Management Of Insulin Therapy Research Articles

Role of Community Health Nursing in Insulin Initiation for Type 2 Diabetes Patients: A Literature Review

Background: Insulin therapy is essential for managing type 2 diabetes in patients who do not achieve adequate glycemic control with oral medications. Despite its benefits, initiating insulin therapy presents numerous challenges due to psychological, physical, and systemic barriers. This study examines the critical role of community health nurses in facilitating the initiation and management of insulin therapy, addressing patient and healthcare provider barriers, and improving clinical outcomes. Methods: A comprehensive review of existing literature was conducted, focusing on the impact of community health nurses on diabetes management, particularly in insulin initiation and adherence. Results: : Community health nurses play a pivotal role in overcoming barriers to insulin therapy. They provide essential patient education, psychosocial support, and practical training in insulin administration. These efforts lead to improved glycemic control, higher rates of insulin adherence, and better patient satisfaction. Additionally, community health nurses facilitate collaborative care models, integrating with primary care teams to provide continuous and coordinated care. The involvement of community health nurses in diabetes management addresses both patient-related and systemic barriers. Their holistic approach includes personalized patient education, emotional support, and care coordination, significantly enhancing patient adherence and clinical outcomes. Conclusions: Community health nurses are integral to the successful initiation and management of insulin therapy in type 2 diabetes. Future research should focus on developing standardized training programs for community health nurses and exploring innovative care models that leverage their unique skills. Policy support is essential to recognize and expand the role of community health nurses in diabetes care.

Errors in diabetic insulin therapy and the vitality of proper precautions in Bangladesh: Real-life insights from the developing world.

Insulin therapy errors can have life-threatening consequences in patients with diabetes. Given the increasing prevalence of diabetes and insulin therapy in Bangladesh, it is crucial to identify and prevent these errors. This study uses case-based clinical experiences to thematically analyze insulin therapy errors and propose preventive measures. The study aims to provide valuable insights into the challenges faced in managing insulin therapy in a developing country setting and the importance of involving various stakeholders. This is a qualitative research that used a case study approach to identify and analyze errors in insulin therapy in diabetic patients who had experienced adverse clinical consequences. The cases were thematically analyzed to generate insights into current global health problems resulting from erroneous insulin therapy. The two case studies highlight potential risks of errors in insulin therapy, including poor glycemic control, complications, and death. The analysis also highlights the importance of careful monitoring, checks, and communication among health-care providers, patients, and pharmacists to prevent such errors. In addition, it emphasizes the need for education and awareness among patients and health-care providers to ensure safe and effective insulin therapy. Accurate insulin therapy is crucial for diabetes management and preventing adverse outcomes. Identified themes emphasize improved communication, education, and monitoring to minimize therapy errors. Insights from this study can inform policies and practices for better patient outcomes. Further research can identify the root causes and develop interventions to prevent errors, leading to improved quality of life for diabetics.

Smart Insulin Pen: Managing Insulin Therapy for People with Diabetes in the Digital Era

The number of insulin users in Korea has doubled over the past 20 years. Numerous studies have shown the benefits of continuous glucose monitoring (CGM) on glycemic outcomes in people with diabetes receiving insulin therapy. However, patients often failed to reach the target even with the CGM. Advanced technology, such as automated insulin delivery (AID), can potentially reduce patient burden and improve glycemic status in people on insulin therapy. However, wearing a CGM all day and complex device operation could also burden users. Additionally, since insulin users are often elderly with type 2 diabetes, there is an urgent need for new devices that are more efficient and simpler than AID. In that sense, the smart insulin pen (SIP) is the expected future technology that does not need to be worn all day and helps to calculate insulin doses with a built-in bolus calculator integrated with CGM. In this context, we discuss efficient use of SIP as an educational tool.

Diabetes mellitus canina transitoria en un paciente con piómetra: Reporte de caso

Diabetes mellitus (DM) is one of the most common endocrinopathies in dogs. It is considered a multifactorial syndrome caused by absolute or relative insulin deficiency, and may be linked to different factors such as genetic, hormonal, inflammatory, infectious or even immunological. The present report aims to describe a case of a 10-year-old mongrel dog presenting transient diabetes that progresses to the diestrus phase and a uterine infection as the main factors of insulin resistance. The treatment was carried out with therapeutic ovary-salpingohysterectomy and management of insulin therapy, along with nutritional management via an adjuvant diet for diabetes. After starting treatment, the patient showed improvement and complete remission of the persistent hyperglycemia condition.

