A practical approach for implementation of a basal-prandial insulin therapy regimen in patients with type 2 diabetes

Basal-prandial insulin therapy is a physiologic approach to insulin delivery that utilizes multiple daily injections to cover both basal (ie, overnight fasting and between-meal) and prandial (ie, glucose excursions above basal at mealtime) insulin needs. While basal-prandial therapy with multiple daily injections is an important therapeutic option for patients with type 2 diabetes, there is a common perception that this therapy is difficult to initiate in the primary care setting. To address this issue, a panel of clinical experts convened to develop practical recommendations on how to initiate basal-prandial therapy in patients with type 2 diabetes, focusing on patient selection, simple dosing and titration, and monitoring. Patients with type 2 diabetes who are appropriate candidates for basal-prandial insulin therapy include those who: 1) are unable to achieve glycemic control on oral antidiabetic drugs, 2) are unable to achieve glycemic control on split-mixed/premixed insulin regimens, 3) are newly diagnosed but unlikely to respond to oral antidiabetic drugs alone (ie, the patient has severe hyperglycemia or a markedly elevated glycosylated hemoglobin A1C level for which oral antidiabetic drug therapy alone is unlikely to achieve goals), and 4) prefer this therapy due to socioeconomic or other individual considerations. Basal-prandial insulin can be initiated in a simple stepwise manner, starting first with the addition of basal insulin to the existing oral antidiabetic drug regimen, followed by the introduction of 1 prandial insulin injection to the basal insulin plus oral antidiabetic drug regimen (after basal insulin has been optimized). Subsequently, other injections of prandial insulin may be added when needed. Based on home glucose monitoring data, patients may be converted from split-mixed or premixed insulin regimens to basal-prandial regimens with similar ease. Basal-prandial therapy using newer insulin formulations, such as long- and rapid-acting insulin analogs, can be relatively simple to use in patients with type 2 diabetes and is an appropriate methodology for application by primary care clinicians

A patient-centered approach to managing patients with type 2 diabetes

Despite the availability of a number of therapeutic options, management of type 2 diabetes (T2DM) and hyperglycemia remains suboptimal. Evidence shows that physicians are not adequately individualizing incretin-based therapies as there is lack of clear understanding of the similarities and differences between various incretin-based therapies. Additionally, sodium-dependent glucose co-transporter 2 (SGLT2) inhibitors, a very recent addition to the therapeutic armamentarium, are not adequately utilized in managing patients with T2DM due to a lack of awareness or an increased concern regarding their safety, efficacy, and the mechanism of action. Insulin therapy is also not initiated or intensified appropriately due to a lack of clear understanding on when to add and how to intensify them and, more importantly, due to fear of increasing the risk of hypoglycemia in patients. To address these gaps, in the first section of this educational activity, the expert faculty will review the current understanding of the risks associated with hypoglycemia-one of the main factors that limit the successful use of insulin therapy-and when to initiate insulin therapy, as well as the available data on the risk of hypoglycemia with emerging agents. The expert faculty will also provide practical strategies on how to minimize the risk of hypoglycemia in patients. In the second section, the expert faculty will highlight the differences between the various incretin-based therapies in addition to providing strategies for physicians to individualize their choice of incretin-based therapy. The expert faculty will also review the mechanism of action, safety, efficacy, and the appropriate place for this class of therapies in the treatment continuum. In the third section, the expert faculty will discuss the mechanism of action, safety, and efficacy of the currently available SGLT2 inhibitors as well as the appropriate use of these newer agents in T2DM management. This CME Multimedia Activity is also available through the Website of The American Journal of Medicine (www.amjmed.com). Click on the CME Multimedia Activity button in the navigation bar for full access. Or access: www.elseviercme.com/537

Safety and efficacy of a glucagon-like peptide-1 receptor agonist added to basal insulin therapy versus basal insulin with or without a rapid-acting insulin in patients with type 2 diabetes: results of a meta-analysis

<p><b>Objective</b>: To consolidate the evidence from randomized controlled trials evaluating the use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) as add-on to basal insulin therapy in type 2 diabetes (T2D) patients.</p> <p><b>Research design and methods</b>: We searched the EMBASE® and NCBI PubMed (Medline) databases and relevant congress abstracts for randomized controlled trials evaluating the efficacy and safety of GLP-1 RAs as add-on to basal insulin compared with basal insulin with or without rapid-acting insulin (RAI) through 23 May 2016. The pooled data were analyzed using a random-effects meta-analysis model. A subanalysis was performed for trials investigating basal insulin plus GLP-1 RAs versus basal insulin plus RAI.</p> <p><b>Results</b>: Of the 2617 retrieved records, 19 randomized controlled trials enrolling 7,053 patients with T2D were included. Compared with basal insulin ± RAI, reduction in glycated hemoglobin (HbA1c) from baseline (difference in means: –0.48% [95% confidence interval (CI), –0.67 to –0.30]; <i>p</i> < 0.0001) and weight loss (–2.60 kg [95% CI, –3.32 to –1.89]; <i>p</i> < 0.0001) were significantly greater with basal insulin plus GLP-1 RA. The subanalysis similarly showed significant results for change in HbA1c from baseline and for weight loss, as well as a significantly lower risk of symptomatic hypoglycemia in patients treated with basal insulin plus GLP-1 RA versus basal insulin plus RAI (odds ratio, 0.52 [95% CI, 0.42 to 0.64]; <i>p</i> < 0.0001).</p> <p><b>Conclusions</b>: Addition of GLP-1 RA to basal insulin provided improved glycemic control, led to weight reduction and similar hypoglycemia rates versus an intensified insulin strategy; however, symptomatic hypoglycemia rates were significantly lower when compared with a basal insulin plus RAI.</p