Initiating Insulin Treatment Research Articles

WITHDRAWN: Myoinositol supplementation for the prevention of gestational diabetes in at-risk patients. Systematic review and meta-analysis

Gestational diabetes (GD) is associated with an increase in maternal and fetal morbidity. The risk factors involved have been clearly identified but no prevention strategies have yet provided robust evidence of their efficacy. Myoinositol has insulin sensitization properties and is of potential interest in the treatment of the disorder. The aim of this work was to assess the efficacy of myoinositol supplementation during pregnancy to prevent GD in patients with known risk factors. A systematic literature review was performed on studies comparing the effects of myoinositol supplementation and placebo on the occurrence of GD in at-risk pregnant women. The main judgement criterion was diagnosis of GD between 24 and 28 gestational weeks by an oral glucose tolerance test. The secondary judgement criteria were the occurrence of maternal fetal complications and the need to initiate insulin treatment to manage GD. Nine studies were included in the meta-analysis. The results showed a significantly higher risk of GD in patients on placebo than in those receiving myoinositol (RR​=​2.58, CI 95%: 1.68 to 3.97, p​<​0.0001) but wide variations between studies (I2​=​71.94%, p​<​0.001). And the risk of prematurity was significantly greater in the children of mothers on placebo (RR: 2.15, IC 95%: 1.32 to 3.20, p​=​0.002). Myoinositol supplementation taken from the beginning of pregnancy reduces the incidence of GD and could be of interest at a dose of 4​g/day as a prevention strategy for patients with identified risk factors.

ODP604 | LBSUN287 Ketosis-prone Type 2 Diabetes (Flatbush Diabetes) In Remission: Report Of Two Cases

Abstract Diabetic ketoacidosis (DKA) is a triad of uncontrolled hyperglycemia, metabolic acidosis, and increased total body ketone concentration1. Diabetic ketoacidosis (DKA) is a well-known manifestation of Type 1 diabetes2; however, there has been an increase in the incidence of DKA as the first presentation in Type 2 diabetes. This subtype of diabetes is typically seen in non-Caucasian middle-aged obese males due to non-autoimmune disruption of glucose metabolism, which requires an initial intensive insulin regimen. After initial insulin treatment for several weeks to several months, a significant percentage of people can become insulin independent with an oral hypoglycemic agent(OHA) and /or just lifestyle modification, and in remission for many years3. This hybrid form of diabetes sharing the characteristics of T1DM and T2DM is called "Flatbush diabetes", also known as "ketosis-prone T2DM4 5. This article aims to emphasize the importance of early recognition of this heterogeneous syndrome through the two representative case reports of Ketosis-prone T2DM. Case presentation We describe two cases of African American men (elderly and young adult) with no past medical histories, who presented to the Emergency Department with a few days history of polyphagia, polydipsia, polyuria and fatigue. New onset of Type 2 diabetes and unprovoked DKA were diagnosed. Both of them received standard treatment with intravenous fluid and insulin drip, recovered uneventfully and discharged with insulin. Both of them followed up closely in our endocrinology clinic, their GAD antibodies were 0. 00(n&amp;lt;=0. 02nmol/L), Islet cell antibody&amp;lt;1: 4(n&amp;lt;1: 4) and C-peptide were 2.6ng/mL and 6ng/mL(1.1-4.4ng/mL) respectively. Their insulin was gradually withdrawn with the addition of an oral hypoglycemic agent. Both the patients are currently insulin independent for more than 15 months. Conclusion This is an important clinical entity to recognize ketosis-prone T2DM as insulin independence positively impacts quality of life and decreases economic burden on the health care system. For patients with suspected ketosis-prone T2DM, B-cell autoantibodies and C-peptide level should be obtained 1-3 weeks at the first outpatient visit, as it can predict patients’ prognosis. These patients should also be referred to an endocrinologist and need careful follow-up. Among all ketosis-prone T2DM patients, those with preserved B-cell function are more likely to be insulin independent and go into remission phase. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

The “Life-World” trip of type 2 diabetes patients with allopathic treatment options: a triangulated qualitative investigation