Hypoglycemia with insulin in post-transplant diabetes mellitus

IntroductionTo prevent hypoglycemic episodes, the management of insulin therapy against post-transplant diabetes mellitus (PTDM) is important. We compared glargine (long-acting insulin) versus NPH isophane (intermediate-acting insulin) as an armamentarium against PTDM. Indeed, the study evaluated PTDM patients with hypoglycemic episodes treated with isophane or glargine. Material and methodsWe evaluated a total number of 231 living-donor renal transplant recipients with PTDM of age ≥ 18 years admitted to the hospital between January 2017 and September 2021. However, patients taking hypoglycemic agents before transplantation were excluded from this study. Out of 231 patients, 52 (22.15%) suffered from PTDM out of whom 26 were treated with glargine or isophane. ResultsAfter applying exclusion criteria, out of 52 PTDM patients 23 were included in the study: 13 PTDM patients were treated with glargine, whereas 10 PTDM patients with isophane. Our analysis revealed 12 episodes of hypoglycemia in glargine-treated PTDM patients compared to 3 in isophane-treated PTDM patients (p = 0.056). Clinically, 9 out of 15 hypoglycemic episodes were nocturnal (60%). Furthermore, no other risk factors were observed in our study population. Detailed analysis showed that both groups had equivalent doses of immunosuppressants and oral hypoglycemic agents. The odds ratio for hypoglycemia in the group treated with isophane compared to that treated with glargine was 0.224 (95% CI, 0.032–1.559). Glargine users recorded significantly lower blood sugar levels before lunch, dinner and at bedtime with p-values of 0.001, 0.009 and 0.001 respectively. A better hemoglobin A1c (HbA1c) level was seen in the glargine vs. isophane group (6.98 ± 0.52 vs. 7.45 ± 0.49, p-value 0.03). ConclusionThe study shows better blood sugar control with long-acting insulin analog, glargine, than with intermediate-actin analog, isophane. Overall, a higher number of hypoglycemic episodes was nocturnal. Long term safety of long-acting insulin analogs needs to be further studied.

Tele-education model for primary care providers to advance diabetes equity: Findings from Project ECHO Diabetes.

In the US, many individuals with diabetes do not have consistent access to endocrinologists and therefore rely on primary care providers (PCPs) for their diabetes management. Project ECHO (Extension for Community Healthcare Outcomes) Diabetes, a tele-education model, was developed to empower PCPs to independently manage diabetes, including education on diabetes technology initiation and use, to bridge disparities in diabetes. PCPs (n=116) who participated in Project ECHO Diabetes and completed pre- and post-intervention surveys were included in this analysis. The survey was administered in California and Florida to participating PCPs via REDCap and paper surveys. This survey aimed to evaluate practice demographics, protocols with adult and pediatric T1D management, challenges, resources, and provider knowledge and confidence in diabetes management. Differences and statistical significance in pre- and post-intervention responses were evaluated via McNemar's tests. PCPs reported improvement in all domains of diabetes education and management. From baseline, PCPs reported improvement in their confidence to serve as the T1D provider for their community (pre vs post: 43.8% vs 68.8%, p=0.005), manage insulin therapy (pre vs post: 62.8% vs 84.3%, p=0.002), and identify symptoms of diabetes distress (pre vs post: 62.8% vs 84.3%, p=0.002) post-intervention. Compared to pre-intervention, providers reported significant improvement in their confidence in all aspects of diabetes technology including prescribing technology (41.2% vs 68.6%, p=0.001), managing insulin pumps (41.2% vs 68.6%, p=0.001) and hybrid closed loop (10.2% vs 26.5%, p=0.033), and interpreting sensor data (41.2% vs 68.6%, p=0.001) post-intervention. PCPs who participated in Project ECHO Diabetes reported increased confidence in diabetes management, with notable improvement in their ability to prescribe, manage, and troubleshoot diabetes technology. These data support the use of tele-education of PCPs to increase confidence in diabetes technology management as a feasible strategy to advance equity in diabetes management and outcomes.

