Effectiveness of patterns of intensification of premixed insulin analogue therapy
Sanjay Kalra1, Bharti Kalra1, A G Unnikrishnan2 & Navneet Agrawal3
This study was designed as a retrospective multicentric study to assess the efficacy of various methods of effective intensification and optimization of premixed insulin analogue therapy. 200 consecutive OPD charts of patients poorly controlled on premixed insulin twice daily were reviewed for changes advised by the treating physician. Data was assessed for cues, methods and efficacy of intensification of therapy.
A casual blood glucose value >250 mg% was used as the sole reason for intensification in 14% patients, while high fasting glucose (>126 mg%) and high postprandial glucose (>200 mg%) were the cues in 36 and 28% respectively. An HbA1c >8.5% was the motive for intensification in 15.5% and patients symptoms formed the cue in 32.5%.
Of the 200 cases reviewed, 144 demonstrated effective control (as assessed by HbA1c reduction >1%) at 6 weeks, and were compared with the 56 non-responders.
Increasing the dose of premixed analogue was the commonest method of optimization (48%) while increase in frequency of premixed injections (4%) or addition of lunchtime regular insulin (8%) was less frequent. Of 22% were shifted to three dose regime (regular before breakfast and lunch; premixed aspart before dinner), 8% were shifted to 50:50 analogue mixture before breakfast and 25:75 before dinner, and 10% to basal-bolus regime. Oral hypoglycemics were increased in 76% patients (10% prescribed repaglinide/sulfonylurea, 66% metformin, 8% pioglitazone, 16% voglibose/acarbose).
The most effective method of intensification was shifting to three or four dose regime (86.36% response), and adding metformin (45.45%). Increasing the dose of insulin worked only in 33.33% patients, while changing the type of insulin to 50:50 was effective in 50.00%. Adding oral drugs other than metformin helped achieve response only in 23.52%.
This study highlights the effectiveness of various methods available for intensification and optimization of premixed insulin analogue therapy. The most effective methods of intensification are increasing the number of doses of insulin per day, with addition of or substitution by regular aspart or a 50:50 mix, and addition of metformin.