Background Patients with type 2 diabetes usually start treatment with oral hypoglycaemic medications once they have been diagnosed. They eventually require insulin injections. We looked into the experiences of such patients with allopathic treatment alternatives over the course of their journey. Methods The study was conducted using a qualitative inquiry (phenomenological approach triangulated with modified grounded theory) from July 2019 to January 2020. A total of 24 participants (11 men and 13 women) were recruited purposively and interviewed face-to-face until theoretical saturation was reached. QDA Miner Lite v2.0.9 was used to categorise the data. Results The majority of patients had no previous notions regarding their illness. They did not have an emotional reaction to being diagnosed. They were uncomfortable on oral hypoglycaemic agents because of uncontrolled blood glucose and gastrointestinal disturbances, which were thought to be the main causes for medication changes. Initial insulin treatment experiences included fear of injection pain, difficulty self-injecting, and a sense of last resort. Insulin’s effectiveness, ease of injection with a little needle, and lack of gastrointestinal discomfort were all key reasons in changing the patients’ minds about it. Patients have rigorously adhered to insulin since it was found to improve health and bring life. Conclusion The “life-world” journey of patients with type 2 diabetes with allopathic treatment options was started to be informed of the “unknown” (diabetes), which leads to the “ugly life” (with oral agents), and bridge to and living with the “terrible” (insulin), which was later found to be effective and perceived as “life.” KEY MESSAGES Patients with type 2 diabetes believed that life with oral hypoglycaemic medications was “boring.” The major reasons for switching to insulin were “uncontrolled blood sugar levels” and “gastrointestinal disturbances” brought on by oral medications. Insulin first terrified type 2 diabetes patients, but they eventually referred to it as “life.”

Where to Initiate Basal Insulin Therapy: Inpatient or Outpatient Department? Real-World Observation in China.

This study aims to compare the effectiveness of initiating insulin therapy in inpatient and outpatient settings during a 6-month follow-up period among patients with type 2 diabetes mellitus (T2DM) in real-world settings. The study was based on the ORBIT study, a real-world observational study which recruited patients with inadequate glycemic control by oral antidiabetic drugs (OAD) and initiated basal insulin (BI). We compare difference in initiation and evolution of insulin therapy and glycemic control after six months were compared between patients initiating basal insulin in the inpatient department (inpatient initiators) and those starting in outpatient (outpatient initiators) among participants without rehospitalization during the six months follow-up. Among all 18,995 participants in the ORBIT study, 56.0% were inpatient initiators and 44.0% outpatient. We conducted in-depth analysis among 14,860 patients without rehospitalization, 8129 inpatient initiators and 6731 outpatient initiators. (1) Inpatient initiators had lower insulin therapy persistence during six months (64.2%) than outpatient ones (78.6%) (p<0.001), which was mainly explained by more therapy switches from basal-bolus regimen to other therapies among inpatient initiators (50.1%) than that among outpatient initiators (37.5%) (p<0.001). (2) Inpatient initiation had a higher proportion of people achieving glucose targets (HbA1c <7%) than outpatient initiation. However, the benefit of inpatient initiation versus outpatient initiation was mainly observed among patients persisting with the initial insulin therapies (46.3% vs 39.5% p<0.001), rather than those nonpersistent (37.3% vs 36.2%, p=0.723). (3) Among patients with HbA1c <9%, taking only one OAD and without complications at baseline, inpatient insulin initiation did not show a higher proportion of people achieving glucose target than outpatient initiation (adjusted odds ratio=0.96, 95% CI: 0.76-1.21). For patients with HbA1c ≥9%, who were taking more than one OAD and had complications at baseline, initiating insulin treatment during hospitalization has a higher proportion of people achieving glucose target than that in the outpatient department, but the premise is that the initial therapy is acceptable and can be maintained after discharge. Patient-centered approach with co-agreed decision-making to select a suitable insulin regimen should be strengthened.

A cross-talk between perceptions and reality on insulin therapy among Type-2 diabetes patients in developing countries

It has been reported that some healthcare providers in the developing countries may be unwilling to initiate insulin treatment due to multiple reasons including the patients’ resistance to accept insulin prescription [1]. World-wide, it is well established that optimal control of the blood glucose levels of type 2 diabetes patients constitute a major challenge for the patients as well as healthcare providers particularly for patients living in the developing countries [2]. The United Kingdom Prospective Diabetes Study (UKPDS) demonstrated some decades ago that most type 2 diabetes patients had only 50 % of normal insulin secretion on diagnosis which decreases to 25 % after six years of diabetes duration [3].

Factor analysis as a tool to explore the heterogeneity of type 2 diabetes: A feasibility study

AimDiabetes is currently classified based on pathogenetic mechanisms and Type 2 diabetes (T2DM) can be considered a residual heterogeneous category. Factor analysis (FA) identifies a limited number of calculated variables related to a larger number of measured parameters, capable of explaining most of their variance. Aim of the present study was to verify the feasibility of the application of FA for the development of pathogenetic models of individual cases of T2DM, using three available databases. MethodsFirstly, a model of FA was applied to an existing dataset of non-diabetic patients, identifying three factors associated with fasting or post-prandial hyperglycemia. These factors were then calculated in: - patients enrolled in a retrospective observational study, assessing time to failure to diabetes treatment in three cohorts of patients (metformin or sulfonylurea monotherapy, or no pharmacological therapy); - in a retrospective cohort of patients failing to dual oral therapy and initiating treatment with DPP4 inhibitors; - in patients enrolled in a case-control study onincident cancer in T2DM subjects initiating insulin treatment. Results and conclusionsDespite limitations, our results confirm the feasibility of approaching the characterization of T2DM through the identification of dimensional factors, providing additional and complementary information to that obtained with cluster analysis.

