Journal of General Internal Medicine

, Volume 29, Issue 2, pp 320–327 | Cite as

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

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



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.


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


Observational study.


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


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.


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.


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.


Metformin Sulfonylurea Insulin Glargine Exenatide Basal Insulin 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



This work was funded by a grant to Brigham and Women’s Hospital from Eli Lilly for the MOSAIc study, F3Z-MC-B010. The authors retained independent and complete control over the design and implementation of the study, as well as the analyses and writing of the manuscript, the manuscripts contents, and the decision to publish. Eli Lilly reviewed the manuscript, but the final decision to publish and decision as to what was published were retained by the study authors. ARP takes full responsibility for the work as a whole, including study design, access to data, and the decision to submit and publish the paper. ARP and JMP designed the study, analyzed the data, and drafted the paper. JL analyzed the data and reviewed the paper. MAF, NKC, WHS, JDS, and JA provided clinical and epidemiologic input to the study design and reviewed/edited the paper.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Supplementary material

11606_2013_2643_MOESM1_ESM.docx (20 kb)
ESM 1 (DOCX 19 kb)


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Copyright information

© Society of General Internal Medicine 2013

Authors and Affiliations

  • Amanda R. Patrick
    • 1
    Email author
  • 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

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