Insulin Matters: A Practical Approach to Basal Insulin Management in Type 2 Diabetes

Diabetes Ther (2018) 9:501–519 https://doi.org/10.1007/s13300-018-0375-7 PRACTICAL APPROACH Insulin Matters: A Practical Approach to Basal Insulin Management in Type 2 Diabetes Lori Berard . Noreen Antonishyn . Kathryn Arcudi . Sarah Blunden . Alice Cheng . Ronald Goldenberg . Stewart Harris . Shelley Jones . Upender Mehan . James Morrell . Robert Roscoe . Rick Siemens . Michael Vallis . Jean-François Yale Received: January 12, 2018 / Published online: February 23, 2018  The Author(s) 2018. This article is an open access publication ABSTRACT It is currently estimated that 11 million Canadians are living with diabetes or prediabetes. Although hyperglycemia is associated with serious complications, it is well established that improved glycemic control reduces the risk of microvascular complications and can also reduce cardiovascular (CV) complications over the long term. The UKPDS and ADVANCE Enhanced content To view enhanced content for this article go to https://doi.org/10.6084/m9.figshare. 5822136. L. Berard (&) Winnipeg Regional Health Authority, Winnipeg Diabetes Research Group, Health Sciences Centre, Winnipeg, MB, Canada e-mail: N. Antonishyn Department of Endocrinology, Alberta Health Services, Edmonton, AB, Canada K. Arcudi Diabetes Clinic, The Montreal West Island Integrated University Health and Social Services Centre (Lakeshore General Hospital), Pointe-Claire, QC, Canada S. Blunden Diabetes Education, LMC Diabetes and Endocrinology, Montreal, QC, Canada A. Cheng Division of Endocrinology and Metabolism, St. Michael’s Hospital, Toronto, ON, Canada landmark trials have resulted in diabetes guidelines recommending an A1C target of B 7.0% for most patients or a target of B 6.5% to further reduce the risk of nephropathy and retinopathy in those with type 2 diabetes (T2D), if it can be achieved safely. However, half of the people with T2D in Canada are not achieving these glycemic targets, despite advances in diabetes pharmacological management. There are many contributing factors to account for this poor outcome; however, one of the major factors is the delay in treatment advancement, particularly a resistance to insulin initiation and intensification. To simplify the process of A. Cheng Trillium Health Partners, Credit Valley Hospital, Mississauga, ON, Canada A. Cheng Department of Medicine, University of Toronto, Toronto, ON, Canada R. Goldenberg LMC Diabetes and Endocrinology, Thornhill, ON, Canada S. Harris Department of Family Medicine, Western University, London, ON, Canada S. Jones Horizon Health Network, Moncton, NB, Canada U. Mehan The Centre for Family Medicine, Kitchener, ON, Canada 502 initiating and titrating insulin in T2D patients, a group of Canadian experts reviewed the evidence and best clinical practices with the goal of providing guidance and practical recommendations to the diabetes healthcare community at large. This expert panel included general practitioners (GPs), nurses, nurse practitioners, endocrinologists, dieticians, pharmacists, and a psychologist. This article summarizes the panel recommendations. Keywords: Basal insulin; Glycemic target; Insulin initiation; Insulin titration; Patient barriers; Patient follow-up; Treatment delay; Type 2 diabetes Diabetes Ther (2018) 9:501–519 In fact, when the maximum output of insulin has decreased to 15% or 20% of normal, noninsulin anti-hyperglycemic agents can no longer sustain glycemic control and insulin supplementation becomes a necessity [5]. The usual starting point for insulin therapy in T2D is with basal insulin owing to its simplicity and lower risk of hypoglycemia [7]. When and in Whom to Initiate Insulin in T2D The panel recommendations as to when and in whom to initiate insulin are summarized in Table 1. What are the Barriers to Insulin Initiation? BASAL INSULIN INITIATION Do We Still Need Insulin? Type 2 diabetes (T2D) is a progressive disorder characterized by multiple pathophysiological defects. The core defects include insulin resistance in the muscle and liver and impaired insulin secretion due to b-cell failure [1, 2]. The progressive nature of the disease is such that it requires therapy to be intensified over time to compensate for the ongoing b-cell deficiency [2–4]. At the time of T2D diagnosis, more than 50% of b-cells have already been lost, and continue to decline at an average rate of 5% per year [1, 2, 5]. Therefore, the use of insulin is an appropriate option at any point in the management of T2D to replace the insulin that the pancreas is unable to produce sufficiently [1, 6]. Clinical inertia, defined as the failure on the part of the provider to advance therapy when required, adversely affects timely management of T2D [9–12]. Insulin is often initiated late in the course of the disease, after failure with multiple antihyperglycemic agents, and at glycemic values well above the recommended targets [11–15]. In Canada, mean A1C levels are [8.5% and mean diabetes duration is C 9 years before initiation of basal insulin in T2D patients [13, 15]. A UK retrospective study of pharmacologically treated T2D patients on one, two, or three oral antihyperglycemic agents reported that the median time to insulin initiation was [7 years with an A1C C 7.0% and the mean A1C levels at initiation was [9.0% [12]. There are many barriers that contribute to this delay in initiation and intensification of U. Mehan Department of Family Medicine, McMaster University, Hamilton, ON, Canada M. Vallis Behaviour Change Institute, Nova Scotia Health Authority, Halifax, NS, Canada J. Morrell Diabetes Services, Island Health, Victoria, BC, Canada M. Vallis Department of Family Medicine, Dalhousie University, Halifax, NS, Canada R. Roscoe Diabetes Education Centre, Saint John Regional Hospital, Saint John, NB, Canada J.-F. Yale Department of Medicine, McGill University, Montreal, QC, Canada R. Siemens London Drugs Pharmacy, Lethbridge, AB, Canada Diabetes Ther (2018) 9:501–519 503 Table 1 When and in whom to initiate insulin in T2D When to consider insulin initiation When NOT to initiate insulin Maximally tolerated noninsulin agents but A1C above the individualized target (usually 7.0%) There are no contraindications for the use of insulin but insulin may not be appropriate for: New diagnosis A1C C 8.5% Metabolic decompensation Some older, asymptomatic patients, who may not End-organ failure gain sufficient benefit Patients with previous or because of short life current gestational expectancy diabetes People limited in their Acute illness capacity (physical or Prolonged course of steroids cognitive) to manage their diabetes who are at greater Intolerance to oral risk of hypoglycemia medications Any time you consider this is an appropriate option for your patients from diagnosis onwards [8]; http://guidelines.diabetes.ca/fullguidelines; http:// www.rcn.org.uk; https://www.rcn.org.uk/professionaldevelopment/publications/pub-002254 insulin in T2D. It is important to emphas (...truncated)