Initiation of Insulin Degludec in Chinese Hospitalized Patients with Type 2 Diabetes - A Single Center's Experience.

Introduction: The long-acting insulin analogue insulin degludec (IDeg) is increasingly recommended for type two diabetes (T2DM), yet clinical experience in China remains limited. This retrospective study aimed to delineate the initiation strategy for IDeg in Chinese hospitalized patients with T2DM. Methods: We retrospectively analyzed 217 Chinese hospitalized patients with T2DM who initiated IDeg from December 2018 to June 2020, calculating the initial dose and examining correlations between clinical characteristics and glucose profiles. Results: The initial IDeg doses ranged from 0.15 to 0.18 IU/kg·d, showing no association with clinical characteristics. During titration, mean blood glucose levels (MEAN) correlated positively with diabetes duration, age, and Glycosylated Hemoglobin (HbA1c), and negatively with body mass index (BMI), triglycerides (TG), and low-density lipoprotein (LDL). The coefficient of variation (CV) in glucose levels correlated positively with HbA1c and negatively with BMI and TG. The mean amplitude of glycemic excursions (MAGE) mirrored these trends, with additional negative correlations to estimated glomerular filtration rate (eGFR) and serum albumin (ALB). Notably, glycemic variability parameters did not correlate with the presence of diabetic ketoacidosis (DKA) at admission. Hypoglycemia was observed in 21 patients, with differences in MEAN and CV during titration being the only significant findings. Conclusion: The initial IDeg dosing was inadequate and not tailored to clinical features, and there were weak correlations between diabetes duration, age, BMI, eGFR, LDL, and ALB levels and glucose profile post-initiation.

Expert Opinion on Current Trends in the Use of Insulin in the Management of People with Type 2 Diabetes from the South-Eastern European Region and Israel.

Despite the availability of various antihyperglycaemic therapies and comprehensive guidelines, glycaemic control in diabetes management has not improved significantly during the last decade in the real-world clinical setting. Treatment inertia arising from a complex interplay among patient-, clinician- and healthcare-system-related factors is the prime reason for this suboptimal glycaemic control. Also, the key factor leading to inadequate glycaemic levels remains limited communication between healthcare professionals (HCPs) and people with type 2 diabetes (PwT2D). Early insulin administration has several advantages including reduced glucotoxicity, high efficacy and preserved ß-cell mass/function, leading to lowering the risk of diabetes complications. The current publication is based on consensus of experts from the South-Eastern European region and Israel who reviewed the existing evidence and guidelines for the treatment of PwT2D. Herein, the experts emphasised the timely use of insulin, preferably second-generation basal insulin (BI) analogues and intensification using basal-plus therapy, as the most-potent glucose-lowering treatment choice in the real-world clinical setting. Despite an increase in the use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs), the experts urged timely insulin initiation for inadequate glycaemic control in PwT2D. Furthermore, the combination of BI and GLP-1 RA addressing both fasting plasma glucose and post-prandial excursions as a free- or fixed-ratio combination was identified to reduce treatment complexity and burden. To minimise discontinuation and improve adherence, the experts reiterated quality, regular interactions and discussions between HCPs and PwT2D/carers for their involvement in the diabetes management decision-making process. Clinicians and HCPs should consider the opinions of the experts in accordance with the most recent recommendations for diabetes management.

The Barriers to Insulin Therapy Initiation in Type 2 Diabetes Patients: A Study of General Practitioner Perceptions in Huinan Community in South Shanghai.

