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Initiation And Titration Of Basal Insulin In Primary Care: Barriers And Practical Solutions
L. Perreault, L. Vincent, J. Neumiller, Tricia Santos-Cavaiola
Published 2019 · Medicine
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Basal insulin therapy is a critical part of effective type 2 diabetes (T2D) management for many patients, yet its initiation and titration are often delayed or avoided. Aversion to basal insulin therapy contributes to unnecessary hyperglycemia and poorer outcomes for patients. Primary care physicians often make decisions regarding the initiation of basal insulin in T2D, as they work closely with patients and are well placed to discuss and manage the transition to basal insulin therapy. However, many primary care clinicians hesitate to initiate basal insulin due to concerns regarding time or effort needed to educate patients, doubts about patient acceptance or ability to manage titration or injection, or patient fears of hypoglycemia. Resistance to basal insulin therapy is often linked to the outdated perception that the need for insulin represents a failure to control the disease, or that insulin is dangerous or toxic. Time concerns can be addressed via group classes and mobile technology and by working with diabetes educators in the community. Hypoglycemia or weight gain can be minimized with proper titration and use of second-generation basal insulins. This article reviews strategies for the initiation of basal insulin therapy, with an emphasis on the characteristics and titration of second-generation basal insulins, introducing current guidelines and offering suggestions for recognizing and overcoming barriers to insulin therapy in the management of T2D.
This paper references
Basaglar® prescribing information
Real-life experience of patients starting insulin degludec. A multicenter analysis of 1064 subjects from the German/Austrian DPV registry.
B. Bohn (2017)
Glycaemic control and hypoglycaemia with insulin glargine 300U/mL versus insulin glargine 100U/mL in insulin-naïve people with type 2 diabetes: 12-month results from the EDITION 3 trial.
G. Bolli (2017)
Barriers to initiating insulin therapy in patients with type 2 diabetes mellitus in public-sector primary health care centres in Cape Town
Monirul Haque (2005)
Patients’ perceptions of injecting insulin and self‐monitoring of blood glucose in the presence of others
S. Mehmet (2015)
C. Edwards (2020)
A Real-World Approach to Insulin Therapy in Primary Care Practice
I. Hirsch (2005)
A 26-Week, Randomized, Parallel, Treat-to-Target Trial Comparing Insulin Detemir With NPH Insulin as Add-On Therapy to Oral Glucose-Lowering Drugs in Insulin-Naïve People With Type 2 Diabetes
L. Kennedy (2007)
Psychological insulin resistance: patient beliefs and implications for diabetes management
M. Brod (2008)
Randomized Trial of Long-Acting Insulin Glargine Titration Web Tool (LTHome) Versus Enhanced Usual Therapy of Glargine Titration (INNOVATE Trial).
H. Bajaj (2016)
Efficacy and safety of LY2963016 insulin glargine compared with insulin glargine (Lantus®) in patients with type 1 diabetes in a randomized controlled trial: the ELEMENT 1 study
T. Blevins (2015)
Management of Hyperglycemia in Type 2 Diabetes, 2015: A Patient-Centered Approach: Update to a Position Statement of the American Diabetes Association and the European Association for the Study of Diabetes
S. Inzucchi (2014)
Basal insulin persistence, associated factors, and outcomes after treatment initiation among people with type 2 diabetes mellitus in the US
M. Perez-Nieves (2016)
Improved treatment engagement among patients receiving insulin glargine 300 units/mL who enrolled and received live support through the COACH patient support program
J Goldman (2017)
Randomized Trial of Long-Acting Insulin Glargine Titration Web Tool (LTHome) Versus Enhanced Usual Therapy of Glargine Titration (INNOVATE Trial)
S. BajajHarpreet (2016)
Recognition of and steps to mitigate anxiety and fear of pain in injectable diabetes treatment
D. Kruger (2015)
When oral agents fail: practical barriers to starting insulin
M. Korytkowski (2002)
New prescription medication gaps: a comprehensive measure of adherence to new prescriptions.
A. Karter (2009)
Global report on diabetes: executive summary
Comparison of insulin degludec with insulin glargine in insulin-naive subjects with Type 2 diabetes: a 2-year randomized, treat-to-target trial
H. Rodbard (2013)
The impact of hypoglycaemia on quality of life and related patient‐reported outcomes in Type 2 diabetes: a narrative review
S. Barendse (2012)
Tresiba® dosing and device
B. Boehm (2019)
Coordinated primary and specialty care for type 2 diabetes mellitus, guidelines, and systems: an educational needs assessment.
R. Beaser (2011)
Lessons from DAWN: Implementing Effective Insulin Therapy
Martha M. Funnell (2008)
Management of Hyperglycemia in Type 2 Diabetes
N. Skolnik (2012)
Insights into optimal basal insulin titration in type 2 diabetes: Results of a quantitative survey
L. Berard (2018)
New insulin glargine 300 U/ml compared with glargine 100 U/ml in insulin-naïve people with type 2 diabetes on oral glucose-lowering drugs: a randomized controlled trial (EDITION 3)
G. Bolli (2015)
10-year follow-up of intensive glucose control in type 2 diabetes.
