Insulin Therapy In Patients Research Articles

Association between glucose-lowering drugs and circulating insulin antibodies induced by insulin therapy in patients with type 2 diabetes.

Insulin antibodies (IAs) affect blood glucose control in patients receiving insulin therapy. To investigate the relationship between different hypoglycemic treatments and IAs in patients with type 2 diabetes mellitus (T2DM). This cross-sectional, retrospective study included 1863 patients with T2DM who were receiving exogenous insulin therapy. All patients received stable antidiabetic therapy in the last 3 months and IA levels were measured using an iodine-125 array. A total of 1863 patients were enrolled. There were 902 (48.4%) patients who had positive IAs (IA level > 5%), with a mean IA level of 11.06% (10.39%-11.72%). IA levels were positively correlated with high fasting blood glucose (odds ratio = 1.069, P < 0.001). The proportion of positive IAs was lowest in patients using glargine only (31.9%) and highest in patients using human insulin only (70.3%), P < 0.001. The IA levels in patients using sulfonylureas/glinides (8.3%), metformin (9.6%), and dipeptidyl peptidase-4 inhibitors (8.2%) were all lower than in patients without these drugs (all P < 0.05). Nearly half of patients on insulin therapy have positive IA antibodies, and IA antibody levels are associated with blood glucose control. Insulin glargine and a combination of oral glucose-lowering drugs were correlated with lower IA levels.

Which Diabetes Patients Will Benefit the Most from Once-Weekly Basal Insulin Analogs? A Review with a Special Focus on Type 1 Diabetes Patients

Basal insulin analogs, typically administered once or twice daily, have been one of the two pillars of the multiple daily injection (MDI) insulin therapy of patients with type 1 diabetes (T1D) for the last twenty years. Recently, once-weekly basal insulin analogs have been developed and are in late-phase clinical trials. One of these analogs is insulin icodec (icodec), appropriately developed to bind reversibly to albumin and to be gradually released into the patient’s circulation. Icodec has been tried mostly in clinical trials of adult patients with type 2 diabetes. A recent phase 3a clinical trial comprising adult patients with T1D was designed to evaluate icodec’s efficacy and safety compared with a daily basal insulin analog (degludec) after a 26-week main phase plus a safety extension of another 26 weeks. Icodec showed non-inferiority to once-daily degludec in glycated hemoglobin (HbA1c) reduction at week 26, and no significant differences in time in range (TIR) (70–180 mg/dL) and in time above range (TAR) (&gt;180 mg/dL). On the other hand, it was associated with increased rates of clinically significant hypoglycemia (blood glucose &lt; 54 mg/dL) and severe hypoglycemia (external assistance need for recovery), remaining either below or close to the internationally recommended targets for hypoglycemia. Another once-weekly insulin analog, basal insulin Fc (BIF), has been investigated in a phase 2 clinical trial comprising adult patients with T1D, with equally promising results. These preliminary data suggest that once-weekly insulin analogs could be of use for some patients with T1D, for example, patients not taking insulin regularly or those who are on MDI and wish for fewer injections. In addition, due to its prolonged mode of action, it could decrease the risk of diabetic ketoacidosis and the need for hospitalization. Additionally, patients with T1D that struggle with wearing diabetes mellitus devices/closed-loop insulin pumps either due to the cost or due to skin issues may also benefit from long-acting insulin. There is increasing evidence of the benefits of adjunctive therapies to insulin in T1D patients, but these therapies are not FDA-approved due to a possible higher risk of diabetic ketoacidosis. These long-acting insulin analogues could be used with adjunctive therapies in selected patients. This review aims to present available data on the mode of action, clinical trial results, and possible benefits of once-weekly insulin analogs for patients with T1D. In addition, it intends to suggest a future research framework for important clinical questions, such as once-weekly insulin analog use and exercise, sick days, or surgery, that will enhance our knowledge regarding this indisputable innovation in insulin management.

C-peptide index at 2 h post-meal is a useful predictor of endogenous insulin secretory capacity and withdrawal from insulin therapy in subjects with type 2 diabetes.

