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Adding Insulin Glargine in Type 2 Diabetes

A single daily injection of insulin glargine, added to oral antidiabetic therapy, improves glycemic control substantially.

Adding basal insulin to oral agents improves glycemic control in type 2 diabetes. In this industry-sponsored study, researchers compared several ways to initiate basal insulin therapy.

Nearly 8000 patients with inadequately controlled type 2 diabetes were recruited at about 2000 U.S. practices (mostly primary care). Patients continued oral agents (except for thiazoladinediones), commenced taking single evening doses of insulin glargine (Lantus), and were randomized to one of four groups:

• Usual insulin titration plus standard glycosylated hemoglobin (HbA_1c) testing
  
• Usual insulin titration plus point-of-care HbA_1c testing
  
• Active insulin titration plus standard HbA_1c testing
  
• Active insulin titration plus point-of-care HbA_1c testing
  

All patients were instructed in algorithmic titration of insulin doses and attended office visits every 6 weeks, but those in the active-titration groups also had weekly contact with clinicians (by phone, email, or fax). Results of standard HbA_1c testing were available to clinicians several days after office visits, whereas point-of-care test results were available immediately during visits.

At baseline, mean HbA_1c level was 8.9%. After 24 weeks, mean HbA_1c levels decreased by 1.5% in the active-titration groups and by 1.3% in the usual-titration groups — a significant difference. The proportion of patients with final HbA_1c levels <7% was significantly higher in the active-titration groups than in the usual-titration groups (38% vs. 30%). However, mean HbA_1c levels were similar for the point-of-care-testing and the standard-testing groups. Only 72% of patients completed the trial.

Comment: The main finding of this trial is that a single daily injection of insulin glargine, added to oral antidiabetic therapy, improves glycemic control substantially. Weekly contact with patients resulted in somewhat better outcomes, but point-of-care HbA_1c measurements made little difference in this study.

— Allan S. Brett, MD

Published in Journal Watch General Medicine January 20, 2006

Citation(s):

Kennedy L et al. Impact of active versus usual algorithmic titration of basal insulin and point-of-care versus laboratory measurement of HbA_1c on glycemic control in patients with type 2 diabetes: The Glycemic Optimization with Algorithms and Labs at point of care (GOAL A1C) trial. Diabetes Care 2006 Jan; 29:1-8.

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• Medline abstract (Free)