Background: Despite the demonstrated benefits of insulin therapy, many general practitioners (GPs) are hesitant to administer it due to challenges such as a lack of knowledge, time constraints, and patient reluctance. The barriers that prevent a GP from initiating insulin therapy may vary in comparison to those encountered by a diabetic patient; this aspect of clinical research in the South Shanghai metropolitan area has received limited attention so far. Objective: This is a 6-months of interventional analytic cohort study. The prime aim is to investigate the barriers general practitioners (GPs) face when initiating insulin therapy for patients with type 2 diabetes (T2D). Materials and Methods: As part of a training program, all 189 registered GPs in Nanhui Health Service Center in Shanghai were given a structured online-multi-choice questionnaire before and after a six-month interval, during which the GPs received sessions of training on insulin therapy either on theoretic classes or clinical practices. Results: Before and after training, via the methods of multiple-response analyses, the results showed that social, GP's, and patient barriers to initiating insulin therapy were comparable. However, through the crosstabs chi-square test, we found significant changes in the basal insulin initiation following the prescription of the senior endocrinologists, the titration of insulin, and the need for training (p<0.05). The Spearman analyses discovered significant changes associated with the cause of initial insulin refusal and the factors influencing insulin administration. Finally, the binary logistic regression analysis revealed that distinct causes such as social factors, insurance, GP experience, insulin dosage calculation, follow-up, and patients' feelings are related to insulin treatment application before and after training. Conclusion: According to this study, training increased general practitioners' confidence in initiating insulin administration, especially basal insulin. General practitioners require additional education on insulin therapy, with a potential need for increased face-to-face training for insulin initiation.

Insulin initiation in patients with type 2 diabetes is often delayed, but access to a diabetes nurse may help-insights from Norwegian general practice.

Objective: We opted to study how support staff operational capacity and diabetes competences may impact the timeliness of basal insulin-initiation in general practice patients with type 2 diabetes (T2D).Design/Setting/Outcomes: This was an observational and retrospective study on Norwegian primary care patients with T2D included from the ROSA4-dataset. Exposures were (1) support staff size, (2) staff size relative to number of GPs, (3) clinic access to a diabetes nurse and (4) share of staff with diabetes course (1 and 2 both relate to staff operational capacity, whereas 3 and 4 are both indicatory of staff diabetes competences). Outcomes were 'timely basal insulin-initiation' (primary) and 'attainment of HbA1c<7%' after insulin start-up (secondary). Associations were analyzed using multiple linear regression, and directed acyclic graphs guided statistical adjustments.Subjects: Insulin naïve patients with 'timely' (N = 294), 'postponed' (N = 219) or 'no need of' (N = 3,781) basal insulin-initiation, respectively.Results: HbA1c [median (IQR)] increased to 8.8% (IQR, 8.0, 10.2) prior to basal insulin-initiation, which reduced HbA1c to 7.3 (6.8-8.1) % by which only 35% of the subjects reached HbA1c <7%. Adjusted risk of 'timely basal insulin-initiation' was more than twofold higher if access to a diabetes nurse (OR = 2.40, [95%CI, 1.68, 3.43]), but related only vaguely to staff size (OR = 1.01, [95%CI, 1.00, 1.03]). No other staff factors related significantly to neither the primary nor the secondary outcome.Conclusion: In Norwegian general practice, insulin initiation in people with T2D may be affected by therapeutic inertia but access to a diabetes nurse may help facilitating more timely insulin start-up.

In patients with type 2 diabetes (T2D) cared for by their general practice physician (GP), insulin therapy was susceptible to therapeutic inertia.In Norwegian general practice, chance of timely basal insulin-initiation was found more than two-fold higher if the GP had access to a diabetes nurse.In contrast, the timeliness of basal insulin-initiation in general practice patients with T2D seemed unaffected by share of support staff with diabetes course and by factors indicatory of support staff overall operational capacity.In Norwegian general practice, a diabetes nurse seems to offer unique clinical benefits to the care of insulin treated patients with T2D.

Barriers and Attitudes of Primary Healthcare Physicians to Insulin Initiation and Intensification in Saudi Arabia.

