Three major problems that need to be faced squarely in insulin treatment of type 2 diabetes!

*It is only for medical professionals to read and refer to the clinical status of insulin therapy.
In the blood glucose control program for patients with type 2 diabetes (T2DM), insulin is widely used as a powerful hypoglycemic drug.
Recently, at the Peking University Diabetes Forum, Professor Ji Linong from Peking University People’s Hospital has comprehensively analyzed T2DM patients in combination with multiple clinical studies.
Current status of insulin therapy and unmet clinical needs.

This article extracts the highlights of the meeting to share with you.

 Professor Ji Linong recounted the changes that have taken place in the clinical practice of insulin therapy since he became a doctor.

The guidelines for late initiation of insulin therapy recommend that T2DM patients use 2 or more hypoglycemic agents, if the blood sugar still does not reach the control target [glycated hemoglobin (HbA1c) ≥ 7.
0%], insulin therapy can be initiated.

However, studies in various countries have shown that there is clinical inertness in insulin therapy, and many countries and regions have not initiated basal insulin therapy in time.

The ORBIT study, a large-scale real-world study of basal insulin in China, shows that the clinical use of basal insulin in my country is late, and 55% of patients with HbA1c >9% start insulin therapy; more than 1/3 of the patients have been combined when they start insulin therapy.
Complications; and 75% of patients have a low initial basal insulin dose.

 Table 1 The HbA1c level was higher when insulin was initiated for T2DM in my country.
Insulin treatment was not adjusted in time.
After the initiation of insulin treatment, how about the blood sugar control of T2DM patients? Professor Ji first reviewed multiple randomized controlled clinical trials (RCTs).

The results of the DEVOTE study showed that under the conditions of rigorous clinical trials, basic insulin therapy can control HbA1c in T2DM patients at 7.
5%, but there is still a certain distance from the 7% target.

The results of the 4T study showed that although continuous changes in insulin treatment strategies can better control the patient's blood sugar, it is necessary to increase the basal insulin dose or increase the insulin during meals, which is accompanied by weight gain and an increased risk of hypoglycemia.

 Studies in the real world have shown that although patients have started insulin therapy, their blood glucose control is not satisfactory, and the glucose control effect in RCT has not been observed.

The ORBIT study showed that only 40% of patients reached the HbA1c control goal after starting insulin therapy; among patients with substandard blood glucose control, more than 1/3 of the patients did not undergo insulin adjustment within 3 months.

Both the ORBIT study and the FINE study showed that the dose adjustment of basal insulin after the initial treatment was insufficient.

Professor Ji concluded that the lack of timely adjustment and increase of insulin dose is the main reason for the failure of blood glucose control in the initial insulin therapy.

 From the patient's perspective, compliance is also an important factor affecting blood glucose standards.

The ORBIT study shows that the frequency of blood glucose monitoring in patients is very low, and it does not meet the standard at all.

Many patients do not adjust the dose according to the results of blood glucose monitoring; and there is a phenomenon of stopping and switching to insulin.

 Figure 1 The frequency of blood glucose monitoring in T2DM patients is low.
Professor Ji emphasized that insulin therapy is a process of comprehensive management.

Multiple factors, doctors and patients, hinder the initial treatment to reach the target.

If hypoglycemia occurs early, the probability of stopping the drug will increase.

How to recognize and avoid hypoglycemia early is a key issue, and how to treat hypoglycemia in an individualized way is of vital importance to the management of patients with T2DM.

 The rate of blood glucose compliance is low, and the effect of intensive treatment is not satisfactory.
Global statistical research shows that after 3 months of insulin treatment, the proportion of patients with HbA1c less than 7% is 1/5; the proportion of patients with HbA1c less than 7% after 24 months of insulin treatment is also only 1/3; The Chinese HbA1c monitoring network shows that the blood glucose compliance rate of patients undergoing insulin therapy is only 1/3.

The general dissatisfaction of blood glucose control among patients undergoing insulin therapy is a global problem.

 For T2DM patients with poor blood sugar control in insulin therapy, intensive treatments such as increasing the dose of insulin and adding insulin during meals are often used.

 The OpT2mise study compared the efficacy and safety of insulin pump therapy and multiple daily insulin injections for 6 months in patients with type 2 diabetes with poor insulin therapy.

The results of the study were negative, there was no significant improvement in blood glucose control with insulin pump treatment, and the risk of hypoglycemia did not decrease.

The COMPASS Ⅱ study showed that after intensive insulin treatment, blood sugar has improved but it is still not ideal.

The improvement of blood glucose in patients with different insulin treatment time is different.
For patients with a long course of disease or longer treatment with insulin, the improvement of blood glucose is not ideal and the risk of hypoglycemia is increased.

 The above studies have shown that after receiving insulin treatment, patients with T2DM still have substandard blood glucose control, and 20% of T2DM patients are at risk of hypoglycemia, which has a serious impact on the quality of life of patients.

 Prospects Insulin preparations are constantly evolving with technological changes.
At the same time, the emergence of more blood glucose monitoring methods has also helped the comprehensive management of T2DM, but overall, the current clinical blood glucose control compliance rate is still unsatisfactory.

Better blood sugar control and higher quality of life are what we are after, and require the joint efforts of medical staff and patients.

 Expert profile Professor Ji Linong • Director of the Endocrinology Department of Peking University People's Hospital • Director of Peking University Diabetes Center • Chairman of the Endocrinology and Metabolic Disease Branch of the Chinese Society for Geriatric Care • Vice President of the Chinese Stroke Society • Vice President of the Endocrinology and Metabolism Physicians Branch of the Chinese Medical Doctor Association • Editor-in-chief of the Chinese Journal of Diabetes • Former Chairman of the Diabetes Branch of the Chinese Medical Association, Vice Chairman of the International Diabetes Federation, Chairman of the International Diabetes Federation Western Pacific Region (IDF-WPR)