To evaluate the correlation between C-peptide index (CPI) at 2 h post-meal and endogenous insulin secretory capacity and to develop clinical models to predict the possibility of withdrawal from insulin therapy in patients with type 2 diabetes. This was a single-centre retrospective study of patients with type 2 diabetes admitted to our hospital. Patients were divided into a withdrawal group (n = 72) and a non-withdrawal group (n = 75) based on whether they were able to withdraw from insulin therapy at discharge, and the correlation between CPI at 2 h after meal and diabetes-related parameters was evaluated. In addition, we created two clinical models to predict the possibility of withdrawal from insulin therapy using machine learning. The glycated haemoglobin values of the study participants were87.8 ± 22.6 mmol/mo. The CPI at 2 h post-meal was 1.93 ± 1.28 in the non-withdrawal group and 2.97 ± 2.07 in the withdrawal group (p < 0.001). CPI at 2 h post-meal was an independent predictor of withdrawal from insulin therapy. In addition, CPI at 2 h post-meal was a better predictor than fasting CPI. Six factors associated with insulin therapy withdrawal (age, duration of diabetes, creatinine, alanine aminotransferase, insulin therapy until hospitalization, and CPI at 2 h post-meal) were used to generate two clinical models by machine learning. The accuracy of the generated clinical models ranged from 78.3% to 82.6%. The CPI at 2 h post-meal is a clinically useful measure of endogenous insulin secretory capacity under non-fasting conditions.

Recellularization via electroporation therapy of the duodenum combined with glucagon-like peptide 1 receptor agonist to replace insulin therapy in patients with type 2 diabetes: 12-month results of a first-in-human study

Studies have shown that hydrothermal duodenal mucosal ablation results in improved glycemic control. Recellularization via electroporation therapy (ReCET) is a novel endoscopic procedure that uses electroporation to induce cellular apoptosis and subsequent reepithelization. In this study, we aimed to eliminate exogenous insulin treatment in type 2 diabetes (T2D) patients through a single ReCET procedure combined with a glucagon-like peptide 1 receptor agonist. Feasibility, safety, and (dose) efficacy of ReCET were assessed. This first-in-human study included patients with T2D on basal insulin (age, 28-75 years; body mass index, 24-40 kg/m2; glycosylated hemoglobin,≤64mmol/mol; C-peptide,≥0.2 nmol/L). The electroporation dose was optimized during the study, starting with single 600 V and ending with double 750 V treatments. All patients underwent ReCET, after which insulin was discontinued and semaglutide (glucagon-like peptide-1 receptor agonist) was initiated. The primary endpoints were feasibility (procedure time [from catheter in to catheter out], technical success rate), safety, and efficacy (patients off insulin at 6 months; HbA1c,≤58mmol/mol). Fourteen patients underwent endoscopic ReCET. The median procedure time was 58 (interquartile range, 49-73) minutes. ReCET demonstrated a technical success rate of 100%. No device-related severe adverse events or severe hypoglycemic events were observed. At the 12-month follow-up, 12 (86%) patients remained off exogenous insulin therapy, with significant improvements in glycemic control and metabolic parameters. The 2 patients in whom insulin therapy was reintroduced both received ReCET at the lowest voltage (single 600 V). These results suggest that ReCET is feasible and safe. In combination with semaglutide, ReCET may be a promising therapeutic option to replace insulin therapy in selected T2D patients while improving glycemic control and metabolic health.