Saudi Arabia is a country with high prevalence of diabetes, uncontrolled diabetes, and diabetes-related complications. Poor glycemic control is multifactorial and could be explained in part by physician and patient reluctance toward insulin or insulin inertia. This study aimed to address physician barriers toward insulin therapy in primary care settings. It included 288 physicians from 168 primary healthcare centers (PHC) in the Jazan region of Saudi Arabia. Participants responded to questionnaire investigating physicians' attitude and barriers to insulin initiation and intensification in PHCs. In physician opinion, the most common barriers among their patients were fear of injection, lack of patient education, fear of hypoglycemia, and difficult administration. Physicians were reluctant to initiate insulin for T2D patients mostly due to patient non-adherence to blood sugar measurement, non-adherence to appointment or treatment, elderly patients, or due to patient refusal. Physicians' fear of hypoglycemia, lack of staff for patient education, and lack of updated knowledge were the primary clinician-related barriers. Exaggerated fears of insulin side effects, patient non-adherence, limited staff for patient's education, patient refusal, and inadequate consultation time were the main barriers to insulin acceptance and prescription.

Prospective study of the association between depressive symptoms at type 2 diabetes diagnosis and time to insulin initiation in the South London diabetes (SOUL-D) cohort.

AIMS: Initiation of insulin is usually delayed even when required. We aim to estimate the association between depressive symptoms on time to become insulin requiring and time to insulin initiation. METHODS: 8-year follow-up of a cohort of newly diagnosed people with T2D recruited in south-east London, UK (2008-2012). Baseline depressive symptoms were assessed using the Patient Health Questionnaire-9. Time to insulin-requiring was defined when optimal glycaemic levels were not achieved (HbA1c >58 mmol/mol) at least three months after the 2nd oral antidiabetic was prescribed, and time to insulin initiation was defined as first insulin prescription. RESULTS: Seventy percent (n = 1166) of the baseline cohort was followed up. Median time to insulin requiring was 84 months (IQR 63-100) and to insulin initiation 93 months (IQR 79-105). Participants with depressive symptoms at baseline required insulin earlier (mean [SD] 73.64 [32.16] vs. 79.05 [29.07] months, p = 0.007) and were prescribed insulin sooner (82.53 [30.19] vs. 89.72 [22.02] months, p < 0.001). In Cox regression, depressive symptoms at baseline were not associated with time to insulin requiring (HR [95 % CI]; 1.16 [0.86-1.57], p = 0.34) nor to insulin initiation (HR = 1.00 [0.99-1.00], p = 0.49). CONCLUSIONS: Depressive symptoms were not associated with time to insulin requiring and initiation after adjusting for potential confounding.

Which Aspect of Patient-Provider Relationship Affects Acceptance and Adherence of Insulin Therapy in Type 2 Diabetes Mellitus? A Qualitative Study in Primary Care.

PURPOSE: In type 2 diabetes mellitus (T2DM), insulin therapy is often recommended to achieve the optimal control of disease, thereby preventing the onset and progression of diabetes-related complications. Despite knowing about the benefits, it has been reported that 71% of patients refuse insulin and the adherence rate ranges from 30 to 80%. Patient-provider relationship (PPR) may affect such insulin-related behaviours, but little is known about which aspect of PPR affects this. This study aimed to explore the key aspect of the patient-provider relationship that affects the initial insulin acceptance and continued adherence. PATIENTS AND METHODS: We used the grounded theory approach in this qualitative research. The study was conducted at two primary care clinics between September 2019 and January 2021. Patients with T2DM on basal or premixed insulin were recruited using maximum variation sampling. Data were collected using semi-structured in-depth interviews and transcribed verbatim for analysis using constant comparison and synthesis. RESULTS: Twenty-one participants with different levels of diabetes control and adherence were recruited. Four themes that emerged were 1) patient-provider interaction, 2) addressing the psychological fears, 3) gaining confidence in handling insulin equipment and 4) follow-up after insulin initiation. Among the subthemes, trust in doctors, provider's communication skills, patient-centred decision-making and continuity of care positively influenced insulin acceptance and adherence. Conversely, fear of being judged by the provider hindered open communication around non-adherence. Various aspects of interaction with nurses helped in alleviating patient's fear of injection and gaining confidence with the insulin equipment. CONCLUSION: Many aspects of PPR affect insulin acceptance and adherence. Among these, gaining patients' trust, effective patient-provider communication, patient-centred decision-making, and ensuring continuity of care improve both insulin acceptance and treatment adherence. Various interactions with nurses help in addressing fears surrounding injection and gaining acceptance towards insulin therapy. Patients' fear of being blamed or judged by the provider negatively affects open communication around non-adherence.

