FRINK Linked Data Fragments server

Matches in SemOpenAlex for { <https://semopenalex.org/work/W2094552008> ?p ?o ?g. }

• W2094552008 endingPage "46" @default.
• W2094552008 startingPage "45" @default.
• W2094552008 abstract "Home, PD, Boulton, AJM, Jimenez, J, et al. Issues relating to the early or earlier use of insulin in type 2 diabetes. Pages 63– 70 Gerald F Watts Consultant Physician*, * Diabetic and Lipid Disorders Clinic, Royal Perth Hospital, University of Western Australia, Perth WA6847 Experimental studies clearly show that insulin therapy improves glycaemic control in type 2 diabetes. That this benefits microvascular complications has been well demonstrated by UKPDS,1 and by extrapolation from specific data with insulin in DCCT.2 Given the continuous and direct relationship between macrovascular complications and glycated haemoglobin in observational studies,3, 4 insulin therapy may also decrease cardiovascular events in type 2 diabetes, although this needs to be formally demonstrated in clinical trials. In this issue of Practical Diabetes International, Home et al. provide a generally well argued proposal for the early or earlier use of insulin therapy in patients with type 2 diabetes. This notion is particularly important given that in many patients with type 2 diabetes, optimal glycaemic control is not frequently achievable with diet and use of antidiabetic and insulin-sensitising agents.5 A particularly attractive argument is that earlier insulin therapy may collectively optimise control of hypertension, dyslipidaemia and dysglycaemia, which could offset use of multiple oral medications, emphasising a great opportunity for cost savings. The review clarifies the potential benefits of insulin in decreasing the complications of type 2 diabetes, but also underscores drawbacks, such as hypoglycaemia, weight gain and patient acceptability and compliance. Weighing critically through the evidence and citing a number of important articles, the authors conclude that there is a good case for early or earlier use of insulin in type 2 diabetes. Before universally accepting this approach in routine clinical management, certain questions need to be answered. First, what is the evidence that insulin improves glycaemic control in type 2 diabetes? Second, is there a target HbA1c that should be achieved to prevent complications? Third, is excellent glycaemic control achievable in clinical practice with insulin? Fourth, will the approach be cost-effective in clinical practice? The answers to the first two questions are provided by extensive research,1-4 as well by treatment guidelines for type 2 diabetes.6 General support should be given to the recommendation from Home et al. that one should be aiming for HbA1c <6.5% in patients with type 2 diabetes and especially those with multiple risk factors and established complications. The answers to the third and fourth questions are less clear and this is where, in my view, additional research is required. Of relevance here is the study by Hayward et al. carried out in primary care (the ‘real world situation’), in which among 8668 type 2 diabetic patients use of insulin was shown to safely decrease HbA1c by approximately 1% over three years.7 While this improvement in HbA1c is in general clinically significant, it is noteworthy that this result was a consequence of patients with poor control reverting to moderate glycaemic control. Tight glycaemic control was rarely achieved with insulin, there being no significant reductions in HbA1c to the optimal levels required in treatment recommendations for effectively reversing and preventing complications. Moreover, the improvement in glycaemic control was achieved at a greater cost and frequency of clinic visits, a greater number of laboratory tests and more intensive home glucose monitoring by patients. A rigorous cost-effectiveness analysis was not presented. The Hayward et al. study did not also employ novel regimens of insulin administration, nor did patient care involve diabetes educators and specialist physicians. This implies that the full potential of the cost-effectiveness of insulin therapy within the setting of optimal and contemporary diabetes care was not assessed. Here lies and opportunity for further research that should strengthen the recommendations of Home et al. Application of intensive outpatient education programmes for type 1 diabetes for achieving self-care may be relevant,8 but whether these are cost-effective in type 2 diabetes will need to be demonstrated. Such cost-utility or cost-effective studies of education programmes are essential for eliciting funding from health care sources. To emphasise some implicit observations made by Home et al. one could identify three sub-groups of type 2 diabetic patients who would benefit from earlier insulin therapy. The first is those with multiple cardiovascular risk factors in whom glycaemic control may be difficult to optimise by conventional means. The second group are patients with low plasma C-peptide levels, and hence low endogenous insulin secretion, who are more likely to progress to beta-cell failure and sustain a steady rise in glycated haemoglobin over time. The third is an important group of patients who have sustained an acute myocardial infarction and for whom there is evidence that early and prolonged insulin therapy can improve outcome and decrease mortality.10 Other groups of patients were well specified in the Home et al. review, including those with acute illnesses and with gestational diabetes. The issue of patient acceptability will continue to be a barrier to the more extended and earlier use of insulin in type 2 diabetes. The introduction of novel methods of insulin delivery systems, in particular those that do not involve a needle, may overcome this important barrier.10 A recent evaluation of the J-Tip® needle-free delivery system, also published in this issue,11 showed it to be effective and a potential alternative method for administering subcutaneous insulin. In this particular study, however, type 1 diabetic patients tended to prefer the flexibility of insulin pens and were troubled by the noise associated with using the J-Tip® device. J-Tip® may nevertheless be suitable for once or twice daily insulin in patients with needle anxiety. The success of earlier insulin use in type 2 diabetes will evidently depend on further research to improve the methods of administering insulin.10 As Home et al. emphasise, the use of insulin therapy in type 2 diabetes is a great opportunity for potentially improving quality of life and preventing complications in diabetic patients. However, more research is required to evaluate its cost-effectiveness in different clinical settings. More specifically, further research should address the efficacy and cost-effectiveness of different strategies for employing insulin either alone or in combination with oral agents, and the development and testing of insulin delivery that will be affordable and acceptable to patients." @default.
