has not been reported.MethodsForty patients with type 2 diabetes who were admitted for glycemic control with basal–bolus insulin therapy (BBT) were randomized into the Gla-100 and Gla-300 groups. Insulin doses were adjusted to maintain blood glucose levels within 100–120 mg/dL at each meal. Plasma glucose and C-peptide profiles were estimated serially after admission and before discharge. Daily CGM was also performed before discharge.ResultsIn the Gla-100 and Gla-300 groups, the mean duration of hospitalization was 15 ± 2 and 15 ± 1 days, respectively, and the mean basal insulin dose before discharge was 13 ± 7 and 15 ± 10 units, respectively. The dose of meal-time insulin was not different between the two groups. Compared with the Gla-300 group, the Gla-100 group had significantly lower nocturnal profiles of plasma glucose and C-peptide, but significantly higher frequency of CGM-estimated nocturnal hypoglycemia (10.7% ± 18.4% versus 1.2% ± 3.6%, P = 0.033).ConclusionIn type 2 diabetic patients, reduction in the incidence of CGM-estimated nocturnal hypoglycemia by BBT under tightly controlled diet therapy was higher with Gla-300 than with Gla-100.Trial RegistrationUMIN clinical trials registry (UMIN000023360).

The effectiveness of lixisenatide as an add on therapy to basal insulin in diabetic type 2 patients previously treated with different insulin regimes: a multi-center observational study

IntroductionThis observational study aimed to assess the effectiveness of lixisenatide as add on therapy to basal insulin in diabetic type 2 patients previously treated with different insulin regimes.MethodsPatients with diabetes type 2, prescribed with lixisenatide and basal insulin were divided in three groups (premixed insulin, basal bolus insulin and basal oral therapy (BOT). Difference in mean change in HbA1c, body mass index, total insulin doses, fasting blood glucose (FPG) and prandial blood glucose (PPG) were assessed after 3–6-months of follow-up.ResultsThe primary outcomes were assessed in 111 patients. Lixisenatide added to basal insulin, reduced HbA1c and body weight significantly in all three groups of patients (p < 0.001 for all), with the most prominent reduction in the basal bolus group of patients which had the highest baseline HbA1c compared to premix and BOT treatment groups. Regarding a difference in total insulin dose the reduction was statistically significant in the basal bolus (p = 0.006) and premix group (p < 0.001). FPG and PPG were also significantly reduced over time in all three groups (p < 0.001 for all). A composite outcome (reduction of HbA1c below 7% (53 mmol/mol) with any weight loss) was achieved in 27% of total patients included in the study, reduction of HbA1c below 7% was observed in 30% of patients, while 90% of patients experienced weight reduction.ConclusionThese results indicate that lixisenatide add on basal insulin treatment (BIT) can improve glycemic control in a population with long-standing type 2 diabetes and previously uncontrolled on other insulin therapy.

Qualitative Evaluation of the Barriers and Facilitators Influencing the Use of an Electronic Basal Bolus Insulin Therapy Protocol to Improve the Care of Adult Inpatients With Diabetes.

A qualitative evaluation of the perceived impact of a new evidence-informed electronic basal bolus insulin therapy order set on clinical workflow and practice, and exploration of potential barriers and facilitators to electronic basal bolus insulin order set uptake and use in acute care facilities for various acute care team members. We conducted 9 semistructured focus groups with multidisciplinary nursing staff (n=22), resident trainees (n=24) and attending physicians (n=23) involved in the delivery of inpatient diabetes care at 3 adult acute care facilities. The domains of inquiry included impact on workload, perceived impact on patient care and discipline-specific barriers and facilitators to use, including care-providers' needs, comfort and competencies, contributions from the clinical environment and efficacy of communication. The interviews were transcribed and analyzed using a content analysis approach. Several major themes emerged from the focus group discussions, including impact of education, information technology/user interface, workflow, organizational issues and practices, and perceived outcomes. Barriers and facilitators were identified relating to each theme. The outcomes highlight the complex interplay between educational, organizational and technical themes and the significance of employing a systemic approach to support the implementation of electronic inpatient glycemic-management protocols within complex social organizations.