1159-P: Associations of HOMA2 with Clinical Outcomes in Type 2 Diabetes

Background: In patients with type 2 diabetes (T2D) negative for glutamic acid decarboxylase antibodies (GADA-) , the prognostic significance of insulin deficiency (ID) and insulin resistance (IR) remained uncertain. Methods: In 4590 patients with T2D consecutively enrolled to the Hong Kong Diabetes Register in 1995-2012 followed up till 2019, we measured GADA and fasting C peptide (CP) in stored samples at baseline. Using the updated homeostasis model assessment (HOMA2) , we defined below-median HOMA2-%B as ID and above-median HOMA2-IR as IR. We defined incident insulin use as the first insulin prescription of at least 28 days and used ICD-9 codes to define cardiovascular-renal diseases, severe hypoglycemia event (SHE) and all-cause mortality. We used Cox regression model to examine the associations between HOMA2 and clinical outcomes. Results: Amongst 3198 GADA- patients with available HOMA2 data, the median of HOMA2-%B was 52.4 (33.1, 60.9) and that of HOMA2-IR was 1.6 (1.1, 1.8) . The ID group was more likely to initiate insulin treatment [adjusted HR (95%CI) 1.26 (1.11-1.42) ] but less likely to progress to chronic kidney disease (CKD) , end-stage kidney disease (ESKD) and all-cause mortality than the non-ID group. The IR group had increased risks of incident insulin therapy [HR 1.13 (1.00-1.27) ], CKD, ESKD, and all-cause mortality than the non-IR group. Compared with the ID-/IR- group, the ID/IR group had the highest hazard of incident insulin use [HR 1.59 (1.30, 1.94) ], SHE and cardiovascular-renal diseases with HRs ranging from 1.45 to 2.09, although the associations for complications became insignificant after adjusting for metabolic factors and baseline treatments. Conclusions: In GADA- patients with T2D, ID and IR contributed differently to clinical outcomes with the co-existence of ID and IR associated with the highest risk of insulin requirement and adverse clinical outcomes. The assessment of ID and IR using HOMA2 improved risk stratification to identify high risk people for individualized intervention. Disclosure B.Fan: None. A.Luk: None. J.C.Chan: Board Member; Asia Diabetes Foundation, Consultant; Bayer AG, Boehringer Ingelheim International GmbH, Celltrion, Merck Sharp &amp; Dohme Corp., Roche Diabetes Care, Viatris Inc., Research Support; Applied Therapeutics, AstraZeneca, Eli Lilly and Company, Hua Medicine, Servier Laboratories, Stock/Shareholder; GemVCare Ltd. E.S.H.Lau: None. H.Wu: None. M.Shi: None. A.Yang: None. C.K.Lim: None. A.P.Kong: Advisory Panel; Abbott, Kyowa Kirin Co., Ltd., Other Relationship; AstraZeneca, Novo Nordisk, Research Support; Boehringer Ingelheim, Speaker's Bureau; AstraZeneca, Bayer, Eli Lilly and Company, Sanofi, Stock/Shareholder; Aptorum Group Limited. E.Chow: Research Support; Hua Medicine, Medtronic, Powder Pharmaceuticals Inc., Speaker's Bureau; Novartis AG, Sanofi. R.C.Ma: Other Relationship; Bayer AG, Boehringer Ingelheim International GmbH, Research Support; AstraZeneca, Bayer AG, Novo Nordisk A/S, Pfizer Inc., Tricida, Inc. Funding The HKG Health Medical and Research Fund and RGC Research Impact Fund

Key factors for overcoming psychological insulin resistance: A qualitative study in Japanese people with type 2 diabetes

AimsWe report the key factors that motivate reluctant Japanese people with type 2 diabetes (T2D) to initiate insulin treatment. MethodsParticipants were asked questions pertaining to 2 primary areas of exploration in a concurrent mixed methods approach: (a) understanding people’s thoughts and perceptions before and after insulin initiation and any related factors; and (b) exploring the reasons behind people’s responses. Data were analyzed using Steps for Coding and Theorization. ResultsParticipant responses broadly related to 3 themes which influence insulin initiation; 1. Advice from a health care provider (HCP) that insulin is an appropriate treatment; 2. Demonstration by HCPs on how to use the insulin pen/needle and the injection process; and 3. Resignation/surrender/acceptance of insulin, where participants felt there was no other choice but to commence insulin. ConclusionsBased on the 3 identified themes, it is important for HCPs to explain the benefits of insulin and demonstrate and explain the injection procedure to reluctant Japanese people with T2D. We also identified resignation/surrender/acceptance of insulin as a reason for treatment commencement. This study provides important information to assist HCPs in helping reluctant Japanese people with T2D to initiate basal insulin therapy.

