Patient-led titration of basal insulin appears effective in type 2 diabetes
A meta-analysis of six studies found that patient-led titration was associated with lower HbA1c and fasting plasma glucose levels than physician-led titration, although hypoglycemia risk and body weight were slightly higher.
Patient-led titration of basal insulin in type 2 diabetes appeared to be noninferior to physician-led titration in a recent meta-analysis.
Researchers selected randomized controlled trials published through March 2020 that involved patients with type 2 diabetes assigned to patient-led or physician-led titration and had at least 12 weeks of follow-up. Data were extracted on glycemic endpoints (HbA1c level, fasting plasma glucose level, and hypoglycemia) and other outcomes (insulin dose, body weight, patient-reported outcomes, adverse events, rescue medication, and discontinuation) and pooled in a random-effects model.
The primary outcome was the difference in change in HbA1c from baseline to the last available follow-up between patient-led and physician-led basal insulin titration. Secondary outcomes included differences in change in fasting plasma glucose level, daily basal insulin dose, and body weight; the number of patients who had at least one hypoglycemic event, required rescue medication, and discontinued treatment; and patient-reported outcomes and adverse events. The study results were published July 6 by BMJ Open Diabetes Research & Care.
The analysis included six studies involving 12,409 patients, 6,174 allocated to patient-led titration and 6,235 allocated to physician-led. Three of the studies used glargine U-300 as basal insulin, two studies used glargine U-100, and one study used detemir. Weighted mean baseline HbA1c level was 8.7%±1.4%, 51% of patients were men, and mean weighted age was 58.6±10.9 years.
Patient-led titration was associated with a significantly higher basal insulin dose than physician-led titration (5.9 IU/d; 95% CI, 0.2 to 11.8 IU/d). In addition, HbA1c level was −0.12% (95% CI, −0.16% to −0.07%) lower and fasting plasma glucose level was −5 mg/dL (95% CI, −9.3 to −1.2 mg/dL) or 0.3 mmol/L (95% CI, −0.5 to −0.1 mmol/L) lower with patient-led titration, although risk for any level of hypoglycemia was higher (relative risk, 1.12; 95% CI, 1.02 to 1.23) and body weight increased slightly (0.25 kg; 95% CI, 0.06 to 0.44 kg). No differences were seen for the other study outcomes.
Among other limitations, the authors noted that their analysis included a small number of studies with relatively short-term follow-up and that their results should be generalized with caution to clinical practice, where patients usually have less contact with clinicians than in randomized controlled trials. They concluded that patient-led titration of basal insulin did not appear to be inferior to physician-led titration in patients with type 2 diabetes and said that it should be “acknowledged as an adequate strategy to be widely adopted in clinical practice.” The authors also called for additional studies comparing the two strategies to assess potential differences in long-term outcomes.