Capsule Commentary on Pilla et al., Predictors of Insulin Initiation in Patients with Type 2 Diabetes: an Analysis of the Look AHEAD Randomized Trial Rosette J. Chakkalakal, MD, MHS Vanderbilt University Medical Center, Nashville, TN, USA. J Gen Intern Med 33(6):944 As stated by the authors, the racial/ethnic differences in DOI: 10.1007/s11606-018-4358-1 insulin initiation identified in this study are especially note- © Society of General Internal Medicine 2018 worthy and deserve further evaluation. Discerning between differences and disparities in treatment by race/ethnicity re- quires knowledge of treatment appropriateness, patient atti- tudes and preferences for the treatment, and clinical outcomes of the treatment across racial/ethnic groups. Clarifying if the his study by Pilla et al. identifies sociodemographic and racial/ethnic variation identified in this study represents differ- clinical predictors of insulin initiation among participants ences or disparities would greatly inform efforts to ensure enrolled in the Look AHEAD (Action for Health in Diabetes) equitable treatment of type 2 diabetes for all patients. trial. Nearly 28% of study participants not using insulin at baseline were found to have initiated insulin for management of type 2 diabetes during a median follow-up of 8 years. Using Corresponding Author: Rosette J. Chakkalakal, MD, MHS; Vander- Cox proportional hazards models, the investigators found that bilt University Medical Center, Nashville, TN, USA (e-mail: Rosette.j. firstname.lastname@example.org). insulin initiation was inversely associated with older age and Black or Hispanic race/ethnicity and positively associated with Compliance with Ethical Standards: hemoglobin A1C, current smoking, body mass index, hyperten- sion, the presence of macrovascular and microvascular compli- Conflict of Interest: The author declares that she does not have a cations, number of antihyperglycemic drugs, family history of conflict of interest. diabetes, and care at a hospital-affiliated medical clinic. The decision to intensify type 2 diabetes treatment, especially via insulin initiation, requires Ba patient-centered approach, in- REFERENCES cluding assessment of efficacy, hypoglycemia risk, impact on 1. Pilla SJ, Yeh HC, Juraschek SP, Clark JM, Maruthur NM, Predictors of weight, side effects, costs, and patient preferences^. Thus, insu- insulin initiation in patients with type 2 diabetes: an analysis of the Look AHEAD randomized trial. J Gen Intern Med. https://doi.org/10.1007/ lin initiation may be appropriate for some but not all patients. s11606-017-4282-9 Pilla et al. are unable to explain the extent to which the differences 2. Look AHEAD Research Group, Wing RR, Bolin P, et al. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med they identified in insulin initiation may be explained by appro- 2013;369(2):145–54. priateness of insulin initiation because their analysis did not 3. American Diabetes Association. 8. Pharmacologic approaches to glycemic account for all of the factors included in the decision-making treatment: standards of medical care in diabetes-2018. Diabetes Care. 2018;41(Suppl 1):S73-S85. process. In particular, hypoglycemic risk may play a critical role 4. Lipska KJ, Ross JS, Wang Y, et al. National trends in US hospital in the decision to initiate insulin given increased recognition of admissions for hyperglycemia and hypoglycemia among Medicare benefi- ciaries, 1999 to 2011. JAMA Int Med 2014;174(7):1116–24. the significant negative impact of hypoglycemia on long-term 4 5. Rathore SS, Krumholz HM. Differences, disparities, and biases: outcomes of patients with type 2 diabetes but it was not ad- clarifying racial variations in health care use. Ann Int Med dressed in this study. 2004;141(8):635–8. Published online February 22, 2018
Journal of General Internal Medicine – Springer Journals
Published: Feb 22, 2018
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