R. Holman (2008)
Insulin detemir and insulin aspart: a promising basal-bolus regimen for type 2 diabetes.
K. Rašlová (2004)
Insulin Degludec Versus Insulin Glargine in Insulin-Naive Patients With Type 2 Diabetes
B. Zinman (2012)
Insulin Matters: A Practical Approach to Basal Insulin Management in Type 2 Diabetes
L. Berard (2018)
Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)
M. Davies (2018)
What's So Tough About Taking Insulin? Addressing the Problem of Psychological Insulin Resistance in Type 2 Diabetes
W. Polonsky (2004)
Basal insulin and cardiovascular and other outcomes in dysglycemia.
H. Gerstein (2012)
Role of Emerging Insulin Technologies in the Initiation and Intensification of Insulin Therapy for Diabetes in Primary Care
S. Brunton (2016)
Diabetes Fear of Injecting and Selftesting Questionnaire: a psychometric evaluation. Diabetes Care 2000;23:765–9
ED Mollema (2000)
National diabetes statistics report , 2017 . Estimates of diabetes and its burden in the United States
Barriers to insulin initiation and intensification and how to overcome them
T. Kunt (2009)
Barriers and myths to initiate insulin therapy for type 2 diabetes mellitus at primary health care centers of Hyderabad District.
Atif Sitwat Hayat (2010)
Patient-level meta-analysis of the EDITION 1, 2 and 3 studies: glycaemic control and hypoglycaemia with new insulin glargine 300 U/ml versus glargine 100 U/ml in people with type 2 diabetes
R. Ritzel (2015)
Insulin stacking versus therapeutic accumulation: understanding the differences.
T. Heise (2014)
Hypoglycemia risk associated with basal insulin use in type 2 diabetes (T2DM): the LIGHTNING study
L Meneghini (2018)
The usage of a simplified self‐titration dosing guideline (303 Algorithm) for insulin detemir in patients with type 2 diabetes – results of the randomized, controlled PREDICTIVE™ 303 study
L. Meneghini (2007)
Insulin degludec results in lower rates of nocturnal hypoglycaemia and fasting plasma glucose vs. insulin glargine: A meta-analysis of seven clinical trials.
D. Russell-Jones (2015)
Insulin Therapy and Type 2 Diabetes: Management of Weight Gain
S. McFarlane (2009)
CONSENSUS STATEMENT BY THE AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY ON THE COMPREHENSIVE TYPE 2 DIABETES MANAGEMENT ALGORITHM - 2018 EXECUTIVE SUMMARY.
A. Garber (2018)
Primary care physician beliefs about insulin initiation in patients with type 2 diabetes
R. Hayes (2008)
Weight changes and their predictors amongst 11 140 patients with type 2 diabetes in the ADVANCE trial
S. van Dieren (2012)
Barriers to insulin initiation: the Translating Research into Action for Diabetes Insulin Starts Project. Diabetes Care 2010;33:733–5
AJ Karter (2010)
Resistance to insulin therapy among patients and providers: results of the cross-national Diabetes Attitudes, Wishes, and Needs (DAWN) study.
M. Peyrot (2005)
Hypoglycemia and Diabetes: A Report of a Workgroup of the American Diabetes Association and The Endocrine Society
E. Seaquist (2013)
Prediction of excessive weight gain in insulin treated patients with type 2 diabetes
S. Cichosz (2017)
New Insulin Glargine 300 Units·mL−1 Provides a More Even Activity Profile and Prolonged Glycemic Control at Steady State Compared With Insulin Glargine 100 Units·mL−1
R. Becker (2014)
TITRATION: A Randomized Study to Assess 2 Treatment Algorithms with New Insulin Glargine 300 units/mL.
J. Yale (2017)
Frequently asked questions about commercial driver's licenses
Toujeo® insulin dosing and titration calculator
Lantus® prescribing information
Standards of medi - cal care in diabetes — 2018
IB Hirsch (2018)
U-300 for subcutaneous use. Prescribing information
Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33)
UK Prospective Diabetes Study Group (1998)
Standards of medical care in diabetes.
H. J. Morris (2005)
Barriers towards insulin therapy in type 2 diabetic patients: results of an observational longitudinal study
N. Hermanns (2010)
Real‐world evidence concerning clinical and economic outcomes of switching to insulin glargine 300 units/mL vs other basal insulins in patients with type 2 diabetes using basal insulin
F. L. Zhou (2018)
Differences in physician and patient perceptions about insulin therapy for management of type 2 diabetes: the DAWN Japan study
N. Yoshioka (2014)
Single-dose new insulin glargine 300 U/ml provides prolonged, stable glycaemic control in Japanese and European people with type 1 diabetes
M. Shiramoto (2015)
Clinical inertia to insulin initiation and intensification in the UK: A focused literature review.
K. Khunti (2017)
Pattern of active and inactive sequences of diabetes self-monitoring in mobile phone and paper diary users
N. Padhye (2015)
Levemir® prescribing information
Cost-effectiveness of switching to insulin degludec from other basal insulins: evidence from Swedish real-world data
L. Landstedt-Hallin (2017)
Addressing barriers to initiation of insulin in patients with type 2 diabetes.