Not All Type-2-Diabetes Patients Increase Body Mass Index After Initiating Insulin: Results of Latent Class Analysis from the DPV Registry.

Background: Is insulin initiation linked to increasing body mass index (BMI) in all patients with type-2-diabetes (T2D)? To determine distinct longitudinal patterns of BMI change over time. Materials and Methods: 5057 patients with T2D (55% males, median BMI [IQR]: 30.0 [26.9-33.3] kg/m2) aged ≥40 years at diabetes diagnosis and with ≥2 years of follow-up after insulin initiation irrespective of previous or concurrent use of metformin/dipeptidyl peptidase-4-inhibitor from the multicenter prospective diabetes registry DPV were studied. To identify subgroups following a similar pattern of BMI change after insulin initiation, longitudinal group-based trajectory modeling was applied. Multinomial logistic regression was then used to analyze covariates associated with group membership. Results: Three heterogeneous groups with either relevant BMI increase (delta-BMI: +4.0 kg/m2 after 2 years; 12% of patients); slight BMI increase (+0.4 kg/m2; 80%); or BMI decrease (-3.2 kg/m2; 8%) were identified. Patients with older age [OR (95% CI): 1.37 (1.11-1.69)] and obesity [2.05 (1.65-2.55)] before insulin start were more often in the BMI decreasing group, and less often in the BMI increasing class [0.80 (0.67-0.95); 0.82 (0.69-0.98)]. A worse HbA1c both at insulin start and during follow-up [1.90 (1.60-2.26); 1.17 (1.07-1.27)], a higher insulin dose [1.67 (1.33-2.10)], and severe hypoglycemic events [2.38 (1.60-3.53)] after insulin initiation were all linked with higher odds of belonging to the BMI increasing trajectory. Conclusions: Patient heterogeneity with respect to weight gain after initiation of insulin therapy in adult T2D was detected by an objective computer algorithm. Older people with obesity should not defer from insulin use due to fear of weight gain.

Initiating Insulin in the Emergency Center and Urgent Care to Prevent Hospital Admission for Patients with Hyperglycemia: A Unique Insulin Starter Kit.

BACKGROUND: Clinicians in the Emergency Center (EC) and Urgent Care (UC) can play a vital role in preventing hospital admissions and improving outcomes of patients with newly diagnosed diabetes or pre-existing diabetes who present with hyperglycemia and the need to initiate insulin. METHODS: This article describes a unique EC/UC discharge insulin starter kit protocol with clinician instructions via an Electronic Medical Record (EMR) order set that includes: starting doses for insulin, a prescription for glucose monitoring supplies, and an emergent referral to diabetes education at International Diabetes Center. Patients receive insulin during the EC/UC visit and are provided an insulin pen to take home. Nurses from the EC or UC review and provide educational material on how to use an insulin pen, treating hypoglycemia and healthy eating. The Certified Diabetes Care and Education Specialist (CDCES) sees patients within 24-72 hours after the referral is placed. RESULTS: Within our single healthcare system's EC and UC (multiple sites), the kit has enabled clinicians to metabolically stabilize patients and decrease the need for hospitalization without experiencing hypoglycemia. In the recent three years of use, of 42 patients given the insulin starter kit, there were only 2 patients with repeat EC/UC visits within the first six months (1 hyperglycemia and 1 hypoglycemia). CONCLUSIONS: An insulin starter kit and EMR-based order set initiated in the EC/UC setting is a tool that can be used to improve the quality of care for people with newly diagnosed or pre-existing diabetes experiencing significant hyperglycemia.

Expert Opinion: A Call for Basal Insulin Titration in Patients with Type 2 Diabetes in Daily Practice: Southeast European Perspective.

