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Brief Report

Successes and challenges of insulin therapy for type 2 diabetes in a managed-care setting

, , , , &
Pages 9-15 | Accepted 15 Oct 2009, Published online: 05 Nov 2009
 

Abstract

Objective:

Although insulin is the most effective diabetes medication for lowering blood glucose, how insulin is used in clinical practice and how well patients respond to insulin therapy over the course of several years has not been documented. Our objective was to describe glycemic control, side-effects and dose titration over 7 years among persons starting insulin in a health plan that has long used a treatment algorithm similar to the current American Diabetes Association/European Association for the Study of Diabetes (ADA-EASD) algorithm for the management of hyperglycemia.

Research design and methods:

Patients (n = 2417) who initiated insulin therapy between 1 January 1999 and 31 December 2004 were followed for a mean of 49.5 months until 30 June 2007, death, or health plan termination. Mean hemoglobin A1C, number of units of insulin purchased and body weight were assessed on a quarterly basis. The proportion experiencing edema or hypoglycemia was assessed annually.

Results:

Mean population A1C declined from 9.3 to 7.8% following insulin initiation and remained at that level for 7 years. However, A1C remained above 8% for 40% of patients, half of whom remained above 9.0%. The mean individual coefficient of variation in A1C was 0.12 (inter-quartile range 0.072–0.143). Mean daily insulin dosage started at 55 units and increased to ∼100 units. Patients gained a mean of 6 lb (2.7 kg) during the first year then gained weight more gradually thereafter. Physicians diagnosed edema in 8–9% of patients annually. Hypoglycemia occurred in fewer than 2% of patients in any given year, with no cases requiring hospitalization.

Conclusions:

Insulin lowered mean A1C by about 1.5 percentage points to stable levels, but this required ongoing dosage increases. Nevertheless, many patients remained in poor control. Insulin is effective when used per ADA-EASD guidelines but health plans wishing to optimize diabetes care may need to intensify insulin therapy or consider the use of adjunct therapies in the years after initiation. This study was limited by its observational descriptive design, and its reliance on insulin purchases rather than actual consumption.

Transparency

Declaration of funding

The study was funded by Amgen, Inc. Kaiser Permanente Northwest were contracted by Amgen to carry out this analysis. By contract and in accordance with the Uniform Requirements for Biomedical Journal submissions, the first author G.A.N. had final say in the design, interpretation and presentation of the data and text.

Declaration of financial/other relationships

G.A.N. and J.B.B. are employees of Kaiser Permanente Northwest; in addition, they have received research support for other projects from Novo Nordisk, Novartis Pharmaceuticals, Takeda Pharmaceuticals North America, Tethys BioScience and GlaxoSmithKline, Inc. S.R.G., C.F.C., M.S.A. and M.A.B. are Amgen employees and may hold stock or stock options in Amgen.

Peer reviewers may receive honoraria from CMRO for their review work. Peer Reviewer 1 has disclosed that he/she is a former employee and stock holder of Merck & Co and is currently employed at a medical device and technology company. Peer Reviewer 2 has disclosed that he/she has no relevant financial interests.

Acknowledgments

The authors receive no third-party medical writing assistance in the preparation of this article.

Data reported here were previously presented in poster form at the American Diabetes Association’s 68th Scientific Sessions, San Franciso, CA, 6–10 June 2008.

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