Comparison of Efficacy of Metformin and Insulin in management of Gestational Diabetes. An experience in Social Security Teaching Hospital, Ferozepur Road Lahore

Objective: To compare the feto-maternal outcomes in patients receiving metformin with those receiving standard insulin therapy for management of gestational diabetes mellitus (GDM). Methods: This randomized control study was conducted in gynecology unit of Social security Teaching Hospital, Ferozepur Road Lahore from January-2021 to December-2021. We included patients of GDM who needed pharmacologic intervention. In group M; Metformin was administered at a dose of 500mg twice daily for the first week, followed by an increase to a maximum dose of 2500mg daily in divided doses until the goal glycemic control was reached. In group I patients, regular insulin (Humulin R) was prescribed three times a day before each meal, with a single dose of intermediate acting insulin (NPH) given at bedtime. The primary study outcomes were birth weight, APGAR score, pre-term birth and maternal HBA1c levels before birth. Results: Maternal HbA1c levels before birth were 6.1±1.1 in group M and 6.0±1.2 in group I (p-value 0.66). The mean gestational age at birth was 37.9±1.1 weeks in group M and was 37.1±1.0 weeks in group I (p-value 0.0002). The frequency of pre-term was high in group I (16%) in comparison to only 6.0% in group M, but with insignificant p-value 0.11. The mean birth weight was 2.9±0.5 Kg in group M and 3.0±0.6 kg in group I (p-value 0.36). Conclusion: Better maternal glycemic control has been linked to the usage of metformin during pregnancy. In terms of patient compliance, the medicine is well tolerated. Patients with gestational diabetes mellitus who took Metformin experienced fewer neonatal problems than those who used insulin. Keywords: Gestational diabetes mellitus, metformin, insulin

470-P: Usability and Satisfaction of a Mobile Application to Support Individuals with Insulin Therapy Management

People with type 2 diabetes mellitus (T2DM) continue to be reluctant to begin insulin therapy. Methods to assure education access and support are critically important. To supplement health care provider efforts, the BD Diabetes Care App was developed to offer information on injection administration and self-management strategies. Ongoing support is built into the app in the form of articles and videos related to starting and using insulin. The purpose of this study was to evaluate patient and educator usability of and satisfaction with the app. Methods: Patients >18 years with T2DM, new to or identified as having issues with insulin therapy were recruited from in- and outpatient settings. Participants received insulin education according to standard practice and were then introduced to the app. Over the study period, participants were able to use the app as much or as little as preferred; use was tracked with app analytics. HbA1c was measured at baseline and 3 months and satisfaction surveys were administered. Results: Participants (n=22) were 27% female, 73% White Non-Hispanic, mean age 55 years, with baseline mean HbA1c of 11%. Glycemic control significantly improved during the study period, with an average reduction in HbA1c of 3.2±2.9%. All participants used the app; 86% launched it within one day of enrollment. Average use was 11 times over the course of the study, 55% were considered highly engaged (consistently used app over the course of study). Participants were most likely to access curriculum (articles and videos) about insulin pen therapy followed by living with diabetes. Most participants found the app easy to use (75%), visually appealing (81%), to contain helpful content, especially articles (77%); 73% said that they would recommend the app to another person with diabetes. Educators reported high satisfaction and a positive experience in using the app. Conclusion: The BD Diabetes Care App offers a promising approach to support patients starting and using insulin. Disclosure L. M. Siminerio: Advisory Panel; Self; Abbott Diabetes, Bayer U. S., Research Support; Self; Becton, Dickinson and Company. L. L. Bednarz: Other Relationship; Self; Medtronic, Tandem Diabetes Care. C. Dejesus: None. J. Ng: Research Support; Self; Sanofi-Aventis. S. L. Reynolds: None. J. S. Krall: Research Support; Self; Becton, Dickinson and Company, Sanofi. Funding BD

Designing an integrated, nurse-driven and home-based digital intervention to improve insulin management in under-resourced settings.