Therapeutic inertia related to insulin treatment, i.e. delays in initiation, especially titration of basal insulin, is a significant problem in daily practice in Southeast European countries. This phenomenon can be traced back to several patient-, physician- and health system-related factors. In recognition of the issue of inadequate insulin titration, 11 leading experts from countries in this region held a consensus-seeking meeting to review the current status of insulin initiation after non-insulin treatment and the potential barriers to insulin titration to provide an algorithm and tools for outpatient physicians and for patients aimed at optimizing basal insulin titration. The experts reached a consensus on the majority of the topics and proposed recommendations on how clinical inertia can be overcome. The outcomes of the meeting have been summarized in this paper.

Insulinization in T2DM with Basal Analogues During COVID-19 Pandemic: Expert Opinion from an Indian Panel.

The ongoing global pandemic of the coronavirus disease 2019 (COVID-19) has placed a severe strain on the management of chronic conditions like diabetes. Optimal glycemic control is always important, but more so in the existing environment of COVID-19. In this context, timely insulinization to achieve optimal glycemic control assumes major significance. However, given the challenges associated with the pandemic like restrictions of movement and access to healthcare resources, a simple and easy way to initiate and optimize insulin therapy in people with uncontrolled diabetes is required. With this premise, a group of clinical experts comprising diabetologists and endocrinologists from India discussed the challenges and potential solutions for insulin initiation, titration, and optimization in type 2 diabetes mellitus (T2DM) during the COVID-19 pandemic and how basal insulin can be a good option in this situation owing to its unique set of advantages like lower risk of hypoglycemia, ease of training, need for less monitoring, better adherence, flexibility of using oral antidiabetic drugs, and improved quality of life compared to other insulin regimens. The panel agreed that the existing challenges should not be a reason to delay insulin initiation in people with uncontrolled T2DM and provided recommendations, which included potential solutions for initiating insulin in the absence or restriction of in-person consultations; the dose of insulin at initiation; the type of insulin preferred for simplified regimen and best practices for optimal titration to achieve glycemic targets during the pandemic. Practical and easily implementable tips for patients and involvement of stakeholders (caregivers and healthcare providers) to facilitate insulin acceptance were also outlined by the expert panel. Simplified and convenient insulin regimens like basal insulin analogues are advised during and following the pandemic in order to achieve glycemic control in people with uncontrolled T2DM.

Feasibility of a New Approach to Initiate Insulin in Type 2 Diabetes.

BACKGROUND: Treatment inertia and prescription complexity are among reasons that people with type 2 diabetes (T2D) do not reach glycemic targets. This study investigated feasibility of a new approach to basal insulin initiation, where the dose needed to reach a glycemic target is estimated from two weeks of insulin and continuous glucose monitoring (CGM) data. METHODS: This was an exploratory single arm study with a maximum length of 84 days. Eight insulin naïve people with T2D, planning to initiate basal insulin, wore a CGM throughout the study period. A predetermined regime was followed for the first two weeks after which the end dose was estimated. The clinician decided whether to follow this advice and continued the titration until target was reached using a twice weekly stepwise titration algorithm. The primary outcome was the comparison between the estimated and the actual end doses. RESULTS: Median age of participants was 57 years (range: 50-77 years), duration of diabetes was 16 years (range: 5-29 years), and Bodi Mass Index (BMI) was 30.2 kg/m2 (range: 22.0-36.0 kg/m2). The median study end dose was 37 U (range: 20-123 U). The estimated end dose was smaller than or equal to the study end dose in all cases, with median error of 26.7% (range: 0.0%-75.8% underestimation). No self-monitoring of blood glucose values were below 70 mg/dL and no severe hypoglycemia occurred. CONCLUSION: While accuracy may be improved, it was found safe to predict the study end dose of insulin degludec from two weeks of data.

Cardiovascular disease risk and the time to insulin initiation for Medicaid enrollees with type 2 diabetes.