Youth with type 2 diabetes have a high rate of treatment failure after discontinuation of insulin: A Pediatric Diabetes Consortium study.

Insulin is commonly used to reverse gluco-toxicity in youth with newly diagnosed type 2 diabetes (T2D), but many are subsequently weaned off insulin. We analyzed Pediatric Diabetes Consortium (PDC) data to determine how long glycemic control is maintained after termination of initial insulin treatment. Youth with T2D who had previously been on insulin but were on either an intensive lifestyle intervention alone or metformin alone upon enrollment in the PDC T2D Registry were studied (N=183). The primary outcome was time to treatment failure, defined by need to restart insulin or metformin or another diabetes medication. Data were analyzed using logistic regression to assess risk factors for treatment failure. Of the 183 participants studied (mean age 15 years, diabetes duration 1.7 years), 54% experienced treatment failure (median follow-up time 1.7 years). In the subgroup on metformin monotherapy (N=140), 45% subsequently required restart of insulin. Moreover, of participants in the subgroup treated with an intensive lifestyle intervention alone (N=43), 81% restarted insulin or were treated with metformin or other diabetes medication. In both groups, median time to treatment failure was 1.2 years. Higher HbA1c at enrollment was significantly associated with treatment failure (p < 0.001). Youth with T2D who are initially treated with insulin have a high rate of treatment failure when switched to intensive lifestyle alone or metformin alone. Our data highlight the severe and progressive nature of youth onset T2D, hence patients should be monitored closely for deteriorating glycemic control after being weaned off insulin.

Course of body weight before and after the initiation of insulin therapy in type 2 diabetes mellitus: Retrospective inception cohort study (ZODIAC 58).

AimsThe aim of this study was to explore the effect of insulin treatment initiation on weight by taking weight change prior to initiation into account.Materials and methodsWe performed an observational retrospective inception cohort study, concerning Dutch primary care. We identified all patients that initiated insulin treatment (n = 7967) and individually matched patients with a reference patient (n = 5213 pairs). We obtained estimated mean weight changes in the five years prior to five years post insulin therapy. We applied linear regression analysis on weight change in the first year after insulin therapy (T0 to T+1), with matched group as primary determinant adjusted for pre‐insulin weight change and additional covariates.ResultsEstimated mean weight increased in the five consecutive years prior to insulin therapy (−0.23 kg in year T‐5 to T‐4, 0.01 kg in year T‐4 to T‐3, 0.07 kg in year T‐3 to T‐2, 0.24 kg in year T‐2 to T‐1, and 0.46 kg in year T‐1 to T0) and continued to increase in the first year after, that is T0 to T+1, at a slightly lower rate (0.31 ± 3.9 kg). Pre‐insulin weight change had the highest explained variance and was inversely and independently associated with weight change (p < .001). Starting insulin was associated with weight increase, independent of pre‐insulin weight change (β‐adjusted 1.228, p < .001). Stratification revealed that despite having a more or less similar baseline BMI, patients with substantial weight increase showed higher estimated mean BMI’s followed by weight loss pre‐insulin. In matched references, estimated mean weight changes were negative in all years concerning the study period, indicating consistent weight loss.ConclusionsInitiation of insulin therapy was independently associated with weight increase; however, overall effect on weight was small and subject to substantial variation. Pre‐insulin weight change is identified as a relatively strong inverse determinant of weight change after insulin initiation.

Practical use of insulin degludec/insulin aspart in a multinational setting: beyond the guidelines.

