Insulin treatment of type 2 diabetes needs to face up to 3 big problems!

The clinical status of insulin treatment is worrying and there is a long way to go.

Blood glucose control in type 2 diabetes mellitus (T2DM) patients in the scenario, the insulin as a potent oral glucose-lowering drugs clinical widely used, Peking University diabetes BBS recently, Beijing university people’s hospital professor JiLiNong combining multiple clinical research comprehensive analyzes the current situation of T2DM patients with insulin therapy and is not meet the clinical needs.
This article is to share with you the highlights of the meeting.

Professor Ji Linong talked about the changes in insulin treatment in the clinic since he started working as a doctor.

The initiation of insulin therapy is late

The guidelines recommend that patients with T2DM who are taking two or more hypoglycemic agents should initiate insulin therapy if their blood glucose is still below the control target [HbA1c ≥7.0%].
However, studies in various countries have shown that insulin therapy is clinically inert, and many countries and regions have not initiated basic insulin therapy in time.

According to ORBIT, a large-scale real-world study on basic insulin in China, the starting time of clinical use of basic insulin in China is relatively late, 55% of the patients.
9% started insulin therapy;
More than 1/3 of the patients had complications when starting insulin therapy;
The initial basal insulin dose was low in 75% of patients.

Table 1 The level of HbA1c is higher in the initial insulin of T2DM patients in China

Insulin therapy was not adjusted in time

What about glycemic control in patients with T2DM after initial insulin therapy?
Ji first reviewed several randomized controlled clinical trials (RCTs).
The results of DEVOTE show that basic insulin therapy can control HbA1c in patients with T2DM at 7.5% in a rigorous clinical trial, but there is still some distance from the target of 7%.
The results of the 4T study showed that although patients’ blood glucose was well controlled through continuous changes in insulin treatment strategy, increased basal insulin dose or increased insulin at meal time was required, accompanied by weight gain and an increased risk of hypoglycemia.

Studies in the real world have shown that although patients start insulin therapy, their blood glucose control is not ideal, and no effect of glucose control in RCT has been observed.
According to ORBIT, only 40% of patients achieved the HbA1c control target after starting insulin treatment;
More than 1/3 of the patients with substandard blood glucose control did not undergo insulin adjustment within 3 months.
Both ORBIT and FINE studies have shown that dose adjustment after basal insulin initiation is inadequate.
Professor Ji concluded that the failure to adjust and increase the insulin dose in time was the main reason for the substandard blood glucose control in the initial insulin treatment.

From the perspective of individual patients, compliance is also an important factor affecting the blood glucose standard.
ORBIT study shows that the frequency of blood glucose monitoring in patients is very small and completely substandard.
Many patients did not fully adjust the dose according to the results of blood glucose monitoring;
There were discontinuation and change of insulin use.

Fig. 1 Low frequency of blood glucose monitoring in T2DM patients

Ji stressed that insulin treatment is a process of integrated management.
Multiple factors prevent doctors and patients from reaching the target at the start of treatment.
If hypoglycemia occurs early, the risk of withdrawal increases.
How to early identify hypoglycemia and avoid hypoglycemia is a key issue, and how to individualize the treatment of hypoglycemia is crucial to the management of T2DM patients.

The blood glucose reached the standard rate was low, and the effect of intensive treatment was unsatisfactory

Global statistical studies have shown that after 3 months of insulin treatment, the proportion of patients with HbA1c less than 7% is 1/5;
The proportion of patients with HbA1c less than 7% after 24 months of insulin treatment was only 1/3.
The Chinese HbA1c monitoring network showed that only one third of patients receiving insulin treatment had their blood sugar levels up to the standard.
Dissatisfaction with glycemic control in patients receiving insulin is a global problem.

For T2DM patients with poor blood glucose control treated with insulin, intensive treatment, such as increasing insulin dose and increasing insulin during meal, is often adopted.

The OPT2MISE study compared the efficacy and safety of insulin pump therapy with multiple daily insulin injections after 6 months in patients with type 2 diabetes who had not responded well to insulin therapy.
The results of the study were negative, with no significant improvement in blood glucose control and no reduction in the risk of hypoglycemia after insulin pump therapy.
Compass Ⅱ Studies have shown improvements in blood glucose following intensive insulin therapy, but still not ideal.
The improvement of blood glucose in patients with different duration of insulin treatment is different. For patients with long course of disease or with longer duration of insulin treatment, the improvement of blood glucose is not ideal and the risk of hypoglycemia is increased.

All the above studies have shown that T2DM patients still have substandard blood glucose control after receiving insulin treatment, and 20% of T2DM patients have the risk of hypoglycemia, which has a serious impact on the quality of life of the patients.

Looking forward to

With the change of technology, insulin preparations are constantly evolving. At the same time, the emergence of more blood glucose monitoring methods also helps the comprehensive management of T2DM. However, in general, the current clinical blood glucose control rate is still unsatisfactory.
Better blood glucose control and better quality of life are what we are looking for, and it requires the joint efforts of medical staff and patients.

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