AIMS: We evaluated the relationship between the timing of insulin initiation and cardiovascular diseases (CVD) risk in Pennsylvania Medicaid enrollees with type 2 diabetes (T2D). METHODS: We included 17,873 enrollees (age 47.4 ± 10.3 years; range 18-64 years) initially treated with non-insulin glucose-lowering agents (GLAs) in 2008-2016. Based on clinical guidelines, we identified early (N = 1,158; 6%; insulin initiation ≤ 6 months after first-line GLAs), in-time (N = 569; 3%; 6-12 months), delayed (N = 2,761; 15%; >12 months), and non-insulin users (N = 13,385; 75%). The Prentice-Williams-Peterson (PWP) models with inverse probability weighting estimated CVD risk across the four groups and the change in risk after insulin initiation. RESULTS: Regardless of time to insulin initiation, insulin users had higher CVD risks after first-line GLAs than non-insulin users (aHR: early: 2.0 [1.5-2.5], in-time: 1.8 [1.2-2.6], delayed: 1.9 [1.6-2.3]). However, we found only a borderline increase in CVD risk after insulin initiation vs. before in early (aHR: 1.4 [1.1-1.8]) and delayed users (aHR: 1.3 [1.0-1.7]), and no increase in in-time users (aHR: 1.3 [0.9-2.0]). CONCLUSIONS: We observed no gains in CVD benefits from insulin initiation in the early stages of pharmacotherapy possibly because CVD developed before insulin initiation. Additional management of hypertension and dyslipidemia may be important to reduce CVD risk in this young and middle-aged T2D cohort.

Delays in Insulin Initiation among Patients with Type 2 Diabetes Mellitus in Southeast China: A Retrospective, Real-World Study.

PURPOSE: To describe the extent of delays in insulin initiation, analyze its impact on glycemic control, and explore factors influencing delayed insulin initiation among Chinese type 2 diabetes mellitus (T2DM) patients. METHODS: A real-world, retrospective cohort study with regional electronic health records from Fuzhou, southeast China was conducted among T2DM patients. Adult patients uncontrolled with oral antidiabetic drugs (OADs; HbA1c ≥7%) and initiated on insulin treatment were included. Time to insulin initiation was described. After propensity-score matching, Wilcoxon rank-sum test and chi-square test were used to compare follow-up HbA1c (first HbA1c 3 months after insulin initiation) between timely (initiated insulin within 6 months after OAD failure) and delayed (initiated after 6 months) insulin-initiation groups. Sensitivity analysis was also performed by linear and logistic regression. Factors associated with delayed insulin initiation were explored using logistic regression. RESULTS: A total of 940 patients were included, with mean±SD age 66.3±11.9 years. In sum, 328 had HbA1c recorded 3 months after insulin initiation. After propensity-score matching (1:1 matching), 184 patients were included for further analysis. Median follow-up HbA1c was lower in the timely-initiation group than the delayed-initiation group (7.25% vs 8.25%, P=0.009). Patients in the timely initiation group also had higher odds of achieving HbA1c <7% (OR=3.15, P=0.001). Results were confirmed by logistic regression. Hypertension, coronary artery disease, baseline HbA1c, and hospital level at insulin initiation were associated with delays in insulin initiation. CONCLUSION: Timely insulin initiation after OAD failure is associated with better glycemic control.

Use of Traditional Chinese Medicine May Delay the Need for Insulin Treatment in Patients with Type 2 Diabetes: A Population-Based Cohort Study.

Objectives: Traditional Chinese medicine (TCM) has been shown to reduce insulin resistance and improve beta cell function in previous studies. The aim of this study was to assess whether the use of TCM can delay the need for insulin therapy in patients with type 2 diabetes. Design: Data on patients with type 2 diabetes who received medical treatment for the first time between 2000 and 2003 were obtained from National Health Insurance Research Database (NHIRD) in Taiwan. Among these patients, those with a cumulative use of TCM of more than 28 days were defined as TCM users, and the others as non-users. Kaplan-Meier analysis was used to evaluate the cumulative risk of initiating insulin therapy. Cox proportional hazards models with and without competing risk events were used to evaluate the association between the use of TCM and insulin therapy. Settings/Location: Data were obtained from National Health Insurance Research Database (NHIRD) in Taiwan. Subjects: Patients with type 2 diabetes who received medical treatment for the first time between 2000 and 2003. Interventions: Among these patients, those with a cumulative use of TCM of more than 28 days were defined as TCM users, and the others as non-users. Outcome measures: After 1:1 propensity score matching, both groups were tracked until the initiation of insulin therapy, death, or the end of 2013. Results: We identified 6524 TCM users and 6524 non-users. The TCM users had a significantly lower risk of insulin initiation in a dose-dependent manner (log-rank test p < 0.001). This effect was consistent across subgroups with different severities of diabetes, and remained significant in competing risk analysis (for TCM users with 28 to 83 days cumulative use, HR 0.78 [0.70-0.87], p < 0.0001; for TCM users with ≥ 84 days cumulative use, HR 0.47 [0.42-0.53], p < 0.0001). Conclusions: The use of TCM in addition to standard diabetes treatment may delay the need for insulin treatment in patients who received medical treatment for type 2 diabetes for the first time. This benefit was strongly dose-dependent and applicable in patients with different severities of diabetes.

