Choosing an insulin injector by a structured, pharmaceutical-neutral curriculum via an informed shared decision-making process in 349 insulin-naive patients with diabetes mellitus.

BACKGROUND: The national guideline for diabetes type 2 claims to involve patients in their decision-making on therapy. Unfortunately, no structured, pharmaceutical-neutral curriculum is available to guide patients in this shared decision-making (SDM) process regarding the insulin injector. The aim of the study was to evaluate which injector patients chose after SDM process and the reasons for their choice. METHODS: We developed a curriculum for a SDM process to choose an insulin injector for insulin-naive patients with diabetes mellitus, which took place immediately before the start of the initial treatment with insulin. It was conducted by a physician or diabetes educator with no conflicts of interest. All available human short-acting disposable insulin injectors (A, B and C) were handed out for try-out accompanied by individual counselling. The patients selected their injector of choice and were asked immediately afterwards about the criteria for their selection. RESULTS: 349 consecutive patients (94% diabetes type 2; age 58.6 + 13.4y; HbA1c 10.4 + 2.1%) were included. Patients choose Injector A in 10.0%, B in 61.9% and C in 28.1%. Criteria for selection were: design (41.8%), general impression (23.5%), dose window (7.7%), dose selection dial (7.4%), most practical (6.6%) and other (13%). Selection of a specific injector was not associated with age, diabetes type, diabetes duration, BMI, HbA1c, presence of concomitant diseases, retinopathy, neuropathy, diabetic foot or physician/diabetes educator. DISCUSSION: Insulin-naive patients with diabetes mellitus chose their own insulin injector within a newly developed structured SDM process to meet the national guideline. Main selection criteria were design and practicability.

Screening Results for Diabetic Retinopathy in Germany in a Real-world Cohort in a Metropolitan Diabetes Care Center.

BACKGROUND: Retinal screening is mandatory to prevent vision loss and blindness due to diabetic retinopathy (DR). The aim of the study was to determine retinopathy screening rates and potential barriers in a German metropolitan diabetes care center. METHODS: Between May and October 2019, 265 patients with diabetes mellitus (95% type 2 diabetes; age 62±13.2 years; diabetes duration 11.1±8.5 years, HbA1c 7.4±1.0%) were referred to an ophthalmologist (referral form with order "Fundoscopy in diabetes mellitus, findings requested," completed documentation form "General practitioner's/diabetologist's report to the ophthalmologist" and prepared documentation form "Ophthalmologist's report"). A structured interview was used to assess the level of compliance with the guidelines and to identify potential barriers to retinopathy screening in a real-world setting, including the quantification of extra payments. RESULTS: All patients were interviewed at 7.9±2.5 months after the referral for retinopathy screening had been issued. According to patient reporting, fundoscopy was performed in 191 (75%) patients. Ophthalmological reports were obtained from 119/191 (62%) patients (46% of the entire cohort). 10/119 (8%) patients had been previously diagnosed with DR and 6/119 (5%) with new-onset DR. In 158/191 (83%) of patients, the referral had been accepted by the ophthalmology practice, of which 25,1% made a co-payment of 36.2±37.6 €. DISCUSSION: Despite a high screening performance in a real-world setting, complete screening in compliance with German guidelines, including written reporting, was found in less than half of the cohort. The prevalence and incidence of DR are high. Even when referred according to the regulations, one-quarter of patients made a co-payment. Efficient solutions to current barriers can emerge with mutual time-saving information prior to examination and feedback about the implementation of findings into treatment.

Successful Treatment with Bedtime Basal Insulin Added to Metformin without Weight Gain or Hypoglycaemia over Three Years.

The aim of this observational study was to follow-up patients with bedtime basal insulin (NPH insulin) added to metformin. In 285 patients with type 2 diabetes, a therapy with bedtime basal insulin added to metformin was started due to failure to achieve a glycaemic goal. Up until July 2019, 272 patients (95.4%) were followed-up (59.5 y, 92.6 kg, diabetes duration 6.6 y, HbA1c 8.4%/68.6 mmol/mol). HbA1c decreased by -1.2% and bodyweight by -1.7 kg after a duration of 31.7 ± 29.1 (range 2-133) months. Severe hypoglycaemia did not occur. In 144/272 patients (52.9%), the therapeutic goal for HbA1c was achieved over 32.7 months. In 69/272 patients (25.4%), the HbA1c target was achieved over 25.0 months (afterwards, therapy with basal insulin was discontinued because HbA1c was under target). In 36/272 patients (13.2%), the HbA1c goal was achieved until the submission of this manuscript (mean duration of treatment 57.4 ± 28.2 (range 13-121) months). Over 90% of patients with type 2 diabetes and failure of metformin reached their HbA1c goal with additional basal insulin at bedtime over several years in association with a reduction of bodyweight and without any event of severe hypoglycaemia.