Insulin degludec/insulin aspart (IDegAsp) is a fixed‐ratio co‐formulation of insulin degludec, which provides long‐lasting basal insulin coverage, and insulin aspart, which targets postprandial glycaemia. This review provides expert opinion on the practical clinical use of IDegAsp, including: dose timings relative to meals, when and how to intensify treatment from once‐daily (OD) to twice‐daily (BID) dose adjustments, and use in special populations (including hospitalized patients). IDegAsp could be considered as one among the choices for initiating insulin treatment, preferential to starting on basal insulin alone, particularly for people with severe hyperglycaemia and/or when postprandial hyperglycaemia is a major concern. The recommended starting dose of IDegAsp is 10 units with the most carbohydrate‐rich meal(s), followed by individualized dose adjustments. Insulin doses should be titrated once weekly in two‐unit steps, guided by individualized fasting plasma glucose targets and based on patient goals, preferences and hypoglycaemia risk. Options for intensification from IDegAsp OD are discussed, which should be guided by HbA1c, prandial glucose levels, meal patterns and patient preferences. Recommendations for switching to IDegAsp from basal insulin, premixed insulins OD/BID, and basal‐plus/basal–bolus regimens are discussed. IDegAsp can be co‐administered with other antihyperglycaemic drugs; however, sulphonylureas frequently need to be discontinued or the dose reduced, and the IDegAsp dose may need to be decreased when sodium‐glucose co‐transporter‐2 inhibitors or glucagon‐like peptide‐1 receptor agonists are added. Considerations around the initiation or continuation of IDegAsp in hospitalized individuals are discussed, as well as in those undergoing medical procedures.

Using 2nd generation basal insulins in type 2 diabetes: Costs and savings in a comparative economic analysis in Italy, based on the BRIGHT study

Background and aimsTo evaluate the economic impact of using 2nd generation basal insulin analogs, Glargine 300 Units/ml (Gla-300) vs Degludec 100 Units/ml (IDeg-100), in patients with type 2 diabetes (T2D). Methods and resultsAn economic analysis was conducted using findings from the BRIGHT study (the first controlled, head-to-head study comparing Gla-300 vs IDeg-100), and costs for the Italian National Healthcare Service (NHS). A cost-minimization analysis (CMA) and a budget impact analysis (BIA) were conducted. Only pharmacological costs were included in the analysis. The CMA estimated patient treatment costs at 24 weeks and 1 year; the BIA assessed the economic impact of treating the overall Italian population of T2D insulin-naïve patients, who initiated insulin treatment during the period September 2017–August 2018 (N = 55 318).In the BIA, four different scenarios were compared: i) all patients receive IDeg-100 (Scenario A); ii) 61% of patients receive Gla-300, 39% IDeg-100 (Scenario B); iii) 80% of patients receive Gla-300, 20% IDeg-100 (Scenario C); iv) all patients treated with Gla-300 (Scenario D). The average treatment costs per patient were lower with Gla-300 vs IDeg-100 (at 24 weeks: €129 vs €161; at 1 year: €324 vs €409, respectively). Results of the BIA showed that comparing Scenario D vs Scenario A, total savings would amount to €1.76 million at 24 weeks, €4.73 million at 1 year, €5.53 million at 2 years. ConclusionA larger use of Gla-300 vs IDeg-100 for the treatment of T2D patients would lead to a relevant reduction of therapy costs in Italy.

1026-P: Physician-Related Factors Associated with Delay Insulin Initiation in Type 2 Diabetes Mellitus Patients with Oral Antihyperglycemic Agent Treatment Failure

Aims: Despite the availability of numerous glucose-lowering therapies and clear guidelines for T2DM management, only 1/3 of the patient with T2DM in Thailand can achieve their glycemic targets. Timely initiation of insulin therapy has been suggested as one of the strategies to solve this problem. Therefore, the purpose of this study was to identify physician’s attitudes among the internal medicine residents regarding insulin initiation. Methods: The questionnaire adapting from Physician Attitudes to Insulin Therapy questionnaire was used to conduct a questionnaire-based survey among the internal medicine residents in Siriraj Hospital, Mahidol University. Results: The questionnaire was sent to 100 internal medicine residents. The response rate was 80%. The majority of respondents (60%, n=48/80) were willing to initiate insulin therapy for the patients with T2DM, who failed oral antihyperglycemic drug (OHD) treatment at HbA1c level between 7.5-9.5%. In addition, 45% (n=36/80) of respondents use HbA1c threshold of above 8.5% to initiate insulin treatment add on to OHD. However, if the internal medicine residents themselves were diabetes mellitus, they would decide to receive insulin at HbA1c level between 7.0-8.5%. The main reasons regarding insulin initiation barrier by physicians were a consideration of burden on the patients and families to initiate insulin therapy (88%, n=70/80), time-consuming for an explanation about insulin devices, monitoring and adjustment (74%, n=59/80) and difficult to advise the patients who fear the injection drugs to use insulin (70%, n=56/80). Conclusions: Physician-related factors associated with delay insulin initiation need to be addressed for better diabetes management. Internal medicine resident aspects according to high HbA1c thresholds, high effort regarding explanation, and motivation, and the patients and family burdens are the main barriers for insulin initiation. Disclosure T. Sitasuwan: None. S. Choksakunwong: None. W. Srivanichakorn: None.

