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Appropriate Insulin Regimes for Type 2 Diabetes a Multicenter Randomized Crossover Study

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Appropriate Insulin Regimes for Type 2 Diabetes a Multicenter Randomized Crossover Study Clinical Care/Education/Nutrition ORIGINAL ARTICLE Appropriate Insulin Regimes for Type 2 Diabetes A multicenter randomized crossover study ROY TAYLOR, MD MICHAEL SAMPSON, MD diurnal pattern of blood glucose control ROBERT DAVIES, MD JOLA U. WEAVER, PHD achieved during insulin therapy for type 2 CHARLES FOX, MD LINDA WOOD, RN diabetes requires description for the various insulin regimens. It is important to note that the applicability of regimens has rarely been tested outside of specialized centers. The original UKPDS protocol described OBJECTIVE — To directly compare the rate of hypoglycemia and metabolic control only the use of once-daily ultralente insulin achieved on once-daily ultralente insulin administration with twice-daily NPH insulin admin- administered before the evening meal (8). istration in patients with type 2 diabetes. Patient treatment satisfaction and quality of life were Published information suggested a relatively also examined before and during each treatment. high rate of hypoglycemia on this regimen, with 5.6–12 hypoglycemic episodes per RESEARCH DESIGN AND METHODS — A crossover study was performed involv- ing five centers and 79 patients with type 2 diabetes (fasting blood glucose Ͼ8 mmol/l) with patient-year (9,10). In contrast, use of twice- a 2-month run-in followed by two 6-month periods of either NPH or ultralente insulin admin- daily intermediate-acting (NPH) insulin istration. Patients were managed by a specialist nurse using a dosage adjustment protocol. under usual clinical conditions has been reported to be associated with only three RESULTS —HbA1c was lower with NPH insulin therapy during each of the 6-month peri- episodes per patient-year (4). It is commonly ods (9.7 ± 0.2 vs. 9.1 ± 0.3 and 9.8 ± 0.2 vs. 9.0 ± 0.3 mmol/l; both P Ͻ 0.01). The difference assumed by doctors and nurses that once- was accounted for by higher evening glucose levels with ultralente insulin (fasting 8.2 ± 0.3 daily insulin will be better accepted by vs. 8.2 ± 0.3 mmol/l, 6:00 P.M. 11.5 ± 0.4 vs. 10.6 ± 0.4 mmol/l). Despite worse control, the patients than twice-daily insulin, but no reli- total number of hypoglycemic episodes was greater with ultralente insulin (220 vs. 171), and able information exists to test this premise. hypoglycemic episodes requiring third-party assistance occurred almost entirely with ultra- The Appropriate Insulin Regime Study, lente (14 vs. 1). Treatment satisfaction scores increased more with NPH insulin compared with ultralente and rose further upon changing to NPH insulin, but fell upon changing to ultra- a randomized crossover study, was there- lente insulin. These changes were highly significant (P Ͻ 0.001). Diabetes quality of life fore designed to compare twice-daily NPH improved on both regimens. insulin with once-daily ultralente insulin under conditions of routine clinical care. To CONCLUSIONS — These data clearly demonstrate the lower hypoglycemia rate, better glu- ensure general applicability of the findings cose control, and greater treatment satisfaction accompanying therapy for type 2 diabetes with and to avoid bias introduced as a conse- twice daily NPH compared with once daily ultralente insulin. quence of the enthusiasm of any one inves- tigator for a particular regimen, it was Diabetes Care 23:1612–1618, 2000 designed as a multicenter study. The spe- cific objectives were to compare between each regimen rates of hypoglycemia, effi- he dramatic impact of the U.K. are concerned about the risk of hypogly- cacy in achieving diurnal blood glucose Prospective Diabetes Study (UKPDS) cemia (1,3,4), but few studies have defined control, and degrees of well-being and Tdata has drawn attention to the use of the frequency of hypoglycemia under rou- treatment satisfaction. insulin in type 2 diabetes (1). Current inter- tine clinical conditions (5,6). The anecdotal est in achieving good blood glucose control increase in well-being and treatment satis- RESEARCH DESIGN AND has led to the compilation of guidelines on faction after commencement of insulin ther- METHODS optimal management of the condition (2). apy has previously been quantified (7), but However, practical information on the there is little evidence concerning the com- Patients impact of any one insulin regimen on parative extent of such effects as they relate Study subjects were recruited from those patients is scarce. Both patients and doctors to different insulin regimens. Similarly, the patients who were thought by their dia- betes physician to require a change to insulin therapy. The specific inclusion cri- From the Diabetes Center (R.T., L.W.), Newcastle upon Tyne; Crewe General Hospital (R.D.), Crewe; Ͼ Northampton General Hospital (C.F.), Northampton; Norfolk and Norwich Hospital (M.S.), Norwich; and teria were