Lessons in initiating insulin in clinical practice.

Insulin therapy in type 2 diabetes (T2DM) can produce greater improvements in fasting plasma glucose (FPG) and glycated haemoglobin (HbA1c) than oral antidiabetic drugs (OADs). There is a growing trend to recommend initiation of insulin in T2DM patients sooner in the course of the disease, and good results have been achieved in insulin-naïve patients during randomised, controlled trials, often using aggressive dose titration algorithms. The Physicians' Routine Evaluation of Safety & Efficacy NovoMix((R)) 30 Therapy (PRESENT) study was a 6-month observational study of the safety and efficacy of biphasic insulin aspart 30 (BIAsp 30) as monotherapy or in combination with OADs in inadequately controlled patients with T2DM. This review article compares results from those patients who entered the study insulin-naïve (either with or without previous OAD treatment), with results from randomised, controlled trials of BIAsp 30 in insulin-naïve T2DM patients. It aims to provide guidance on the initiation of insulin in patients with T2DM, focusing on the efficacy of BIAsp 30 when used for this purpose, and highlighting both the low risk of hypoglycaemia associated with therapy, and the availability of delivery devices that can minimise injection site discomfort and help to overcome psychological insulin resistance.

Glycaemic control and hypoglycaemia in the PRESENT study.

The PRESENT study was a 6-month multinational observational study in patients with type 2 diabetes receiving biphasic insulin aspart 30 (BIAsp 30). Data from PRESENT were analysed according to predefined subgroups stratified by age, body mass index (BMI) and ethnic origin. Achieved HbA1c levels were similar in each of: four age subgroups (<40 years 7.82%, 40-50 years 7.70%, 50-60 years 7.75%, >or=65 years 7.75%); five BMI subgroups (<25 kg/m(2): 7.78%, 25-30 kg/m(2): 7.58%, 30-35 kg/m(2): 7.57%, 35-40 kg/m(2): 7.74%, >or=40 kg/m(2): 7.93%); and Asian/Pacific Islander, Middle Eastern/Asian, White ethnic-origin subgroups (7.78%, 7.40%, 7.59%, respectively). The Black ethnic-origin subgroup had a higher baseline HbA1c of 11.61% (other groups 9.29-9.63%) and achieved a final HbA1c of 8.59%. Major hypoglycaemia was reported by fewer than 1% of subjects in any subgroup at end of study; overall end of study hypoglycaemia rates were less than four events/subject year (all subgroups). In conclusion, data from subgroups in the PRESENT study indicate that BIAsp 30 can be initiated and titrated effectively to help patients of all ages, of all degrees of obesity, and from a variety of ethnic origins, to achieve clinically relevant improvements in glycaemic control with low rates of hypoglycaemia.

A survey study on diabetes management and complication status in primary care setting in Thailand.

OBJECTIVE: Healthcare service in Thailand is stratified into three levels with different facilities of care. This cross-sectional survey study described diabetes management, diabetes control, and late complication status among patients managed in urban primary health care clinics. MATERIAL AND METHOD: Thirty-seven primary health care units were randomly selected. Each unit enrolled up to 30 patients having been managed in the unit for at least one year. The patients were interviewed, and the medical records such as demographic data, management practice, glycemic control, and complications were retrospectively reviewed for a period of one year. All data were entered in the case record forms, transferred into a database by electronic scanning, and analyzed by SAS version 6.12. One thousand and seventy-eight patients, including 300 males and 778 females, were recruited in the present study. RESULT: Their mean +/- SD of age, onset age, and diabetes duration were 58.2 +/- 11.3, 52.2 +/- 11.4 and 6.2 +/- 4.0 years, respectively. Six percent of the patients were type 1, and 94% were type 2 diabetes. Two-thirds of the patients engaged in diabetes education > or = 5 days during the previous year. Monitoring of glycemic control was largely by measurement of fasting plasma glucose (FPG) in the unit. Determination of hemoglobin A1c (HbA1c), total cholesterol, triglyceride, HDL-cholesterol, serum creatinine, urinary protein, and microalbuminuria were observed in 0.7, 17.4, 11.7, 6.9, 38.2, 33.0, and 0.9% of the patients, respectively. Mean +/- SD of FPG was 8.3 +/- 2.7 mmol/l, and HbA1c was 8.6 +/- 1.9%. The percentage of patients with FPG < 6.7 mmol/l and HbA1c < 7% were 28.7 and 19.6%, respectively. An annual eye and foot examination was performed in 21.5% and 45% of the patients, respectively. The prevalence of late complications included retinopathy (13.6%), proteinuria (17.0%), end stage renal failure (0.1%), peripheral neuropathy (34%), acute foot ulcer/gangrene (1.2%), healed foot ulcer (6.9%), stroke (1.9%), and myocardial infarction (0.7%). CONCLUSION: The present study results demonstrated that necessary, routine assessments were not regularly practiced by caregivers in primary care units. In addition, peripheral neuropathy was the most common observed complication and this might explain the high rate of foot ulcers in this cohort.