Background:In South Africa, initiating insulin for people with type 2 diabetes and subsequent titration is a major challenge for the resource-constrained healthcare system. Inadequate support systems in primary care, including not being able to access blood glucose monitors and test strips for self-monitoring of blood glucose, results in patients with type 2 diabetes being referred to higher levels of care. In primary care, initiation of insulin may be delayed due to a shortage of healthcare workers. The delayed initiation of insulin is also exacerbated by the reported resistance of both healthcare providers and people with type 2 diabetes to start insulin. In South Africa, telehealth provides an opportunity to overcome these challenges and manage insulin therapy in primary care.Methods:We describe the development of a digital health intervention including the framework used, the theoretical approach and subsequent implementation strategies.Results:This intervention is an innovative, nurse-driven and app-enabled intervention called ‘the Tshwane Insulin Project intervention’. The Tshwane Insulin Project intervention was designed and evaluated using the framework recommended by the Medical Research Council for complex interventions. The Tshwane Insulin Project intervention was developed in four sequential phases: planning, design, implementation and evaluation. The Tshwane Insulin Project intervention followed the Integrated Chronic Disease Management framework to facilitate implementation and acceptability. The Tshwane Insulin Project comprises a facility-level intervention, where nurses evaluate patients and initiate insulin, an individual-level intervention where community healthcare workers visit patients at their homes to follow-up and provide educational information, while using telehealth to enable physician-directed insulin titration if needed, and a community-level intervention aimed at empowering community healthcare workers to support people living with diabetes and raise awareness of diabetes.Conclusion:The technological advancements in digital health and telemedicine present an opportunity to improve diabetes care in resource-limited countries. This work can inform those intending to develop and implement complex interventions in primary healthcare in developing countries.

708-P: Effectiveness of CHO-Counting on Glycometabolic Control and Comparison between the Methods of I/CHO Ratio Calculation in Subjects with Cystic Fibrosis-Related Diabetes (CFRD)

DM is a complication of cystic fibrosis and it’s caused mainly by insulin deficiency. A glycometabolic decompensation, due to incorrect therapeutic management, leads to a worsening of the catabolic state (already caused by malabsorption and high metabolic requests, and a known risk factor for worsening of respiratory function). The therapy for CFRD is insulin. Cho-counting, an effective technique to manage insulin therapy in T1DM subjects, allows patients to achieve a better glycemic control. Aim: to evaluate the efficacy of cho-counting in patients with CFRD on glycemic control. Materials and Methods: 21 patients with CFRD, randomized in 2 groups. gr.1: 9 patients performing cho-counting; gr.2: 12 patients followed according to ambulatory standard care. Glycometabolic control was evaluated with: a. variation of HbA1c, b. variation of pre and postprandial average SMBG in a period of 12 months. In group 1, the I/CHO ratio obtained with the 500-formula was compared with those obtained from food and glucose diaries. Results: gr.1 showed a reduction of HbA1c, compared to gr. 2 (7.4 ± 0.9% to 6.6 ± 0.3%, Δ -0.8% vs. 7.4 ± 1.5% to 7.5 ± 1.4%, Δ + 0.1%, P <0.05). There was also an improvement, even if not significant, in gr.1 and a worsening (p <0.05 for post) in gr.2, of pre and post-prandial average SMBG. In gr.1, the I/CHO ratio obtained through the 500-formula was 1/20. Based on diaries, it was 1/18 for breakfast, 1/25 for lunch and 1/25 for dinner. Conclusions: Cho-counting is effective in improving glycometabolic control in individuals with CFRD, avoiding the risk to worsen the already delicate metabolic balance of these patients. The use of dietary and glycemic diaries allows to estimate the I/CHO ratio differentiating the insulin needs during the day. This allows a more accurate personalization of the therapy compared to the use of 500-formula, which, in these patients, often overestimate the need for insulin at meals. Disclosure V. Grancini: Board Member; Self; Roche Diabetes Care. Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc. Speaker's Bureau; Self; Merck Sharp & Dohme Corp. A. Gaglio: Consultant; Self; Roche Diabetes Care. V. Resi: Speaker's Bureau; Self; Sanofi. E. Palmieri: Speaker's Bureau; Self; Eli Lilly and Company. E. Orsi: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Eli Lilly and Company, Novo Nordisk A/S, Sanofi-Aventis.

Capacity and confidence building for general practitioners on optimum insulin use.

