Time to insulin treatment and factors associated with insulin prescription in Swedish patients with type 2 diabetes

doi:10.1016/j.diabet.2009.11.006

Diabetes & Metabolism

Volume 36, Issue 3, June 2010, Pages 198-203

https://doi.org/10.1016/j.diabet.2009.11.006 Get rights and content

Abstract

Aims

The purpose of this study was to investigate the time between the start of OAD treatment and the initiation of insulin therapy and to identify the factors associated with insulin prescription among Swedish patients with type 2 diabetes in Uppsala County.

Methods

Retrospective, population-based, primary-care data gathered within the Swedish RECAP-DM study were used to identify type 2 diabetic patients who initiated OAD treatment. A Kaplan-Meier survival estimate for time to initiation of insulin therapy was generated and factors associated with insulin prescription were tested using a Cox proportional-hazards model.

Results

Within 6 years of starting OAD treatment, an estimated 25% of Swedish patients with type 2 diabetes will be prescribed insulin (95% CI: 0.23–0.26) and, within 10 years, this figure will rise to 42% (95% CI: 0.39–0.45). The probability of insulin prescription was increased in patients aged less than 65 years (HR = 1.24, 95% CI: 1.03–1.50) and in those who initiated OAD treatment with more than one agent (HR = 2.71, 95% CI: 2.15–3.43). HbA_1c at the time of starting OAD treatment was also related to the probability of insulin prescription (HR = 1.20, 95% CI: 1.146–1.25).

Conclusion

Many type 2 diabetic patients who begin treatment with an OAD will eventually be prescribed insulin. Age, disease severity and the type of prior treatment may affect the rate of the transition.

Résumé

Objectif

Estimer le temps passé entre l’initiation d’un traitement par antidiabétique oral et l’initiation d’un traitement par insuline et identifier les facteurs associés à la prescription d’insuline chez les patients diabétiques de type 2 (DT2) en Suède.

Méthodologie

La base de données rétrospectives de soins ambulatoires de l’étude suédoise RECAP-DM a servi à identifier les patients atteints de DT2 qui avaient commencé un traitement par antidiabétique oral. Le délai d’initiation d’un traitement par insuline a été estimé selon la méthode de Kaplan-Meier. Un modèle de risque proportionnel de Cox a été utilisé pour évaluer les facteurs associés à la prescription d’une insuline.

Résultats

Dans les six ans qui suivent l’initiation d’un traitement par antidiabétique oral chez les patients DT2, 25 % ont reçu une prescription d’insuline (IC à 95 % : 0,23–0,26), et 42 % au cours des 10 ans après initiation du traitement oral (IC à 95 % : 0,39–0,45). La probabilité d’initier un traitement par insuline est plus élevée chez les patients de moins de 65 ans (RR = 1,24, IC à 95 % : 1,03–1,50) et chez les patients dont le traitement du diabète a comporté au début plus d’un antidiabétique oral (RR = 2,71, IC à 95 % : 2,15–3,43). Le taux d’ HbA_1c au moment de l’initiation d’un traitement par antidiabétique oral était également associé à l’initiation d’un traitement par insuline (RR = 1,20, IC à 95 % : 1,146–1,25).

Conclusion

De nombreux patients DT2 qui démarrent un traitement par antidiabétique oral recevront une prescription d’insuline. L’âge, la sévérité du diabète et le type de traitement antérieur sont des facteurs associés à la probabilité d’initiation d’une insuline.

Introduction

Diabetes and its associated complications impose substantial health and economic burdens on individual patients and their communities [1], [2]. Comprising approximately 90% of such cases worldwide [3], type 2 diabetes is responsible for the largest proportion of this burden.

Treatment of type 2 diabetes is primarily aimed at glycaemic control and international guidelines recommend reducing HbA_1c to 6.5–7% [4], [5]. It is generally recognized that maintaining HbA_1c at target levels can substantially reduce the risk of developing diabetes-related complications such as retinopathy, nephropathy and neuropathy [6], [7], [8], [9]. Type 2 diabetes management should begin with lifestyle modifications and OADs such as metformin but, as the disease progresses and β-cell function deteriorates, insulin may be necessary for adequate glycaemic control [4].