Effect of complex micronutrient supplement and vitamin D as adjunct to insulin therapy in patients with gestational diabetes mellitus

Purpose: To determine the effect of complex micronutrient supplements and vitamin D as adjunct therapy on pancreatic function, oxidative stress, glucose metabolism and pregnancy outcomes in patients diagnosed with gestational diabetes mellitus (GDM). &#x0D; Methods: 100 GDM patients admitted to Hangzhou Linping District Maternal and Child Health Care Hospital, China between March 2022 and February 2023, were randomly allocated to control and study groups (50 patients each). Control group received insulin injections, whereas study group received complex micronutrients with vitamin D as supplements to insulin. Differences in terms of pancreatic function (homeostatic model assessment-insulin resistance index (HOMA-IR), homeostatic model assessment-beta-cell function index (HOMA-β)), oxidative stress (total antioxidant capacity (TAC), malondialdehyde (MDA)), glucose metabolism indicators (fasting blood glucose (FBG), 2-hour postprandial glucose (2hPG), glycated hemoglobin (HbA1c)) and pregnancy outcomes was assessed. &#x0D; Results: After treatment, both groups showed reductions in serum levels of FBG, 2hPG and HbA1c, but study group exhibited a considerably greater decrease (p &lt; 0.05). In addition, study group had lower HOMA-IR and MDA levels as well as higher HOMA-β and TAC levels (p &lt; 0.05). Negative delivery outcomes occurred less frequently in study group than in control group (p &lt; 0.05). &#x0D; Conclusion: Complex micronutrient supplements (rich in magnesium, calcium, and zinc) in combination with vitamin D as adjunct to insulin treatment effectively reduce pancreatic function and oxidative stress, significantly control blood glucose levels and lower the occurrence of adverse pregnancy outcomes in GDM patients. Further studies will be required in a larger more diverse population to determine the mechanism of enhancing pancreatic function.

Pioglitazone/Exenatide/SGLT-2 inhibitor combination therapy versus insulin therapy in patients with poorly controlled type 2 diabetes

Aims: We aimed to investigate the changes in glycemic status and beta cell function in type 2 diabetes mellitus (T2DM) patients with poor glycemic control despite receiving basal/bolus insulin therapy when switched from insulin therapy to combination therapy [exenatide/pioglitazone/sodium glucose cotransporter 2 inhibitor (SGLT-2i)].&#x0D; Methods: A retrospective examination was made of the data of 64 patients, aged &gt;18 years, diagnosed with T2DM, who were being followed up in the endocrinology outpatient clinic and were switched from basal/bolus insulin therapy to triple combination therapy. At the time of the patients changing to combination therapy, the glycosylated hemoglobin (HbA1c) value was ≥8.5% and fasting c peptide value was within the normal reference range. The anthropometric data of the patients, and glycemic and biochemistry values with modified homeostastis model assessment β (HOMA-β) levels were compared before the combination therapy and at 6 months after. &#x0D; Results: Compared to the baseline values, a decrease was seen after 6 months in the values of body weight (89.6±5.8 vs. 83.8±3.6, p=0.015), body mass index (BMI) (38.3±2.7 vs. 33.5±1.9, p=0.011), and waist circumference (105.6±8.8 vs. 99.7±6, p=0.027). A decrease was determined in fasting blood glucose (FBG) (197±27.3 vs. 129±13.1, p

The Current and Promising Oral Delivery Methods for Protein- and Peptide-Based Drugs.

Drugs based on peptides and proteins (PPs) have been widely used in medicine, beginning with insulin therapy in patients with diabetes mellitus over a century ago. Although the oral route of drug administration is the preferred one by the vast majority of patients and improves compliance, medications of this kind due to their specific chemical structure are typically delivered parenterally, which ensures optimal bioavailability. In order to overcome issues connected with oral absorption of PPs such as their instability depending on digestive enzymes and pH changes in the gastrointestinal (GI) system on the one hand, but also their limited permeability across physiological barriers (mucus and epithelium) on the other hand, scientists have been strenuously searching for novel delivery methods enabling peptide and protein drugs (PPDs) to be administered enterally. These include utilization of different nanoparticles, transport channels, substances enhancing permeation, chemical modifications, hydrogels, microneedles, microemulsion, proteolytic enzyme inhibitors, and cell-penetrating peptides, all of which are extensively discussed in this review. Furthermore, this article highlights oral PP therapeutics both previously used in therapy and currently available on the medical market.

