Physician’s Weekly: online CME courses, articles on hypertension, arthritis

When patients with type 2 diabetes are started on insulin, they will often experience some weight gain as a result of initiating the therapy. While some patients may only gain a few pounds or make the necessary lifestyle modifications (eg, diet and exercise) to avoid weight gain, others may be affected more severely. Considering this point—in conjunction with the fact that most patients with diabetes are overweight or obese to begin with—weight gain associated with the initiation of insulin may act as a barrier to using the therapy or hinder compliance with it. As a result, patients may continue to experience suboptimal glycemic control, potentially increasing their risk for diabetes-related complications. Additionally, increasing weight gain may exacerbate insulin resistance, hypertension, and dyslipidemia, all of which can further increase cardiovascular disease risk.

Weight gain after insulin initiation is often a psychological concern for patients who are overweight or obese and for those who have been repeatedly instructed on the importance of weight loss. Therapies that lower glycemia but increase weight may confer a contradictory message. Along with weight gain, patients initiating insulin therapy may be concerned about hypoglycemia, insulin injections, and/or the intrusion of lifestyle changes resulting from more complex treatment regimens.

Important New Data

The PREDICTIVE (Predictable Results and Experience in Diabetes through Intensification and Control to Target: an International Variability Evaluation) study, a prospective, open-label investigation involving more than 30,000 patients with diabetes evaluated the safety and efficacy of insulin detemir when used in routine clinical practice. A post hoc sub-analysis published in the April 2008 International Journal of Clinical Practice evaluated insulin-naïve patients on oral anti-diabetic drugs who were initiated on insulin detemir as basal therapy.

According to the findings in insulin-naïve subjects from this largely observational study, treatment with the insulin detemir significantly reduced mean A1C levels by an average of 1.3%, fasting glucose levels by 3.7 mmol/l (63 mg/dl), and within-patient fasting glucose variability by 0.5 mmol/l (9 mg/dl). In 82% of the study group, these improvements in glycemic control were achieved with once-daily administration of insulin detemir. On average, patients starting insulin detemir experienced a 0.7 kg weight loss. Interestingly, patients with a higher baseline BMI lost more weight than those with a lower BMI. The outcomes of this study reflected the findings, which supported the effectiveness, low hypoglycemia risk, and relative weight benefit of insulin detemir seen in previous clinical data from randomized controlled trials.

Considerations When Initiating Insulin

Clinicians are certainly aware of the potential for weight gain as glycemic control improves following insulin initiation. Attention to lifestyle interventions, such as reducing caloric intake and increasing physical activity, may mitigate much of this potential weight gain when properly implemented. The type of insulin being initiated can have an impact on weight gain. For example, basal insulin preparations are clearly associated with less weight gain or hypoglycemia risk than regimens that incorporate rapid-acting prandial insulin coverage. Additionally, data from randomized controlled trials, supported by findings in more “real-world” scenarios, clearly indicate a relative weight advantage of insulin detemir when compared with other available basal insulin preparations. Although this difference in weight gain may be modest, it has been consistently observed. For patients, this may represent an additional incentive to initiate effective insulin therapy.

Luigi F. Meneghini, MD, MBA, has indicated to Physician’s Weekly that he has received research support from Novo Nordisk, Sanofi-Aventis, and Merck, and has been on the speaker’s bureau for Novo Nordisk, Eli Lilly, Sanofi-Aventis, Amylin, and Medtronic. He has also been on the advisory panel for NIPRO systems, and has been a consultant for Novo Nordisk, Sanofi-Aventis, and Medtronic.