• W2094552008 created "2016-06-24" @default.
• W2094552008 creator A5079564889 @default.
• W2094552008 date "2003-01-01" @default.
• W2094552008 modified "2023-09-25" @default.
• W2094552008 title "Earlier insulin therapy for type 2 diabetes: striving for cost-effectiveness" @default.
• W2094552008 cites W1968069670 @default.
• W2094552008 cites W2000322258 @default.
• W2094552008 cites W2016431637 @default.
• W2094552008 cites W2027702390 @default.
• W2094552008 cites W2031911010 @default.
• W2094552008 cites W2041144248 @default.
• W2094552008 cites W2053365438 @default.
• W2094552008 cites W2095070268 @default.
• W2094552008 cites W2337454357 @default.
• W2094552008 cites W2769264260 @default.
• W2094552008 doi "https://doi.org/10.1002/pdi.465" @default.
• W2094552008 hasPublicationYear "2003" @default.
• W2094552008 type Work @default.
• W2094552008 sameAs 2094552008 @default.
• W2094552008 citedByCount "1" @default.
• W2094552008 crossrefType "journal-article" @default.
• W2094552008 hasAuthorship W2094552008A5079564889 @default.
• W2094552008 hasBestOaLocation W20945520081 @default.
• W2094552008 hasConcept C126322002 @default.
• W2094552008 hasConcept C134018914 @default.
• W2094552008 hasConcept C177713679 @default.
• W2094552008 hasConcept C2777180221 @default.
• W2094552008 hasConcept C2779306644 @default.
• W2094552008 hasConcept C555293320 @default.
• W2094552008 hasConcept C71924100 @default.
• W2094552008 hasConceptScore W2094552008C126322002 @default.
• W2094552008 hasConceptScore W2094552008C134018914 @default.
• W2094552008 hasConceptScore W2094552008C177713679 @default.
• W2094552008 hasConceptScore W2094552008C2777180221 @default.
• W2094552008 hasConceptScore W2094552008C2779306644 @default.
• W2094552008 hasConceptScore W2094552008C555293320 @default.
• W2094552008 hasConceptScore W2094552008C71924100 @default.
• W2094552008 hasIssue "2" @default.
• W2094552008 hasLocation W20945520081 @default.
• W2094552008 hasOpenAccess W2094552008 @default.
• W2094552008 hasPrimaryLocation W20945520081 @default.
• W2094552008 hasRelatedWork W1563850031 @default.
• W2094552008 hasRelatedWork W2032287785 @default.
• W2094552008 hasRelatedWork W2094113608 @default.
• W2094552008 hasRelatedWork W2167444163 @default.
• W2094552008 hasRelatedWork W2233866314 @default.
• W2094552008 hasRelatedWork W2383009242 @default.
• W2094552008 hasRelatedWork W2415759662 @default.
• W2094552008 hasRelatedWork W3036934084 @default.
• W2094552008 hasRelatedWork W3153783058 @default.
• W2094552008 hasRelatedWork W88627568 @default.
• W2094552008 hasVolume "20" @default.
• W2094552008 isParatext "false" @default.
• W2094552008 isRetracted "false" @default.
• W2094552008 magId "2094552008" @default.
• W2094552008 workType "article" @default.