Type 2 diabetes is characterised by a progressive decline in insulin secretion, and sooner or later patients require insulin therapy. However, physicians are reluctant to initiate insulin therapy because of perceived inadequacy in managing insulin therapy, cost and lack of benefits. Experts from across the country met at a workshop during 12th National Insulin Summit which was held in September at Hyderabad and came up with key recommendations to build capacity and confidence in general practitioners for insulin usage. Barriers can be overcome through self-education and training; effective patient education; imparting coping skill training to patients; and bridging gaps to improve adherence. Moreover, optimum insulinization requires knowledge about the available options for initiation and intensification of insulin therapy; various insulin regimens; dosing and titration; and choosing effective and simple insulin therapy as per patient characteristics. Hence, the objective of this review article is to help build capacity and confidence among general practitioners on optimising insulin therapy.

Effect of Bolus Insulin Administration Followed by a Continuous Insulin Infusion on Diabetic Ketoacidosis Management

Despite the high incidence of diabetic ketoacidosis (DKA) there is no consensus on the most appropriate way to manage insulin therapy. This study was conducted to evaluate the effect of an insulin bolus on the resolution of DKA. A retrospective chart review of patients admitted between 1 September 2014 and 30 June 2016 with a diagnosis of DKA was conducted. Patients were assigned to the bolus or no bolus group based on provider preference. All patients were initiated on a 0.1 unit/kilogram (kg)/hour (h) intravenous (IV) regular insulin infusion, and patients in the bolus group were treated with a 0.1 unit/kg IV regular insulin bolus. Of the 145 admissions evaluated, 58 received a bolus and 87 did not. There was no difference in baseline demographics, except baseline blood glucose was higher in the bolus group (653 vs. 591 milligrams (mg)/deciliter (dL), p = 0.04). The time to resolution of DKA from emergency department admission did not differ between the bolus and no bolus group (15 vs. 15.9 h; p = 0.24). There was no difference in total insulin received (1.3 vs. 1.1 units/kg, p = 0.18), incidence of hypoglycemia (2 vs. 7%, p = 0.64), hypokalemia (16 vs. 29%, p = 0.65), or length of hospital stay (3.2 vs. 2.7 days, p = 0.27). The insulin bolus administration was not associated with reduced time to resolution of DKA.

Optimizing Glycemic Control Through Titration of Insulin Glargine 100 U/mL: A Review of Current and Future Approaches with a Focus on Asian Populations.

Various data have demonstrated inadequate glycemic control amongst Asians with type 2 diabetes mellitus (T2DM), possibly on account of suboptimal titration of basal insulin—an issue which needs to be further examined. Here we review the available global and Asia-specific data on titration of basal insulin, with a focus on the use of insulin glargine 100 U/mL (Gla-100). We also discuss clinical evidence on the efficacy and safety of titrating Gla-100, different approaches to titration, including some of the latest technological advancements, and guidance on the titration of basal insulin from international and local Asian guidelines. The authors also provide their recommendations for the initiation and titration of basal insulin for Asian populations. Discussion of the data included in this review and in relation to the authors’ clinical experience with treating T2DM in Asian patients is also included. Briefly, clinical studies demonstrate the achievement of adequate glycemic control in adults with T2DM through titration of Gla-100. However, studies investigating approaches to titration, specifically in Asian populations, are lacking and need to be conducted. Given that the management of insulin therapy is a multidisciplinary team effort involving endocrinologists, primary care physicians, nurse educators, and patients, greater resources and education targeted at these groups are needed regarding the optimal titration of basal insulin. Technological advancements in the form of mobile or web-based applications for automated dose adjustment can aid different stakeholders in optimizing the dose of basal insulin, enabling a larger number of patients in Asia to reach their target glycemic goals with improved outcomes.Electronic supplementary materialThe online version of this article (doi:10.1007/s13300-017-0322-z) contains supplementary material, which is available to authorized users.