TRIal to slow the Progression Of Diabetes (TRIPOD): study protocol for a randomized controlled trial using wireless technology and incentives

BackgroundThe outcomes for those with type 2 diabetes mellitus (T2DM) in Singapore are poor. In this TRIal to slow the Progression Of Diabetes (TRIPOD), we will evaluate the effectiveness and cost-effectiveness of a comprehensive diabetes management package (DMP), with or without a financial incentives program, M-POWER Rewards, in efforts to improve HbA1c levels for individuals with T2DM.Methods/designTRIPOD is a randomized, open-label, controlled, multi-center, superiority trial with three parallel arms: (1) usual care only, (2) usual care with DMP, and (3) usual care with DMP plus M-POWER Rewards. A total of 339 adults with sub-optimally controlled T2DM (self-reported HbA1c 7.5–11.0%) will be block randomized according to a 1:1:1 allocation ratio to the three arms. The primary outcome is mean change in HbA1c level at Month 12 from baseline. Secondary outcomes include mean change in HbA1c level at Months 6, 18, and 24; mean changes at Months 6, 12, 18, and 24 in weight, blood pressure, and self-reported physical activity, weight monitoring, blood glucose monitoring, medication adherence, diabetes self-management, sleep quality, work productivity and daily activity impairment, and health utility index; and proportion of participants initiating insulin treatment by Months 6, 12, 18, and 24. Incremental cost-effectiveness ratios will be computed based on costs per improvement in HbA1c at Month 12 and converted to cost per quality-adjusted life year gained.DiscussionThe TRIPOD study will present insights about the long-term cost-effectiveness and financial viability of the interventions and the potential for integrating within usual care.Trial registrationClinicalTrials.gov, NCT03800680. Registered on 11 January 2019.

1114-P: Feasibility Study of a Novel Way to Initiate Insulin Treatment in Persons with Type 2 Diabetes

Introduction: Insulin initiation in type 2 diabetes (T2D) can be a complex process. In U.S., more than 60% of T2Ds treated with insulin do not reach recommended glycemic targets. Aim: To investigate the feasibility of using a simple dose response model for predicting the basal insulin dose needed to reach glycemic target for a person with T2D. Methods: To support initiation of a long acting insulin (insulin Degludec), we used CGM and injection data during insulin initiation to create an individual dose response model. Insulin naïve persons with T2D were included. Patients wore a CGM until the glycemic target was reached. CGM data from the first two weeks were used to identify the lowest glucose value of a day. The estimated safe and effective insulin dose (the 2-week dose estimates) were obtained by combining these lowest daily glucose periods with corresponding insulin doses, and extrapolating to a target range of 4-6 mmol/L. At end of study, the 2-week dose estimate was compared to the actual dose needed for glycemic control to assess how safe and effective the initial estimate would have been. Results: Of the first 7 of 10 patients who completed the study, 5 were males of average age 60.3 (9.1) years, BMI 30.5 (4.1) kg/m2 and diabetes duration 15.8 (8.8) years. The observed actual dose for reaching the glycemic target was 49.9 (31.4) IU, and the 2-week dose prediction for reaching 4 and 6 mmol/L was 31.4 (12.6) IU and 45.5 (17.7) IU, respectively. At the end of study, a dose range for reaching the 4-6 mmol/L range was estimated using all the collected data, and all estimates were within or below this range. Conclusion: Preliminary results from this feasibility study show that the insulin Degludec dose predicted two weeks after initiation was within or below the dose range needed for optimal control, thus the prediction errors were on the safe side in all cases. The results indicate that linear glucose and insulin extrapolation can be a safe and effective way to support initiation of insulin Degludec for people with T2D. Disclosure T. Aradóttir: None. H. Bengtsson: None. M.L. Jensen: Employee; Self; Novo Nordisk A/S. N.K. Poulsen: None. D. Boiroux: None. S. Schmidt: Speaker's Bureau; Self; Novo Nordisk A/S. K. Nørgaard: Advisory Panel; Self; Abbott, Medtronic, Novo Nordisk A/S. Speaker's Bureau; Self; Bayer US, Medtronic, Roche Diabetes Care, Rubin Medical, Sanofi, Zealand Pharma A/S. Stock/Shareholder; Self; Novo Nordisk A/S. Funding Novo Nordisk A/S; Innovation Fund Denmark (5189-00033B); Novo Nordisk Foundation

Inercia clínica en el tratamiento con insulina en el primer nivel de atención.