Using Motivational Interviewing to Overcome Psychological Insulin Resistance

Psychological insulin resistance can delay insulin therapy when initiating insulin therapy in patients with type 2 diabetes mellitus. The role of diabetes educator is important in reducing patients’ psychological insulin resistance through various approach. Motivational interviewing not only promotes diabetes selfmanagement, but also can help to overcome psychological insulin resistance. Diabetes educators can help smooth the transition to insulin in diabetic patients using motivational interviewing. In this article, I introduce basic counseling skills of motivational interviewing addressing psychological insulin resistance.

A Three-Step Data-Driven Methodology to Assess Adherence to Basal Insulin Therapy in Patients With Insulin-Treated Type 2 Diabetes.

While health care providers (HCPs) are generally aware of the challenges concerning insulin adherence in adults with insulin-treated type 2 diabetes (T2D), data guiding identification of insulin nonadherence and understanding of injection patterns have been limited. Hence, the aim of this study was to examine detailed injection data and provide methods for assessing different aspects of basal insulin adherence. Basal insulin data recorded by a connected insulin pen and prescribed doses were collected from 103 insulin-treated patients (aged ≥18 years) with T2D from an ongoing clinical trial (NCT04981808). We categorized the data and analyzed distributions of correct doses, increased doses, reduced doses, and missed doses to quantify adherence. We developed a three-step model evaluating three aspects of adherence (overall adherence, adherence distribution, and dose deviation) offering HCPs a comprehensive assessment approach. We used data from a connected insulin pen to exemplify the use of the three-step model to evaluate overall, adherence, adherence distribution, and dose deviation using patient cases. The methodology provides HCPs with detailed access to previously limited clinical data on insulin administration, making it possible to identify specific nonadherence behavior which will guide patient-HCP discussions and potentially provide valuable insights for tailoring the most appropriate forms of support.

THU388 Insulin Edema Associated With Glargine: A Case Report And Brief Review Of Literature

Abstract Disclosure: J. Wood: None. V. Samji: None. F.S. Celi: None. P. Majety: None. Introduction: Insulin edema is an uncommon and poorly understood complication of insulin therapy in patients with diabetes. We report a patient with type 1 diabetes (T1DM) who developed edema within days of initiating insulin glargine that resolved with discontinuation of this medication. Case Report: A 20-year-old man with no past medical history presented with nausea, vomiting, polydipsia, and a 15-pound weight loss and was noted to have a hemoglobin A1c greater than 14.0%. Diabetic ketoacidosis (DKA) was ruled out and was started on weight-based insulin therapy with glargine and lispro three units with meals. Additional diabetes workup was notable for positive Anti-IA2 antibodies. Blood glucose levels improved prior to discharge. A week after discharge, he complained of swelling of limbs. Patient denied any shortness of breath, cough, chest pain, orthopnea, or nocturnal dyspnea. He was found to have extensive 2+ pitting edema in bilateral feet extending up to his calves. Dorsalis Pedis pulses were 2+ bilaterally. No warmth or erythema of legs was noted. His weight in clinic was 70.2 kg (154.4 lbs), up 11.6 kg (25.5 lbs) ten days post discharge. Evaluation for bilateral pedal edema was performed. Labs were notable for normal liver enzymes, creatinine, glomerular filtration rate and urine albumin levels, ruling out hepatic and renal causes of edema. Thyroid function tests were normal. His presentation was discussed with cardiology and brain natriuretic peptide level was drawn which was also normal. No further cardiac workup was recommended at that time given the patient’s history and lack of other clinical signs or symptoms of heart failure. After ruling out other systemic causes of edema in our patient, a diagnosis of insulin edema was made. Based on prior case reports of glargine associated insulin edema, he was switched from insulin glargine to insulin degludec. He noted significant improvement within 24 hours of switching insulin with a 6.4-pound weight loss in just one day and complete resolution of edema within 3 days. He had no recurrence of edema once glargine was discontinued despite increasing insulin dosing for glycemic control. Conclusion: The pathophysiology of insulin edema is unclear. Insulin’s role in renal sodium handling, vasodilation, and increased vascular permeability, have been postulated as possible mechanisms. Risk factors for developing insulin edema include T1DM, high A1C, high dose of insulin, rapid correction of hyperglycemia, DKA on presentation and poor nutritional status. Additional risk factors for developing insulin edema include thiamine deficiency and an underlying genetic predisposition related to a mitochondrial mutation, although this seems to be rare. Insulin edema is a diagnosis of exclusion. Clinicians should be aware of this rare complication, and its occurrence should be documented and differentiated from other causes of edema. Presentation: Thursday, June 15, 2023

Evolution of Guideline Recommendations on Insulin Therapy in Type 2 Diabetes Mellitus Over the Last Two Decades: A Narrative Review.

