Jornayvaz, François

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CAPSULE COMMENTARIESCapsule Commentary on Patrick et al., Trends in Insulin Initiationand Treatment Intensification among Patients with Type 2 DiabetesFrançois R. Jornayvaz, M.D.Service of Endocrinology, Diabetes, Hypertension and Nutrition, Geneva University Hospitals, Geneva, Switzerland.J Gen Intern Med 29(2):356DOI: 10.1007/s11606-013-2676-x© Society of General Internal Medicine 2013T his study by Patrick et al.1 investigated the pattern ofinsulin initiation, as well as treatment intensification,among patients with type 2 diabetes compared to AmericanDiabetes Association (ADA) and European Association forthe Study of Diabetes (EASD) guidelines. Although thisobservational study may not be representative of the generalpopulation, as the 7,932 studied patients were derived froma single commercial insurance company from a single state,the reported data are relevant to the treatment of type 2diabetes for both primary care physicians and specialists.The main finding was that insulin was frequently initiatedwithout the withdrawal of sulfonylureas or meglitinides, asrecommended by the guidelines. Moreover, sulfonylureaswere started in 29 % and meglitinides in 11 % of patientsfollowing insulin initiation. This is concerning, given theimportant risk of hypoglycemia when combining theseantidiabetic agents. Furthermore, insulin and hypoglycemicagents represent, respectively, the number two and numberfour causes of emergency hospitalizations in older Ameri-cans,2 and hypoglycemia was thought to be the cause ofexcess death in the ACCORD trial.3Only one-third of patients benefitted from treatmentintensification after insulin initiation, suggesting suboptimalcare. However, HbA1c levels were not available. Finally, aquarter of patients discontinued insulin following initiation.This might reflect either poor compliance, possibly due tolack of knowledge or side effects, or the transient need forinsulin, such as during steroid use or severe illness.It is uncertain whether endocrinologists would do better;in this study, only 17 % of patients were seen byspecialists,1 though there is data that endocrinologists aremore likely to intensify diabetes treatment and initiateinsulin in type 2 diabetic patients.4 This study suggests thata significant portion of type 2 diabetics being initiated oninsulin are continued on hypoglycemic agents, notablysulfonylureas and meglitinides, a potentially hazardouspractice and in discordance with ADA/EASD guidelines.5Whether this reflects under-appreciation of the hazards ofhypoglycemia, inadequate training and knowledge, or someother factor is unknown and deserving of further research.Conflict of Interest: The author declares that he does not have aconflict of interest.Corresponding Author: François R. Jornayvaz, M.D.; Service ofEndocrinology, Diabetes, Hypertension and Nutrition, GenevaUniversity Hospitals, Rue Gabrielle-Perret-Gentil 4 1211, Geneva,Switzerland (e-mail: francois.jornayvaz@hcuge.ch).REFERENCES1. Patrick AR, Fischer MA, Choudhry NK, Shrank WH, Seeger JD, Liu J,et al. Trends in insulin initiation and treatment intensification amongpatients with type 2 diabetes. J Gen Intern Med. doi:10.1007/s11606-013-2643-6.2. Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergencyhospitalizations for adverse drug events in older Americans. New Engl JMed. 2011;365(21):2002–12. doi:10.1056/NEJMsa1103053.3. Gerstein HC, Miller ME, Byington RP, Goff DC Jr, Bigger JT, Buse JB,et al. Effects of intensive glucose lowering in type 2 diabetes. New Engl JMed. 2008;358(24):2545–59. doi:10.1056/NEJMoa0802743.4. Shah BR, Hux JE, Laupacis A, Zinman B, van Walraven C. Clinicalinertia in response to inadequate glycemic control: do specialists differfrom primary care physicians? Diabetes Care. 2005;28(3):600–6.5. Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E,Nauck M, et al. Management of hyperglycemia in type 2 diabetes: apatient-centered approach: position statement of the American Dia-betes Association (ADA) and the European Association for the Studyof Diabetes (EASD). Diabetes Care. 2012;35(6):1364–79. doi:10.2337/dc12-0413.JGIMPublished online October 18, 2013356

Capsule Commentary on Patrick et al., Trends in Insulin Initiation and Treatment Intensification among Patients with Type 2 Diabetes

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Capsule Commentary on Patrick et al., Trends in Insulin Initiation and Treatment Intensification among Patients with Type 2 Diabetes

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