Guidelines suggest that type 2 diabetic patients who are unable to achieve glycaemic targets with maximum doses of OADs are candidates for insulin therapy [4], [5], [10]. However, little is known of the progression of therapy in clinical practice. Identifying real-life patterns associated with insulin treatment—as opposed to protocol-defined algorithms or assuming that published guidelines represent everyday practices—forms a basis for understanding patient outcomes and identifying means of improving them. Furthermore, a profile of local treatment patterns provides a foundation for accurate health–economic modelling and for assessing the influence of new treatments.

Data collected within the Swedish RECAP-DM study provide information on diagnoses, prescriptions and resource use in a population-based setting [11], [12]. Using such patient-based longitudinal data, the objectives of the present study were to examine the time to initiation of insulin treatment and to identify factors associated with insulin prescription among Swedish type 2 diabetic patients who had started OAD treatment.

Section snippets

Patients

The data collection methods and inclusion criteria for the Swedish RECAP-DM study have been described in detail elsewhere [11], [12]. Briefly, 26 public primary-care centres in Uppsala County participated in this retrospective, population-based, cohort study. Each centre granted access to its computerized medical records, kept from 1993 to 2005. These de-identified records provided a complete account of drug prescriptions, laboratory measurements, diagnoses and biometrics recorded at the

Study sample

Of the 11,856 type 2 diabetic patients included in the Swedish RECAP-DM study, 5403 were identified as initiating OAD treatment during the study period and were thus included in the present analysis. The mean ± S.D. age of those starting OAD treatment was 66 ± 13 years and 45% were women, which is in line with findings from the Swedish National Diabetes Registry [16]. Mean HbA_1c at the time of starting OAD treatment was 8.33 ± 1.69% (n = 4126 with HbA_1c values) and mean BMI was 30.0 ± 5.4 kg/m² (n = 3250

Discussion

In the present study of patients with type 2 diabetes in Uppsala County, we found that an estimated 25% of patients starting OAD treatment will be prescribed insulin within 6 years. The strength of our study lies in the use of population-based data derived from day-to-day clinical practice. These real-life data reflect actual treatment patterns and allow for observation of patients over time.

ADA/EASD guidelines for the initiation and adjustment of treatment in type 2 diabetes recommend starting

Conflict of interest

A.R. and P.L. have served as consultants to and received research grants from, Merck & Co., Inc and D.D.Y. is a full-time employee of Merck & Co., Inc. M.M. and J.S. have no conflicts of interest to declare.

Acknowledgements

The present study was funded by a grant from Merck & Co., Inc., NJ, USA. Medical writing assistance was provided by Elizabeth J. Davis, PhD, i3 Innovus, Eden Prairie, MN, USA. Preliminary data from the study were presented at the American Diabetes Association 67th Science Sessions, held June 22–26, 2007 in Chicago, IL, USA.

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Insulin-naive T2D patients (116 men, 84 women) on ≥ 2 oral hypoglycemic agents with inadequate glycemic control were randomized either to group 1 (insulin Glargine plus Glulisine, n = 101) or group 2 (Premixed Insulin analogue, n = 99).
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Original articleTime to insulin treatment and factors associated with insulin prescription in Swedish patients with type 2 diabetesDélai d’initiation de l’insuline et facteurs associés à sa prescription chez les patients diabétiques de type 2 en Suède

Abstract

Aims

Methods

Results

Conclusion

Résumé

Objectif

Méthodologie

Résultats

Conclusion

Introduction

Section snippets

Patients

Study sample

Discussion

Conflict of interest

Acknowledgements

Diabetes Metab

Lancet

Revealing the cost of type II diabetes in Europe

Diabetologia

Medical management of hyperglycaemia in type 2 diabetes mellitus: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes

Diabetologia

A real-world approach to insulin therapy in primary care practice

Clin Diabetes

Original article
Time to insulin treatment and factors associated with insulin prescription in Swedish patients with type 2 diabetesDélai d’initiation de l’insuline et facteurs associés à sa prescription chez les patients diabétiques de type 2 en Suède