M. Peyrot (2010)
Barriers to Insulin Initiation
A. Karter (2010)
The Prevalence of Meeting A1C, Blood Pressure, and LDL Goals Among People With Diabetes, 1988–2010
Sarah Stark Casagrande (2013)
Psychological insulin resistance: overcoming barriers to starting insulin therapy.
S. Davis (2006)
Low-Volume Insulin Degludec 200 Units/mL Once Daily Improves Glycemic Control Similarly to Insulin Glargine With a Low Risk of Hypoglycemia in Insulin-Naïve Patients With Type 2 Diabetes
S. Gough (2013)
and Drug Administration (FDA)
US Foo (2018)
Management of Hyperglycemia in Type 2 Diabetes, 2015
G. W. D. Landman (2015)
Efficacy and Safety of Degludec versus Glargine in Type 2 Diabetes
S. Marso (2017)
Transition to insulin in Type 2 diabetes: family physicians' misconception of patients' fears contributes to existing barriers.
S. Nakar (2007)
Group based training for self-management strategies in people with type 2 diabetes mellitus.
T. Deakin (2005)
Initiating basal insulin therapy in type 2 diabetes: practical steps to optimize glycemic control.
A. Philis-Tsimikas (2013)
Magnitude of clinical benefit of cancer drugs approved based on single-arm trials (SAT) by the US Food and Drug Administration (FDA).
C. Molto Valiente (2018)
Barriers to insulin initiation : the Translating Research into Action for Diabetes Insulin Starts Project
M Perez-Nieves (2010)
Patient‐directed titration for achieving glycaemic goals using a once‐daily basal insulin analogue: an assessment of two different fasting plasma glucose targets ‐ the TITRATETM study
L. Blonde (2009)
Clinical inertia with regard to intensifying therapy in people with type 2 diabetes treated with basal insulin
K. Khunti (2016)
Efficacy and Safety of Flexible Versus Fixed Dosing Intervals of Insulin Glargine 300 U/mL in People with Type 2 Diabetes
M. Riddle (2016)
Similar efficacy and safety of LY2963016 insulin glargine and insulin glargine (Lantus®) in patients with type 2 diabetes who were insulin‐naïve or previously treated with insulin glargine: a randomized, double‐blind controlled trial (the ELEMENT 2 study)
J. Rosenstock (2015)
Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study
I. Stratton (2000)
Treatment Dosing Patterns and Clinical Outcomes for Patients with Type 2 Diabetes Starting or Switching to Treatment with Insulin Glargine (300 Units per Milliliter) in a Real-World Setting: A Retrospective Observational Study
S. Gupta (2018)
A systematic review of randomized controlled trials examining psychological interventions for needle-related procedural pain and distress in children and adolescents: an abbreviated cochrane review.
L. Uman (2008)
Sanofi gets FDA clearance for insulin dose calculator app
International Diabetes Federation (IDF) Clinical Guidelines Task Force. Global guideline for type 2 diabetes
Morning administration of 0.4U/kg/day insulin glargine 300U/mL provides less fluctuating 24-hour pharmacodynamics and more even pharmacokinetic profiles compared with insulin degludec 100U/mL in type 1 diabetes.
T. Bailey (2018)
Getting Under the Skin of Clinical Inertia in Insulin Initiation
N. Ratanawongsa (2012)
Diabetes Fear of Injecting and Self-Testing Questionnaire: a psychometric evaluation.
E. Mollema (2000)
Comparison of Insulin Glargine 300 Units/mL and 100 Units/mL in Adults With Type 1 Diabetes: Continuous Glucose Monitoring Profiles and Variability Using Morning or Evening Injections
R. Bergenstal (2017)
Achievement of Glycated Hemoglobin Goals in the US Remains Unchanged Through 2014
Ginger Carls (2017)
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.
M. Dalal (2016)
Mortality and Cardiovascular Disease in Type 1 and Type 2 Diabetes
Aidin Rawshani (2017)
Basal insulin glargine and microvascular outcomes in dysglycaemic individuals: results of the Outcome Reduction with an Initial Glargine Intervention (ORIGIN) trial
R. Gilbert (2014)
Barriers that practitioners face when initiating insulin therapy in general practice settings and how they can be overcome
Abdulaziz Bin rsheed (2017)
American Diabetes Association and the European Association for the Study of Diabetes
Estimates of diabetes and its burden in the United States
My Dose Coach" app to optimize basal insulin dosing
This paper is referenced by
Family Medicine: Data Driven Practice with Emphasis on Underserved Patients
M. Bowman (2019)
The Most Frequently Read Articles of 2019
P. Lupo (2020)
Glargine-300: An updated literature review on randomized controlled trials and real-world studies
S. Ghosh (2020)
Physician related barriers towards insulin therapy at primary care centres in Trinidad: a cross-sectional study
Shastri Motilal (2020)
A practical approach to the clinical challenges in initiation of basal insulin therapy in people with type 2 diabetes.
T. Forst (2020)