The prevalence of type 2 diabetes mellitus has been increasing worldwide. As the therapeutic options for type 2 diabetes mellitus have evolved over the last 2 decades, national and global guidelines related to type 2 diabetes mellitus pharmacotherapy issued by various organizations have tended to vary in their recommendations. This narrative review aimed to analyze the key recommendations by major global and national guidelines on the initiation of insulin therapy in patients with type 2 diabetes mellitus over the last 20 years. Strategies for insulin therapy for titration and intensification were also assessed. All guidelines recommend initiation of insulin (basal/ premixed/other formulations) when glycemic targets are not achieved despite lifestyle measures and oral antidiabetic drugs. In the recent decade, early initiation of insulin has been recommended when the glycated hemoglobin levels are >10% or blood glucose levels are ≥300 mg/dL (16.7 mmol/L). Initiation is recommended at a dose of 10 units or 0.1-0.2 U/kg. Titration is advised to achieve the optimal dosage, while intensification is recommended when glycemic targets are not achieved despite titrating to an acceptable level. Glucose monitoring at periodic intervals is recommended for adequate glycemic control. The guidelines further suggest that the choice of insulin should be individualized, considering the clinical status of patients with type 2 diabetes mellitus. The physicians as well as patients should be a part of the decisions made regarding the therapeutic choice of regimen, preparation, and delivery device.

Renal, cardiovascular, and safety outcomes of adding sodium-glucose cotransporter-2 inhibitors to insulin therapy in patients with type-2 diabetes: a meta-analysis.

To investigate the renal, cardiovascular, and safety outcomes when sodium-glucose cotransporter-2 inhibitors (SGLT2is) were added to insulin therapy in patients with type-2 diabetes mellitus (T2DM). We searched Embase, PubMed, and Cochrane libraries for reports published up to Feb 2023. Randomized controlled trials (RCTs) comparing SGLT2is and insulin combination therapy (SGLT2is + INS group) with insulin therapy alone (INS group) in T2DM were included. Fourteen RCTs involving six thousand one hundred twenty subjects with durations of 12-104weeks were included. Compared with the insulin group, the SGLT2is + INS group showed decreased glycosylated hemoglobin values and insulin dosages (P < 0.00001). Meanwhile, the SGLT2is + INS group had a reduced urinary albumin/creatinine ratio (UACR) by 25.42mg/g and uric acid concentration (P = 0.030; P = 0.001, respectively) but the estimated glomerular filtration rate (eGFR) and renal-related adverse events were unaffected (P = 0.070; P = 0.880, respectively). Blood pressure and body weight were lower in the SGLT2is + INS group (P < 0.01). However, the risk of genital infection was bigger when SGLT2is were added to insulin therapy (P < 0.00001), but the risks of severe hypoglycemia or urinary tract infection were equal between the two groups (P > 0.05). Adding SGLT2is to insulin therapy in T2DM patients showed better glucose control and decreased albuminuria, uric acid, blood pressure, and body weight without a reduction in the eGFR.

A case report of homocysteinuria with endophthalmitis and diabetes

Homocysteinuria is a rare inherited metabolic disorder that leads to the accumulation of homocysteine, which is toxic to blood vessels and other tissues. We present the case of a 29-year-old female with homocysteinuria and recently diagnosed diabetes mellitus presented with sudden eye symptoms and was diagnosed with endophthalmitis. High blood glucose levels were detected and further investigation revealed that the patient had a history of childhood vision difficulties and elevated plasma homocysteine levels. This case report highlights the importance of considering homocysteinuria in patients presenting with endophthalmitis in aphakic eyes and diabetes, and underscores the need for close monitoring of blood glucose levels and insulin therapy in patients with homocysteinuria and diabetes.

