| Objectives: Insulin therapy is the key guideline recommended approach to achieve glycemia control target after the oral glucose medications (OHA) failed in patients with type 2 diabetes mellitus. But the rate of patients who reached the target of 7% is still worrying even after the addition of insulin. We had previously tried to explore influencing factors determining insulin dosage in patients who were admitted for poor glycemia control in whom glycemia control failed with OHA and already insulin was used as alternative or supplementation medication for glucose control. We found patients'body weight, duration of diabetes, and the years after use insulin were important factors affected insulin dosage. Even the glycemia control improved significantly, there was no significant different in dosage change before admission and at time of discharge. In order to delineate the exact reason for those interesting results, new factors such as type of insulin, insulin protocol were included in this study.Methods: A total of 214 insulin using patients with type 2 diabetes who failed OHAs and started insulin for at least three months and were admitted in the author's institution for poor glucose control were enlisted for this study during the period of Mar 2009 till Dec 2010. Epidemiologic, biochemical indexes, type of insulin (recombinant human insulin or insulin analogues), type of insulin protocol (basal, premix, or basal bolus), total daily dose (U/Kg) were collected at the time of admission, and mean glucose levels, type of insulin (recombinant human insulin (rhIns) or insulin analogues (aIns)), type of insulin protocol (basal (B), premix (PM), or basal bolus (BB)), total daily dose (U/Kg) were collected the day before discharge. Statistics was processed with SPSS software (Ver 17, Chicago, IN, USA) Results:1. The average age was 62.5±11.1 years, the mean duration of diabetes was 14.0±6.9 years, and mean time of insulin therapy was 4.7±3.2 years. Men accounted 43.9% of the study population Sixty one percent of patients had family diabetes history, 28% of patients had history of alcoholic drinking, 27.6% of people had history of smoking, and 27.6% excised regularly, and 92.9% had chronic diabetic complications.2. After adjusted sex and age, partial correlation analysis showed the discharge insulin dosage was positively associated with duration of diabetes, years of insulin therapy, admission HbA1C, mean admission glucose levels (r=0.172, 0.228, 0.415, 0.294;P<0.05), and similar finding resulted by using multiple linear regression, i.e. discharge insulin dosage was positively correlated with duration of diabetes, admission HBA1C, and mean admission glucose levels (r=0.268, 0.391, 0.182, respectively, and P<0.05).3. Ratios of different types of insulin (rhIns and aIns) used at admission were 49.5% and 50.55%; The ratios changed to 10.7% and 89.3% at discharge, and was significantly different from admission (χ2=26.26,P<0.001). Ten percent with rhIns and 50.5% with aIns maintained the type of insulin, and 38.8% with rhIns switched to aIns. Simple linear model multiple measurement analysis showed the decrease in glucose after adjustment of type of insulin was similar (F(0,2)=0.52,P=0.577), and insulin dosage in those who remained in aIns (F(0,2)=1.48,P=0.230)。Maintain rhIns was significantly from admission. aIns maintained and switched to aIns from rhIns remained similar, while the insulin dosage increased in those who remained in rhIns after adjusted by HBA1C.4. The ratio of insulin therapy protocol PM, BB, and B was 72.9%, 19.6%, 6.1%, and 7.5% before admission, and was changed to 58.9%, 33.6%, and 7.5% at discharge, which was significantly from admission (χ2=95.6, P<0.001). Decrease in glucose was similar among the those who remained preadmission protocol and those who changed to other protocol (F(0,8)=0.44,P=0.894)), but about 14% of PM was switched to BB. After adjusted by admission HbA1C, simple linear model multiple measurement analysis showed the change of insulin dose among different protocols was statistically significant (F(0,8)=9.6,P<0.001). The insulin dosage increased in those whose protocol was changed from PM to BB (0.48±0.17 vs 058±0.23 U/Kg,P<0.05), and decreased in those whose protocol was changed from BB to B (0.33±0.09 vs 0.21±0.06 U/L,P<0.05). Insulin dosage in other protocols remained similar from at admission. 5. The ratios of combined orals agents at admission, such as sulfonylureas (SU), repaglinide (G), metformin (M), pioglitazone (P), and acarbose (A) was 6.1%, 6.1%, 33.2%,0.5% and 31.8%, and those were changed to 9.3%, 7.0%, 53.7%,4.7%,and 62.1%, which was significantly different from those at admission(χ2=5.9,P<0.05); Those who with M and P were more insulin sensitive (HOM-IR were lower compare with those without (7.0±9.1 vs 11.4±19.5,P<0.05)); Those with SU had shorter diabetic duration (14.4±6.9 vs 10.6±6.1 years,P<0.05), shorter time of insulin use (4.9±3.2 vs 3.15±2.1 years,P<0.05), heavier (71.6±10.8 vs 80.8±13.6 Kg,P<0.05), less insulin at discharge (0.51±0.2 vs 0.37±0.2 U/Kg,P<0.05), and lower level of hsCRP (3.2±5.1 vs 1.8±1.2 ng/ml,P<0.05) compared to those of without; Those with repaglinide needed less insulin at discharge compared with non-repaglinide users (0.5±0.21 vs 0.29±0.25 U/Kg,P<0.05). There was no significant difference for insulin dosage between SU users and repaglinide users, while repaglinide users were older with better glucose control.Conclusion: Duration of diabetes, duration of insulin usage, HbA1C on the day of admission affect the insulin dosage at discharge. For similar glucose control less insulin analogues were needed, about 14% of those who on premix protocol should be changed to basal bolus protocol. Combination with metformin or pioglitazone increases insulin sensitivity, and with SU or repaglinide could decreases the insulin dosage. |
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