title: What happens when patients require intensification from basal insulin? A retrospective audit of clinical practice for the treatment of type 2 diabetes from four Australian centres.
abstract: OBJECTIVE
  Little is known about clinical practices beyond the initiation of basal insulin in patients with type 2 diabetes mellitus (T2DM) in Australia. To determine the proportion of patients who progressed from basal insulin to each of three possible therapy groups: Group 1 addition of rapid-acting insulin, Group 2 switch to pre-mixed insulin, Group 3 addition of another therapy (incretin, glitazone, sulphonylurea, metformin, acarbose).
  
  
  METHODS
  Retrospective audit across four Australian hospital clinics. Patients had a diagnosis of T2DM, basal insulin had been initiated and a subsequent treatment intensification/change had occurred during the analysis period (September 2007-March 2012).
  
  
  RESULTS
  Patients were classified into one of three intensification groups for analysis: Group 1, 56.1% (111/198); Group 2, 22.7% (45/198) and Group 3, 21.2% (42/198). Prior to basal insulin initiation, mean T2DM duration was 11 years. Between starting basal insulin and treatment intensification, 42/183 (22.9%) patients achieved the HbA1c target of <7.0% (53 mmol/mol). Initiation of basal insulin provided temporary improvement in glycaemic control followed by subsequent deterioration. With further treatment intensification, only 40/180 (22.2%) patients achieved the HbA1c target of <7.0% (53 mmol/mol). Patients in the insulin groups gained weight (Group 1, rapid acting insulin, 1.9 ± 7.4 kg; Group 2, premixed insulin 2.3 ± 4.8 kg); those in Group 3 lost weight (-0.9 ± 13.54 kg). Hypoglycaemic episodes were uncommon irrespective of group.
  
  
  CONCLUSIONS
  There is continued need for improved patient management; individualised strategies should focus on when to initiate insulin, how to adjust and optimise doses over time and, when required, the introduction of intensification regimens.
authors.affiliation: Department of Diabetes, Endocrinology & Metabolism, Royal North Shore Hospital, Sydney, 2006 NSW, Australia. Electronic address: greg.fulcher@sydney.edu.au.
authors.forename: Gregory
authors.initials: G
authors.lastname: Fulcher
authors.affiliation: South Australian Endocrine Clinical Research, 8A Hampton Rd, Keswick, 5035 SA, Australia. Electronic address: drtony@aproberts.com.au.
authors.forename: Anthony
authors.initials: A
authors.lastname: Roberts
authors.affiliation: Cairns Base Hospital and Diabetes Centre, 381 Sheridan St, Cairns, 4870 QLD, Australia. Electronic address: ashim_sinha@health.qld.gov.au.
authors.forename: Ashim
authors.initials: A
authors.lastname: Sinha
authors.affiliation: Department of Medicine, Austin Health, University of Melbourne, 145 Studley Rd, Heidelberg, 3084 VIC, Australia. Electronic address: j.proietto@unimelb.edu.au.
authors.forename: Joseph
authors.initials: J
authors.lastname: Proietto
mesh_terms: D000368:Aged; D001315:Australia / Q000453:epidemiology; D001786:Blood Glucose / Q000378:metabolism; D054869:Clinical Audit; D003924:Diabetes Mellitus, Type 2 / Q000097:blood / Q000188:drug therapy* / Q000453:epidemiology; D004334:Drug Administration Schedule; D005260:Female; D006442:Glycated Hemoglobin / Q000378:metabolism; D006801:Humans; D007004:Hypoglycemic Agents / Q000008:administration & dosage*; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D012189:Retrospective Studies
chemical_list: D001786:Blood Glucose; D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents
keywords: Drug utilisation; Glycaemic control; Incretin therapy; Insulin therapy; Medicines management