as follows: type 2 diabetes of 2 Queen Elizabeth Hospital (J.U.W.), Gateshead, U.K. years’ duration, maximum dosage of oral Address correspondence and reprint requests to Roy Taylor, MD, Department of Medicine, The Medical agent for at least 2 months, and fasting School, Framlington Place, Newcastle upon Tyne, U.K., NE2 4HH. E-mail: [email protected]. blood glucose Ͼ8.5 mmol/l despite opti- Received for publication 11 April 2000 and accepted in revised form 20 July 2000. mum diet and oral agents. All patients were Abbreviations: DCCT, Diabetes Control and Complications Trial; UKPDS, U.K. Prospective Diabetes Study. Ͻ A table elsewhere in this issue shows conventional and Système International (SI) units and conversion 30–80 years of age and had a BMI 35 factors for many substances. kg/m2. Clinical characteristics are listed in 1612 DIABETES CARE, VOLUME 23, NUMBER 11, NOVEMBER 2000 Taylor and Associates Table 1—Patient characteristics at study entry P.M. blood glucose was Ͻ8 mmol/l, with the rate of increase at the clinical discretion of the diabetes specialist nurse. From 4 Ultralente insulin first NPH insulin first weeks onward, the target blood glucose Personal characteristics range was 4–7 mmol/l. To minimize risk of Age (years) 59.6 ± 9.9 59.4 ± 9.0 hypoglycemia, the total daily dose at the Sex (M/F) 18/16 22/16 time of crossover was decreased by 20% Weight (kg) 81.9 ± 14.6 80.7 ± 14.2 when changing from ultralente to NPH Height (cm) 168.3 ± 8.7 169.0 ± 9.7 insulin and was left constant when chang- Systolic blood pressure (mmHg) 144 ± 20 145 ± 20 ing from NPH to ultralente insulin because Diastolic blood pressure (mmHg) 85 ± 11 84 ± 12 of relative bioavailability (11). Duration of diabetes (years) 8.1 ± 3.9 10.3 ± 4.7 Hypoglycemic episodes were recorded Family history by patients in their monitoring diary using None 10 14 the Diabetes Control and Complications Mother 11 9 Trial (DCCT) classification system (12). Father 4 3 The definitions of each grade were printed Maternal second degree 16 13 in the diaries. These data were recorded by Paternal second degree 6 6 the specialist nurse at each visit (4, 13, 22, Comorbidity and 26 weeks into each treatment period). Ischemic heart disease 3 3 Additionally, on each occasion, the patient’s Atrial fibrillation 2 3 spouse or partner was questioned in person Stroke/transient ischemic attack 2 2 or by telephone using four defined ques- Peripheral vascular disease 4 2 tions to establish whether hypoglycemia Hypertension 9 16 unreported by the patient had occurred. Osteoarthritis 9 12 Blood glucose control was monitored using Asthma/chronic bronchitis 3 2 Companion 2 blood glucose meters Data are means ± SD or n. (Abbott Laboratories), and this informa- tion was downloaded at each visit using Sensorlink (Abbott Laboratories). Tests Table 1. In the group randomized to receive center. They saw the patients at frequent were carried out before meals and before an ultralente insulin first, 22 patients were intervals and advised on adjustment of evening snack (i.e., four per day) on 2 days treated with metformin plus sulfonylurea insulin dosage according to a predetermined per week. In addition, seven-point profiles (11 with gliclazide, 5 with glibenclamide, 4 protocol. They also administered the psy- (at 4:00 A.M., 8:00 A.M., 10:00 A.M., noon, with tolbutamide, and 2 with glipizide). chometric tests under standard conditions. 2:00 P.M., 6:00 P.M., and 10:00 P.M.) were Another 12 were treated with sulfonylurea Meetings of the specialist nurses were held at performed once weekly during the final 4 alone and 1 with metformin alone. In the intervals to ensure as similar an approach as weeks of each treatment period. HbA1c was group randomized to receive NPH insulin possible in each center. measured at each visit to assess overall first, 26 patients were treated with met- After recruitment, all patients were blood glucose control. formin plus sulfonylurea (13 with gli- assessed by a dietitian to optimize dietary At recruitment and at the end of each clazide, 2 with glibenclamide, 3 with therapy. This was followed by a 2-month treatment period, the Diabetes Treatment tolbutamide, and 2 with glipizide). Another run-in phase to ensure that blood glucose Satisfaction Questionnaire (13) and the Dia- 11 were treated with sulfonylurea alone control was not improved by the study betes Quality of Life Questionnaire (14) and 1 with metformin alone. Exclusion cri- itself. Thereafter, subjects were random- were administered under standard condi- teria were insulin treatment in the preced- ized to one of two groups, provided that tions by the specialist nurse. All analyses ing 6 months, history of noncompliance fasting blood glucose remained Ͼ8.5 were performed in a central laboratory with therapy, serum creatinine Ͼ150 mmol/l. One group received twice-daily (Clinical Biochemistry Laboratory, Royal Vic- µmol/l, or significant cardiac or hepatic NPH insulin (Insulatard; Novo Nordisk, toria Infirmary, Newcastle upon Tyne, U.K.).
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