Primary care physician perspectives on basal insulin initiation and maintenance in patients with type 2 diabetes mellitus

AimsTo describe primary care physicians’ (PCPs) perceptions of patient reactions and concerns about insulin initiation and identify opportunities for increased support. MethodsCross-sectional, online survey of PCPs prescribing basal insulin to adults with type 2 diabetes mellitus (T2DM). PCPs were identified from administrative claims of a large commercial health plan and descriptive results of PCP responses were reported. ResultsPCPs (N=100) treated an average of 17 patients receiving insulin during a typical week. More than 85% of insulin initiation recommendations originated with PCPs. Most offered glucose monitoring instructions (96%) and advice on diet, exercise, and diabetes management (96%); 35% provided insulin titration algorithms; 93% reported that patients often or always took their insulin daily within 3 months of initiation; 31% of PCPs reported monthly office contacts with patients for the first 3 months; 16% reported no outreach efforts; fewer than 20% connected patients with support groups. When starting basal insulin, PCPs reported patients feeling personal failure regarding their diabetes treatment (33% often/always) and lacking confidence in their ability to manage insulin therapy (38% often/always). ConclusionsStudy results identify additional opportunities for assisting patients in making the transition to insulin, including more frequent direct outreach to monitor insulin usage.

Sodium-glucose co-transporter 2 inhibitors in addition to insulin therapy for management of type 2 diabetes mellitus: A meta-analysis of randomized controlled trials.

Given inconsistent trial results of sodium-glucose cotransporter 2 (SGLT2) inhibitors in addition to insulin therapy for treating type 2 diabetes mellitus (T2DM), a meta-analysis was performed to evaluate the efficacy and safety of this combination for T2DM by searching available randomized trials from PubMed, Embase, CENTRAL and ClinicalTrials.gov. Our meta-analysis included seven eligible placebo-controlled trials involving 4235 patients. Compared with placebo, SGLT2 inhibitor treatment was significantly associated with a mean reduction in HbA1c of -0.56%, fasting plasma glucose of -0.95 mmol/L, body weight of -2.63 kg and insulin dose of -8.79 IU, but an increased risk of drug-related adverse events by 36%, urinary tract infections by 29% and genital infections by 357%. No significant increase was observed in risk of overall adverse events [risk ratio (RR), 1.00], serious adverse events (RR, 0.90), adverse events leading to discontinuation (RR, 1.16), hypoglycaemia events (RR, 1.07) and severe hypoglycaemia events (RR, 1.24). No diabetic ketoacidosis events were reported. Further studies are needed to establish optimal combination type and dose.

The Role of Clinical Pharmacist in Initiation and / or Dose Adjustment of Insulin Therapy in Diabetic Patients in Outpatient Clinic in Jordan = دور الصيدلاني السريري في بدء و / أو تعديل جرعة الأنسولين في مرضى السكري في العيادات الخارجية في الأردن

Glycemic control in diabetic patients is a challenging issue and requires pharmacist involvement in the patient care plan and patient's awareness to optimize diabetic regimen. Objectives: The aim of this study is to investigate the role of clinical pharmacist on glycemic control of diabetic patients by insulin therapy management in the endocrine outpatient clinic in a teaching hospital in Jordan. Method: This is a prospective, randomized controlled study carried out in the Endocrine-outpatient clinic in Jordan University Hospital (JUH). Patients with type 1 or type 2 diabetes were randomly assigned to intervention (n=50) or control group (n=50). Newly diagnosed patients with (HbA1c > 10%); or those who are diabetic with (HbA1c >7%) and taking insulin with or without oral hypoglycemic agents; or patient with (HbA1C > 7%) and on two or more oral hypoglycemic gents for ≥ 6 months were recruited either in the intervention group or the control group. Follow up started concurrently with data collection; patients were followed up for 3 months after enrollment. During the first visit demographic data, history of diabetes and diabetes assessment, other chronic disease, anti-diabetic medications and current medications used, adherence to medications, diabetes life style adherence and baseline data for HbA1c, FBG and weight were obtained. Moreover, the patients' medical records were reviewed by the pharmacist to obtain other related information. Data analysis was performed using SPSS software version (17.0). Glycosylated hemoglobin A1C (HbA1c), fasting blood glucose (FBG), frequency of hypoglycemic episodes and weight gain were measured. Results: 88 patients completed the study; clinical pharmacist interventions resulted in a significant reduction in HbA1c by 1% (p-value <0.001) and fasting blood sugar by (28.44±84.62) mg/dl compared to the baseline (p-value=0.029) with a statistically significant difference between both groups (p-value <0.05). Insignificant difference in weight gain was found between the 2 groups (p-value = 0.117), but with higher significant weight increase in the intervention group from baseline (p-value=0.001). Although hypoglycemic episodes frequency was significantly higher during the first month in the intervention group compared to the control group (p-value=0.016), none of these episodes required hospitalization. Conclusion: This study supports the role of clinical pharmacist in glycemic control in diabetic insulin users', in a country like Jordan in which clinical pharmacy practice is relatively new.