Refusal of physicians to prescribe insulin to their patients has been scarcely evaluated; the delay in treatment intensification hinders adequate and quality care. To identify the perception of primary care physicians about barriers to initiate insulin treatment in patients with diabetes. Using the Smith Index and multivariate analysis, the relevance and grouping of concepts related to barriers to insulin prescription were assessed in 81 family doctors. Only 35.8% of physicians showed confidence for prescribing insulin; almost half of them rated treatment intensification between moderately and little important (39.5% and 6.2%). Barriers were related to the physician (39.5%), the patient (37%), insulin treatment (11.1%) and the institution (6.2%); 6.2 % of physicians did not perceive any barrier. The barriers were grouped in 5 factors that explained 62.48% of the variance: patient cultural level, lack of medical skills, fear of adverse events, insecurity and lack of training. Clinical inertia was not the result of a complex medical condition or patient comorbidities, but of doctor's perception and confidence in his/her clinical and communication skills.

Innovative Tailored Microlearning Approach to Insulin Self-Management Education Shows High Engagement Levels among Diverse Adults

Self-management education for adults with type 2 diabetes (T2DM) improves knowledge, skills and motivation; yet, new strategies to more effectively educate patients and improve adoption of insulin therapy are still needed. We conducted a prospective, non-randomized multi-center pilot, using a novel Patient Experience Cloud to deliver microlearning education focused on survival skills, insulin injection technique, and lifestyle management. Content was culturally relevant and tailored to minority patients with T2DM who recently initiated insulin treatment to enhance engagement. Consented T2DM adults, ages 20 to 70 years, were presented an online library of 56 education videos (1-4 minutes each). Pre and post surveys of self-reported attitudes towards insulin and patient activation measures (using the validated PAM scale) were obtained. The study enrolled 201 patients: 78 non-Hispanic whites (NHWs), 74 African Americans (AAs), 39 Hispanic whites (HWs) and 10 Other. Of these, 181 (90%) were engaged (defined as completing baseline surveys and watching 4+ videos). The number of videos viewed differed by race, p=0.012; with median number of 23 for AAs, 13 for NHWs and 5 for HWs. One week later, 83 participants (41%) continued engagement via viewing and completion of post questionnaires. Highest engagement was seen among AAs (51%) vs. 40% of NHWs and 26% of HWs. Overall attitudes towards insulin improved significantly, with a mean change of 0.29 points (on a 6 point Likert scale, 95% CI 0.02 to 0.56, p=0.03). Similarly, the PAM score increased significantly after viewing (by 0.17 point on a 4 point scale, 95% CI 0.to 0.26, p&amp;lt;0.001), independent of race. After viewing culturally tailored microlearning delivered via a cloud platform, patient attitudes towards insulin and activation measures for self-care improved significantly. This novel approach should be further investigated for its ability to improve adherence to insulin and glycemic outcomes. Disclosure M.M. Bogun: Other Relationship; Self; Mytonomy. N.E. Jelesoff: None. C.M. Nassar: None. C.R. Thacker: Other Relationship; Self; Amylin Pharmaceuticals, AstraZeneca, Mytonomy. J. Camacho Rivera: Research Support; Self; Mytonomy. C.J. Bourges: None. K. Sethi: None. L. Egbuonu-Davis: Employee; Self; Sanofi. A.C. Beal: Employee; Self; Sanofi. Board Member; Self; AcademyHealth. D.A. Greenwood: Advisory Panel; Self; Novo Nordisk A/S. Consultant; Self; Verily Life Sciences LLC.. Speaker's Bureau; Self; Becton, Dickinson and Company. Employee; Self; Mytonomy, Inc. Advisory Panel; Self; American Association of Diabetes Educators. H. Chatha: Employee; Self; Mytonomy. Employee; Spouse/Partner; Medstar Health. A. Kataria: Stock/Shareholder; Self; Mytonomy, Inc. Stock/Shareholder; Spouse/Partner; Mytonomy, Inc. D.B. McNeill: None. R. Goland: None. M.F. Magee: Research Support; Self; Sanofi, Eli Lilly and Company, MedStar Health Research Institute. Advisory Panel; Self; Merck &amp; Co., Inc.. Research Support; Self; PRIMED. Speaker's Bureau; Self; IMNE, American Diabetes Association. Advisory Panel; Self; Endocrine Society. Speaker's Bureau; Self; Sanofi. Research Support; Self; MedStar Health.