Efficacy of switching from basal-bolus insulin therapy to twice-daily insulin degludec/insulin aspart co-formulation plus insulin aspart in patients with poorly controlled type 2 diabetes.

The aim of this study was to evaluate the efficacy of twice-daily (BID) insulin degludec/insulin aspart (IDegAsp) co-formulation + once-daily (OD) bolus insulin aspart (IAsp) injection (IDegAsp BID-Plus) as simplified intensive insulin therapy in patients with poorly controlled type 2 diabetes mellitus (T2DM) with basal-bolus insulin therapy (BBIT). The retrospective study included 155 patients who switched from BBIT to IDegAsp BID-Plus. After the initiation of the treatment, 73 patients continued regular follow-up and insulin doses, number of injections, hemoglobin A1c (HbA1c) levels, and other parameters were recorded from their files at baseline, 24, and 52 weeks. The mean age of the study population was 54.3±10.2 years, the duration of T2DM was 9.7±5.7 years, fasting plasma glucose (FPG) was 252.7±66.7 mg/dl, and HbA1c levels were 10.5±1.5%. Among the included patients, 15 patients received five injections, 51 patients received four injections, and 7 patients received three injections per day. There was a significant decrease in HbA1c (respectively; 10.46±1.54%, 7.97±1.24%, 7.98±1.23%, baseline and 6th-month p<0.001, baseline and 12th-month p<0.001), FPG (respectively; 251.6±66.5 mg/dl, 136.1±34.7 mg/dl, 125.4±67.0 mg/dl, baseline and 6th-month p<0.001, baseline and 12th-month p<0.001) and daily dose of insulin (respectively; 102.9±29.0 Unit, 73.2±18.2 U, 63.7±20.3 Unit, baseline and 6th-month p<0.001, baseline and 12th-month p<0.001) at the end of week 24 and 52. Based on real-world data, this study demonstrated that IDegAsp BID-Plus treatment provides rapid and sustainable blood glucose control with lower insulin doses and fewer injections than previous intensive insulin therapy.

A cost-effectiveness analysis of linagliptin add-on to insulin treatment for patients with type 2 diabetes mellitus and chronic kidney disease in Iran.

With the high prevalence of chronic kidney disease (CKD) in patients with type 2 diabetes mellitus (T2DM), determining optimal treatment strategies has become a major concern. Linagliptin is aDPP-4 inhibitor that does not require dose adjustment in patients with renal impairment. This study evaluates the cost-effectiveness of adding linagliptin to insulin therapy in patients with T2DM and mild (stage 2) or moderate (stage 3) CKD from a health system perspective in Iran. We developed a cost-utility model using a decision tree and ran it separately for T2DM patients with mild or moderate CKD. Clinical outcomes and health-state utility values were extracted from published studies. Direct medical costs were obtained from national tariffs in Iran in 2021. We adopted an annual time horizon and calculated the difference in costs and quality-adjusted life-years (QALYs) to obtain the incremental cost-effectiveness ratios (ICER). To capture parameter uncertainties, one-way sensitivity analyses were also performed. In T2DM patients with mild CKD, the linagliptin add-on strategy was associated with an additional $23.69 cost and 0.0148 QALYs per patient, resulting in an ICER of 1600.37 USD/QALY. In moderate CKD, the strategy was associated with $22.59 more costs and 0.0191 more QALYs, and the ICER was estimated at 1182.72 USD/QALY. In both populations, the ICER was mainly driven by the impact of HbA1c on utility, cost of linagliptin, and the reduction in insulin usage by adding linagliptin to the treatment. With a cost-effectiveness threshold of $1550 USD/QALY in Iran, adding linagliptin to insulin is cost-effective in patients with T2DM and moderate CKD. However, for those with mild CKD, it seems that the associated costs outweigh the expected benefits. The online version contains supplementary material available at 10.1007/s40200-023-01243-z.