Clinical Considerations for Insulin Pharmacotherapy in Ambulatory Care, Part One: Introduction and Review of Current Products and Guidelines.

In Brief This article describes available insulin products and published guidelines to aid clinicians in making treatment decisions for insulin-dependent patients with type 2 diabetes. It establishes the need for a thorough evaluation of the literature regarding ambulatory insulin dosing to further inform providers who manage insulin therapy for patients with type 2 diabetes.

Registry of people with diabetes in three Latin American countries: a suitable approach to evaluate the quality of health care provided to people with type 2 diabetes

To implement a patient registry and collect data related to the care provided to people with type 2 diabetes in six specialized centers of three Latin American countries, measure the quality of such care using a standardized form (QUALIDIAB) that collects information on different quality of care indicators, and analyze the potential of collecting this information for improving quality of care and conducting clinical research. We collected data on clinical, metabolic and therapeutic indicators, micro- and macrovascular complications, rate of use of diagnostic and therapeutic elements and hospitalization of patients with type 2 diabetes in six diabetes centers, four in Argentina and one each in Colombia and Peru. We analyzed 1157 records from patients with type 2 diabetes (Argentina, 668; Colombia, 220; Peru, 269); 39 records were discarded because of data entry errors or inconsistencies. The data demonstrated frequency performance deficiencies in several procedures, including foot and ocular fundus examination and various cardiovascular screening tests. In contrast, HbA1c and cardiovascular risk factor assessments were performed with a greater frequency than recommended by international guidelines. Management of insulin therapy was sub-optimal, and deficiencies were also noted among diabetes education indicators. Patient registry was successfully implemented in these clinics following an interactive educational program. The data obtained provide useful information as to deficiencies in care and may be used to guide quality of care improvement efforts.

Differences in physician and patient perceptions about insulin therapy for management of type 2 diabetes: the DAWN Japan study

Objective:To better understand patient resistance to initiation of insulin therapy, this study examined the perception gap concerning initiation of insulin therapy between individuals with type 2 diabetes and their physicians by using data from the DAWN Japan study.Methods:The DAWN Japan study is a multi-center, questionnaire-based survey, conducted between 2004–2005. Patients recommended to start insulin therapy (n = 148) answered a questionnaire by rating degree of agreement with 16 statements concerning insulin therapy on a 5-point scale (1: strongly disagree to 5: strongly agree). Ratings of 1 and 2 were categorized as ‘disagree’ with a statement, and 3, 4, and 5 as ‘agree’. Their attending physicians (n = 68) selected statements which could be associated with patient’s concerns about insulin therapy.Results:Nearly all the patients agreed with the statements ‘I don’t want to inject myself for the rest of my life’ (95%), and ‘I don’t want to be bothered with doing injections’ (90%); fewer than half agreed with ‘My friendships may suffer’ (46%), and ‘I don’t understand why insulin is necessary for me’ (45%). Estimation by the physicians and the actual perceptions patients reported differed significantly for 13 statements. Physicians seemed to particularly under-estimate the impact associated with social aspects of insulin use (e.g., ‘I don’t want to be different from others’, 55% patients vs 7% physicians). On the contrary, the statement ‘Injections are painful’ was the only concern over-estimated by the physicians.Conclusions:It was demonstrated that differences in perceptions regarding insulin therapy exist between physicians and patients, particularly in terms of social impacts. The data, obtained in 2004, may not precisely reflect the present situation, but still represents a barrier to insulin therapy widely held by patients and physicians. These results suggest that appropriate understanding of patients’ concerns about insulin therapy is important to encourage timely insulin initiation.

How should we manage insulin therapy before surgery?

Continuing at least part of the basal insulin is reasonable, but prandial insulin should be stopped the morning of surgery.