The impact of phenotype, ethnicity and genotype on progression of type 2 diabetes mellitus.

AIM: To conduct a comprehensive review of studies of glycaemic deterioration in type 2 diabetes and identify the major factors influencing progression. METHODS: We conducted a systematic literature search with terms linked to type 2 diabetes progression. All the included studies were summarized based upon the factors associated with diabetes progression and how the diabetes progression was defined. RESULTS: Our search yielded 2785 articles; based on title, abstract and full-text review, we included 61 studies in the review. We identified seven criteria for diabetes progression: 'Initiation of insulin', 'Initiation of oral antidiabetic drug', 'treatment intensification', 'antidiabetic therapy failure', 'glycaemic deterioration', 'decline in beta-cell function' and 'change in insulin dose'. The determinants of diabetes progression were grouped into phenotypic, ethnicity and genotypic factors. Younger age, poorer glycaemia and higher body mass index at diabetes diagnosis were the main phenotypic factors associated with rapid progression. The effect of genotypic factors on progression was assessed using polygenic risk scores (PRS); a PRS constructed from the genetic variants linked to insulin resistance was associated with rapid glycaemic deterioration. The evidence of impact of ethnicity on progression was inconclusive due to the small number of multi-ethnic studies. CONCLUSION: We have identified the major determinants of diabetes progression-younger age, higher BMI, higher HbA1c and genetic insulin resistance. The impact of ethnicity is uncertain; there is a clear need for more large-scale studies of diabetes progression in different ethnic groups.

Developing a definition for Oral Antidiabetic Drug (OAD) Failure.

Oral antidiabetic failure (OAD failure) is a term which is used frequently in clinical practice. There is no uniformly accepted definition, however, for this term. This communication describes the concept of OAD failure, and develops a working definition for the same. The definition uses resistant hypertension as an example, and assesses the relative role of various classes of OADs, lifestyle modification, secondary causes of hyperglycaemia, and symptomatology in diabetes praxis. It utilizes these concepts to build a definition of OAD failure which states: OAD failure is defined as a clinical situation where HbA1c remains above goal, despite concurrent use of optimum dose of three oral glucose lowering drugs of different classes, one of which should be metformin and the second, preferably a sulfonylurea, provided adequate diet and exercise have been followed, and comorbid conditions causing hyperglycaemia ruled out. OAD failure may also be defined in patients who have symptoms suggestive of insulinopenia (osmotic symptoms, weight loss), and uncontrolled glycaemia (plasma glucose> 300mg %), in spite of using triple OAD therapy.

Best Practices and Tools for Titrating Basal Insulins: Expert Opinion from an Indian Panel via the Modified Delphi Consensus Method.

