HbA1c target more achievable with earlier insulin initiation in Type 2 diabetes

31 January 2012

MedWire News: Starting patients on insulin therapy at lower levels of glycated hemoglobin (HbA1c) improves achievement of glycemic control and increases glycemic response in Type 2 diabetes patients, report US researchers.

“The key to glycemic success with insulin, as with oral agents, is intensifying therapy quickly when current therapies begin to fail,” say Gregory Nichols (Kaiser Permanente Center for Health Research, Portland, Oregon) and colleagues.

The team analyzed data available for 1139 individuals with Type 2 diabetes, aged 45 years or more, who initiated insulin therapy between January 2009 and June 2010. The primary outcomes were the proportion of patients achieving an HbA1c of less than 7% and mean change in HbA1c within 3 to 9 months of initiating treatment.

As reported in Diabetes Care, 464 (40.7%) patients had attained an HbA1c of less than 7% within a mean of 5 months of insulin initiation. The patients who attained the target tended to be older (aged 66.1 vs 62.6 years), were less likely to be of a non-White race (7.1 vs 12.2%), and had slightly shorter duration of diabetes (8.5 vs 9.0 years).

The researchers report that, among those who did attain the target HbA1c level, the mean HbA1c at insulin initiation was significantly lower than it was among patients who did not reach the target (8.2 vs 9.2%).

In addition, the mean decline in HbA1c was significantly greater in the patients who achieved the target than it was in those who did not (1.9 vs 1.3%). And those who achieved the target did so with fewer mean units of insulin per day (47.4 vs 53.2 units/day) and less use of any oral agent (67.2 vs 73.0%) than their peers.

Multivariate analysis revealed that HbA1c level prior to insulin initiation was the most important factor influencing attainment of the HbA1c target level; each percentage point increase of HbA1c prior to insulin reduced the probability of achieving the target by 26%.

The researchers remark that it is not surprising that achieving a given HbA1c target is easier for the patient who is closer to the goal when the therapy is initiated.

“However, these patients also had significantly greater mean change in HbA1c after starting the therapy, and shorter diabetes duration also was independently associated with HbA1c and greater HbA1c reduction,” write the researchers.

“Thus, initiating insulin earlier in the course of oral agent failure seems to improve glycemic goal attainment as well as improve glycemic response,” they conclude.

MedWire (www.medwire-news.md) is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2012

Diabetes Care 2012; Advance online publication