Progression to Insulin Therapy in Patients With Type 2 Diabetes According to Cardiorespiratory Fitness, Body Mass Index, and Statin Therapy

ObjectiveTo evaluate the association between statin therapy, cardiorespiratory fitness (CRF), body mass index (BMI), and progression to insulin therapy in type 2 diabetes mellitus (T2DM). MethodsParticipants were patients with T2DM (mean age, 62.7±8.4 years; men, 178,992; women, 8360) not treated with insulin, with no evidence of uncontrolled cardiovascular disease, who completed an exercise treadmill test between October 1, 1999, and September 3, 2020. Of these, 158,578 were treated with statins and 28,774 were not. We established 5 age-specific CRF categories according to peak metabolic equivalents of task achieved during an exercise treadmill test. ResultsDuring a median follow-up period of 9.0 years, 51,182 patients progressed to insulin therapy with an average annual incidence rate of 28.4 events/1000 person-years. The adjusted progression rate was 27% higher in statin-treated patients (hazard ratio [HR], 1.27; 95% CI, 1.24 to 1.31), related directly to BMI and inversely related to CRF. A progressively higher rate was noted in statin-treated vs non–statin-treated patients within all BMI categories, ranging from 23% for normal weight to 90% for those with BMI of 35 kg/m2 and higher. The statin-CRF interaction revealed 43% higher rate in the least-fit statin-treated patients (HR, 1.43; 95% CI, 1.35 to 1.51) and a progressive decline with increased CRF to 30% lower risk in highly fit statin-treated patients (HR, 0.70; 95% CI, 0.66 to 0.75). ConclusionIn patients with T2DM, the statin-related progression to insulin therapy was associated with relatively low CRF and high BMI levels. The progression rate was mitigated by increased CRF regardless of BMI. Clinicians should foster regular exercise for patients with T2DM to enhance CRF and to lessen the rate of progression to insulin therapy.

Optimization of glycemic control with continuous glucose monitoring in a patient with type 1 diabetes mellitus undergoing maintenance hemodialysis

Patients with type 1 Diabetes Mellitus (T1DM) on renal replacement therapy with maintenance hemodialysis (MHD) are prone to develop hypoglycemia, as well as high glycemic variability on both dialysis and non-dialysis days. Reliability of glycated hemoglobin in dialysis patients with DM as a marker of carbohydrate metabolism compensation is reduced due to the influence of anemia, uremia, mechanical damage of erythrocytes during diffusion through the dialyzing membrane. Continuous glucose monitoring (CGM) is one of the methods for monitoring and correction glycemic variability in dialysis patients with DM.This article presents a description of a clinical case of the patient with T1DM on MHD receiving insulin therapy using an insulin pump in combination with CGM (FreeStyle Libre portable system) and highlights the difficulties of correcting insulin therapy on dialysis and non-dialysis days.The discussion section presents the JBDS-IP 2022 (UK) recommendations for the correction of insulin therapy in patients with DM on dialysis (it is recommended to reduce the insulin dose by 25% on dialysis days, immediately after the start of the HD procedure). Particular attention is focused on the need for a personalized approach to the correction of insulin therapy in dialysis patients with DM due to the comorbidity of this group of patients and the difficulties in extrapolating recommendations into real clinical practice.

Efficacy of combination therapy with GABA, a DPP-4i and a PPI as an adjunct to insulin therapy in patients with type 1 diabetes.

