Stepping-down Approach in Patients With Chronic Poorly-controlled Diabetes on Advanced Insulin Therapy?
Status:
Completed
Trial end date:
2018-12-01
Target enrollment:
Participant gender:
Summary
In traditional step-up approach, the patients with poorly-controlled type 2 diabetes are
instructed to take up to 4 insulin injections daily or multiple daily injections (MDI) as the
most advanced therapy. However, a significant number of these patients continue to have poor
diabetes control. The most common reason is the noncompliance with multiple injections and
the patient's reluctance to accept insulin-induced weight gain. More recently, the algorithm
in diabetes management has significantly changed to accommodate the newer generation of
medications. Addition of the diabetes medications, that can induce weight loss such as oral
Sodium-glucose Cotransporter-2 (SGLT2) Inhibitors and once-weekly glucagon-like peptide
(GLP)-1 receptor agonists (GLP1 RA) injection, to a basal insulin is now recommended before
the patient is advanced to MDI. This approach works very well in most patients since weight
loss gives the patients an extra motivation to take medication regularly. Similarly, the
patient does not require to take an insulin injection before each meal throughout the day in
this approach.
Unfortunately, there are still a large number of patients with poor glycemic control who are
still on MDI. Some of them were initiated on MDI before the availability of newer generations
of medications. Some were started simply because the physician was not aware of or not the
familiar with the new recommendations. Regardless of the reason, these patients are likely to
remain on MDI despite chronic poor glycemic control since the physicians are understandably
reluctant to step down the most advanced insulin therapy. In addition, there has been no data
on the benefits and safety of the stepping-down approach from the most advanced insulin
therapy to the more patient-friendly approach that is the combined use of oral SGLT2i and
once-weekly GLP1 RA injection.