Self-Monitoring of Blood Glucose in Patients with Type 2 Diabetes Before and After Initiating Basal Insulin Treatment in China

Objective: To investigate the situation of self-monitoring of blood glucose (SMBG) in patients with type 2 diabetes before and after initiating basal insulin treatment in China. Materials and Methods: This was a prospective analysis of data from the ORBIT study. Type 2 diabetes patients with HbA1c ≥ 7%, receiving oral antidiabetic agents, and initiated on basal insulin were recruited and followed up for 6 months. Patients were divided into three groups (low, middle, and high SMBG frequency) according to their SMBG frequency at the end of the study. Differences in glucose outcomes were compared among groups to evaluate the association between final SMBG frequency and the glucose control. Factors related to SMBG frequency were also analyzed using multivariate logistic regression. Results: Overall, 18,995 patients were enrolled. The mean self-reported frequency of SMBG at baseline, month 3, and month 6 was 5.2 ± 10.2, 7.1 ± 9.9, and 6.3 ± 7.9 times per month, respectively. Multivariate analysis showed that before initiating insulin treatment, SMBG frequency was related to hospital level, age, gender, body–mass index, education degree, current residence, diabetes duration, types of oral antidiabetic agents, and mild hypoglycemia in the previous 1 month. After initiation of insulin treatment, SMBG frequency was related to hospital level, gender, education degree, current residence, HbA1c level at baseline, current number of insulin injections, and mild hypoglycemia in the previous 1 month. Conclusion: In Chinese type 2 diabetic patients, the frequencies of SMBG before and after insulin treatment are both very low. Hospital level, gender, education degree, current residence, and mild hypoglycemia in the previous 1 month are factors related to the SMBG frequency of both before and after initiation of insulin treatment.

Insulin use and Excess Fracture Risk in Patients with Type 2 Diabetes: A Propensity-Matched cohort analysis

Despite normal to high bone mineral density, patients with type 2 diabetes (T2DM) have an increased fracture risk. T2DM medications could partially account for this excess risk. The aim of this study was to assess the association between insulin use and bone fracture risk in T2DM patients. A population-based matched cohort study based on a primary care records database validated for research use (Catalonia, Spain) was performed. Propensity score (PS) for insulin use was calculated using logistic regression including predefined predictors of fractures. A total of 2,979 insulin users and 14,895 non-users were observed for a median of 1.42 and 4.58 years respectively. Major fracture rates were 11.2/1,000 person-years for insulin users, compared with 8.3/1,000 among non-users. Matched models confirmed a significant association, with an adjusted subhazard ratio (adj SHR) of 1.38 [95% CI 1.06 to 1.80] for major fractures. No differences between types of insulin or different regimens were found. Estimated number needed to harm (fracture) was 82 (95% CI 32 to 416). Insulin use appears to be associated with a 38% excess fracture risk among T2DM patients in the early stages of the disease. Fracture risk should be included among the considerations to initiate insulin treatment.

Insulins NPH, glargine, and detemir, and risk of severe hypoglycemia among working-age adults*

Introduction: The longer acting basal insulin analogs glargine and detemir have shown a lower incidence of hypoglycemia compared to insulin NPH in clinical studies. We evaluated the real-life risk of severe hypoglycemia among new users of insulins in the working-age population in Finland.Methods: All persons aged 18–65 years with diabetes mellitus who were newly prescribed with insulins NPH, glargine, or detemir during 2006–2009, were identified from national registers. Risk of severe hypoglycemia requiring hospital care was compared between insulin types.Results: A total of 16,985 persons initiated basal insulin treatment (5586, 7499, and 3900 patients started NPH, glargine, and detemir, respectively) during follow-up. Five hundred and thirty-six persons were hospitalized because of severe hypoglycemia. Absolute rate (per 1000 patient-years) was 20.6 (95% CI 17.9, 23.8), 17.8 (15.6, 20.3), and 12.4 (9.9, 15.5) for NPH, glargine, and detemir initiators, respectively. With NPH as reference, the adjusted hazard ratio (HR) was 0.92 (95% CI 0.74, 1.15, p = 0.47) for glargine, and 0.70 (0.51, 0.94, p= 0.018) for detemir. The HR for detemir compared to glargine was 0.76 (0.58, 0.99, p = 0.040).Conclusions: Initiating insulin treatment with detemir, but not with glargine, was associated with a significantly lower risk of severe hypoglycemia compared to NPH, among working-age adults.KEY MESSAGESThe comparative safety of modern basal insulins regarding hypoglycemia among the working-age population is unclear.Large reductions in the incidence of severe hypoglycemia were seen among real-life patients who started insulin detemir, as compared to patients who initiated glargine or especially NPH insulin.Given the large amount of patients using insulin, these findings may have considerable clinical consequences at the population level.