AIM: To develop an evidence-based expert group consensus document on the best practices and simple tools for titrating basal insulins in persons with type 2 diabetes mellitus (T2DM). BACKGROUND: Glycemic control is suboptimal in a large proportion of persons with T2DM, despite insulin therapy, thereby increasing the risk of potentially severe complications. Early initiation of insulin therapy and appropriate dose titration are crucial to achieving glycemic targets. Attitudes and practices among healthcare professionals (HCPs) and perceptions about insulin therapy among persons with diabetes contribute largely to suboptimal glycemic control. Improving HCP-patient communication, encouraging the use of additional educational tools, and providing support for the titration process to increase confidence, both at the initiation visit and at home, facilitate the optimization of dose titration. In Indian settings, specific guidelines and a consensus statement are lacking on the optimal insulin initiation dose, frequency of dose titration, and basal insulin profile needed to achieve optimal titration. In clinical practice, physicians and persons with diabetes often do not adhere to the titration algorithms that currently exist for the purpose of achieving optimal titration as they perceive these to be very cumbersome. In this context, a group of experts met at an advisory board meeting and arrived at a consensus on best practices for the titration of basal insulin in persons withT2DM in India, using the modified Delphi methodology. REVIEW RESULTS: After a review of evidence and further discussions, the expert group provided recommendations on insulin initiation dose, ideal period for titration in practice, titration regimen for use in practice, basal insulin profile for titration, and choosing a self-monitoring blood glucose schedule for titration. CONCLUSIONS: In the management of T2DM, insulin can be effectively titrated by following a few simple recommendations. The use of second-generation basal insulin aids in mitigating the risk of hypoglycemic events. The implementation of a simplified titration regimen is crucial to achieving glycemic targets and long-term treatment goals.

Investigation of the barriers about insulin therapy in patients with type 2 diabetes.

AIMS: This study aimed to explore barriers regarding insulin initiation in patients with Type 2 diabetes and investigate the relationship of some demographic characters of patients. MATERIALS AND METHODS: A cross-sectional study was conducted with 142 patients with Type 2 diabetes whose doctors had recommended insulin therapy and who had been unwilling to comply. The participants were patients at an endocrine outpatient clinic in Kovancilar State Hospital in the rural area in Elazig, from November 2016 to May 2017. RESULTS: Half of the patients were illiterate, 60.6% of the participants were female, and the mean age was 57.33 ± 10.56. The most commonly reported barrier was injection-related anxiety (63.4%). In total, 58.5% of the patients refused insulin therapy because they felt it indicated that their disease had worsened and that they had failed at diabetes management. Female patients were 6.9 times more likely to think injection-related anxiety that affecting their decision about insulin therapy than male patients. Elderly patients were 8.2 times more likely to think of their disease worsened than younger patient. CONCLUSIONS: Patients' beliefs related to insulin therapy were very much influenced by their gender, educational status, and age. Giving patient-centered education is a cost-effective way to decrease negative health behaviors.

What will make patients use a patient decision aid? A qualitative study on patients' perspectives on implementation barriers and facilitators.

RATIONALE, AIMS, AND OBJECTIVES: Few studies focus on patients' views on factors influencing implementation of patient decision aids (PDAs). This study aims to explore patients' views on the factors influencing implementation of an "insulin choice" PDA in a primary care setting. METHODS: This study used a descriptive qualitative study design. Interviews were conducted using a semistructured interview guide developed based on the theoretical domains framework. Nine in-depth interviews and three focus group discussions were conducted with patients with type 2 diabetes who have been advised to start insulin or were currently using insulin and those who had been seeking diabetes treatment in the clinic for more than 1 year. Interviews were conducted after the participants were familiarized with the PDA. Data were analysed using a thematic approach. RESULTS: Five themes emerged from the data analysis: (a) trust in the physician (patients preferred physicians to other health care providers in delivering the insulin PDA to them as they trusted physicians more when it comes to making decisions such as starting insulin), (b) physician's attitude (patients were more likely to trust a physician who is friendly and sympathetic hence would be more willing to use the insulin PDA), (c) physician's communication style (patients were more willing to use the insulin PDA if the physicians would take time and guide them in the PDA use), (d) conducive environment (patients preferred to read the PDA at home), and (e) cost (patients would not be willing to pay to use the insulin PDA unless they needed it). CONCLUSIONS: Patients want physicians to play a major role in the implementation of the insulin PDA; physicians' communication style and commitment may influence implementation outcomes. Health care authorities need to create a conducive environment and provide patients with free access to PDA to promote effective implementation.