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Patients more satisfied with once-daily insulin regimen

Patients treated with insulin glargine have a greater improvement in mean fasting glucose and nocturnal blood glucose, and are more satisfied with their regimen, than those who use insulin lispro.

A randomised, parallel, open study compared once-daily basal insulin glargine with three times daily prandial insulin lispro. It recruited 418 patients with type 2 diabetes that had previously been poorly controlled with oral hypoglycaemic drugs alone. Participants were followed up for 44 weeks.

The study found that the mean reduction in HbA1c was 1.7% and 1.9% in the glargine and lispro groups respectively. However, this was below the interval of 0.4% set by the study for any difference to be considered significant.

Mean fasting glucose and nocturnal blood glucose were better controlled in the glargine users than in the lispro group. However, patients in the latter group had better postprandial values. The incidence of hypoglycaemic events was greater with insulin lispro than with glargine (24.0, 95% CI 20-28, events per patient per year compared with 5.2, 95% CI 4-6).

Patients in both groups gained weight, but the difference was not significant (mean weight gain 3.01kg and 3.54kg for glargine and lispro respectively). However, patients assigned to the glargine regimen were more satisfied with their treatment.

It is a shame that the alternative was not a twice daily mixed insulin regimen, which is a more common choice for insulin initiation in the community than three times daily. Nevertheless, this study demonstrates that single dose glargine is an acceptable regimen for patients with type 2 diabetes when oral hypoglycaemics fail, and has a low risk of hypoglycaemia and greater patient satisfaction because of the reduced number of injections.

Standard starting doses and well established dose titration regimens also add to the suitability. Postprandial control is an important aspect of glycaemic treatment, and with time boluses of prandial insulin may also be needed.

Bretzel RG, Nuber U, Landgraf W et al. Once-daily basal insulin glargine versus thrice daily prandial insulin lispro in people with type 2 diabetes on oral hypoglycaemic agents (APOLLO): an open randomised trial. Lancet 2008;371:1073-84

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