Journal of General Internal Medicine

, Volume 29, Issue 2, pp 320–327

Trends in Insulin Initiation and Treatment Intensification Among Patients with Type 2 Diabetes

  • Amanda R. Patrick
  • Michael A. Fischer
  • Niteesh K. Choudhry
  • William H. Shrank
  • John D. Seeger
  • Jun Liu
  • Jerry Avorn
  • Jennifer M. Polinski
Original Research

DOI: 10.1007/s11606-013-2643-6

Cite this article as:
Patrick, A.R., Fischer, M.A., Choudhry, N.K. et al. J GEN INTERN MED (2014) 29: 320. doi:10.1007/s11606-013-2643-6

ABSTRACT

BACKGROUND

Many patients with type 2 diabetes eventually require insulin, yet little is known about the patterns and quality of pharmacologic care received following insulin initiation. Guidelines from the American Diabetes Association and the European Association for the Study of Diabetes recommend that insulin secretagogues such as sulfonylureas be discontinued at the time of insulin initiation to reduce the risk of hypoglycemia, and that treatment be intensified if HbA1c levels remain above-target 3 months after insulin initiation.

OBJECTIVE

To describe pharmacologic treatment patterns over time among adults initiating insulin and/or intensifying insulin treatment.

DESIGN

Observational study.

SUBJECTS

A large commercially insured population of adult patients without recorded type 1 diabetes who initiated insulin.

MAIN MEASURES

We evaluated changes in non-insulin antidiabetic medication use during the 120 days immediately following insulin initiation, rates of increase in insulin dose and/or dosing frequency during the 270 days following an insulin initiation treatment period of 90 days, and rates of insulin discontinuation.

KEY RESULTS

Seven thousand, nine hundred and thirty-two patients initiated insulin during 2003–2008, with the majority (61 %) initiating basal insulin only. Metformin (55 %), sulfonylureas (39 %), and thiazolidinediones (30 %) were commonly used prior to insulin initiation. Metformin was continued by 64 % of patients following mixed or mealtime insulin initiation; the continuation rate was nearly as high for sulfonylureas (58 %). Insulin dose and/or dosing frequency increased among 22.9 % of patients. Insulin was discontinued by 27 % of patients.

CONCLUSIONS

We found evidence of substantial departures from guideline-recommended pharmacotherapy. Insulin secretagogues were frequently co-prescribed with insulin. The majority of patients had no evidence of treatment intensification following insulin initiation, although this finding is difficult to interpret without HbA1c levels. While each patient’s care should be individualized, our data suggest that the quality of care following insulin initiation can be improved.

Supplementary material

11606_2013_2643_MOESM1_ESM.docx (20 kb)
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Copyright information

© Society of General Internal Medicine 2013

Authors and Affiliations

  • Amanda R. Patrick
    • 1
  • Michael A. Fischer
    • 1
  • Niteesh K. Choudhry
    • 1
  • William H. Shrank
    • 1
  • John D. Seeger
    • 1
  • Jun Liu
    • 1
  • Jerry Avorn
    • 1
  • Jennifer M. Polinski
    • 1
  1. 1.Division of Pharmacoepidemiology and PharmacoeconomicsBrigham and Women’s HospitalBostonUSA