The purpose of this retrospective clinic chart review study was to determine the potential of a combination therapy (CT) consisting of γ-aminobutyric acid (GABA), a dipeptidyl peptidase-4 inhibitor (DPP-4i), and a proton pump inhibitor (PPI) to improve glycemic control as an adjunct to insulin therapy in patients with type 1 diabetes (T1D). Nineteen patients with T1D on insulin therapy were treated with additional CT in oral form. Fasting blood glucose (FBG), HbA1c, insulin dose-adjusted HbA1c (IDA-A1c), daily insulin dose, insulin/weight ratio (IWR), and fasting plasma C-peptide were measured after 26-42 weeks of treatments. FBG, HbA1c, IDA-A1c, insulin dose and IWR were all significantly decreased while plasma C-peptide was significantly increased by the CT. Treatment outcomes were further analyzed by separation of the 19 patients into two groups. One group started on the CT within 12 months of insulin treatment (early therapy, 10 patients) and another group started on this therapy only after 12 months of insulin treatment (late therapy, 9 patients). FBG, IDA-A1c, insulin dose, and IWR decreased significantly in both the early and late CT groups, however to a better extent in the early therapy group. Moreover, plasma C-peptide increased significantly only in the early therapy group, and 7 of the 10 patients in this group were able to discontinue insulin treatment while maintaining good glycemic control to study end compared with none of the 9 patients in the late therapy group. These results support the concept that the combination of GABA, a DPP-4i and a PPI as an adjunct to insulin therapy improves glycemic control in patients with T1D, and that the insulin dose required for glycemic control can be reduced or even eliminated in some patients receiving this novel therapy.

Myths and beliefs about insulin therapy in patients with diabetes mellitus and their family caregivers from a hospital in northern Peru, 2020.

To analyze and explore the myths and beliefs about insulin therapy in patients with diabetes mellitus and their family caregivers from a general hospital in northern Peru in 2020. This qualitative study used a thematic analysis model, following the interpretative paradigm. Sociodemographic and clinical data were obtained from medical records. Patients with diabetes that used some type of insulin for at least three months prior to the study were interviewed, as well as their family caregivers. Patients participated in a focus group and in-depth interviews; family caregivers participated only in in-depth interviews. Twelve patients with diabetes (11 with type 2 diabetes mellitus) were included; six in the focus group and six in the in-depth interviews. Seven family caregivers were included. After analysis, we obtained four categories: 1) beliefs related to starting insulin treatment: treatment of choice after failure of other drugs, cures diabetes, regulates sugar, fear of injectables; 2) beliefs related to treatment adherence: decompensation for not using insulin, insulin is necessary to live; 3) beliefs related to alternative therapies and cost: use of alternative therapies, high cost of insulin; and 4) myths related to the use of insulin: generates dependence, dependence for insulin administration, negative effects of insulin. The beliefs and myths of patients treated with insulin arise from the beginning of treatment, remain throughout the course of treatment, and are often reinforced by the worldview of family members.

Basal insulin titration algorithms in patients with type 2 diabetes: the simplest is the best (?)

Basal insulin is the first and main component of insulin therapy in patients with type 2 diabetes mellitus (T2DM). Based on the shortcomings of human NPH insulin and the advantages provided by long-acting basal insulin analogues, they are recommended for priority use in patients with T2DM. The leading factor in the success of insulin therapy is titration of its dose with the achievement of the target range of glycemia. Data from clinical trials and real clinical practice indicate that simpler dose titration algorithms ensure better achievement of glycemic goals with a lower risk of hypoglycemia. In addition, simple dose titration algorithms are better accepted by patients and increase satisfaction with treatment. The leading societies of diabetologists ADA/EASD and AACE/ACE recommend the use of simple dose titration algorithms. Recent clinical trials on the effectiveness of the insulin glargine dose titration based on the INSIGHT algorithm, which, unlike the traditional options for changing the dose 1–2 times a week, involves a daily correction of the insulin glargine dose by 1 Unit, have proven its effectiveness and safety. Most patients prefer this type of insulin dose titration. The same titration algorithm can be used for a fixed combination of glargine with lixisenatide, which was also confirmed by the results of clinical trials. In general, simplified options for correcting the basal insulin dose have demonstrated their effectiveness and allow increasing the percentage of patients who manage to achieve the glycemic goal without increasing the risk of hypoglycemia. When prescribing basal insulin, physician must determine the target range of glycemia, demonstrate the titration algorithm that is acceptable for each insulin and which a patient will use to achieve the glycemic goal.