Do Type 2 Diabetes Patients on Insulin Meet Goals?

A large proportion of patients on insulin-based therapy fail to reach glycemic goals, according to a new study.

Despite the availability of clinical guidelines and the wide variety of anti-diabetes drugs that have reached the market, it is estimated that only about half of the patients with type 2 diabetes mellitus in the US achieve the hemoglobin A1c (HbA1c) target of <7%.

A new retrospective analysis using a US claims database of patient and treatment data adds to a growing body of evidence that shows a significant proportion of patients (half to nearly three-quarters) treated with basal insulin are failing to achieve glycemic targets in the real-world, stated researchers led by Mehul R. Dalal of Millennium Pharmaceuticals.

In this current analysis of 39,074 patients treated with basal insulin, the initiation of basal insulin therapy was associated with a mean decrease in HbA1c of 1.3% at 3 months, which was sustained for up to 12 months. The proportion of patients achieving the glycemic targets of HbA1c <7.0% improved to 27% at 3 months from 11% at baseline.

Patients in the newly initiated basal insulin group had higher baseline HbA1c levels (9.5%) than those on ongoing basal insulin therapy (8.1%). This reduction in HbA1c and increase in the proportion of patients meeting HbA1c targets in the new initiators, as compared to the small changes seen with ongoing basal insulin users, is to be expected, they stated.

However, the majority of new initiators and ongoing users of basal insulin did not achieve either HbA1c (75% and 72%, respectively) targets, as recommended by treatment guidelines at 12 months of follow-up, they stated. These results are in line with data from the National Health and Nutrition Examination Surveys, which reported that for the years 2007–2010, only 30.3% of adult patients with diabetes (receiving any treatment) achieved the HbA1c goal of <7% compared with 25.8% of patients for the years 1999–2002.

“The results of this study reflect the challenges in achieving glycemic targets either in new initiators or ongoing users,” they stated. The treatment patterns for patients who did not achieve glycemic targets suggest some intensification of therapeutic regimens. However, only a relatively small proportion of both new initiators and ongoing users who did not achieve glycemic targets remained on basal insulin only.

The researchers also surveyed 155 physicians about basal insulin prescribing patterns. More than one-third of physicians surveyed stated they would increase basal insulin dose as their first choice measure in patients who no longer met glycemic targets. “The reasons behind the apparent reluctance of many physicians to intensify therapy are unclear, but the main perceived barriers to insulin intensification reported by physicians were patients’ lifestyle, non-adherence, and concerns about out-of-pocket costs; fear of hypoglycemia and weight changes were considered to be less important,” they stated.

The researchers concluded: “More and up-to-date education for patients and physicians may be a promising strategy to improve insulin intensification rates, and thus increase the proportion of patients reaching glycemic targets.”

Reference: Dalal MR, et al. Are patients on basal insulin attaining glycemic targets? Characteristics and goal achievement of patients with type 2 diabetes mellitus treated with basal insulin and physician-perceived barriers to achieving glycemic targets. Diabetes Res Clin Pract. 2016 Aug 24;121:17-26.