Capsule Commentary on Pilla et al., Predictors of Insulin Initiation
in Patients with Type 2 Diabetes: an Analysis of the Look AHEAD
Rosette J. Chakkalakal, MD, MHS
Vanderbilt University Medical Center, Nashville, TN, USA.
J Gen Intern Med 33(6):944
© Society of General Internal Medicine 2018
his study by Pilla et al.
identifies sociodemographic and
clinical predictors of insulin initiation among participants
enrolled in the Look AHEAD (Action for Health in Diabetes)
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
Cox proportional hazards models, the investigators found that
insulin initiation was inversely associated with older age and
Black or Hispanic race/ethnicity and positively associated with
hemoglobin A1C, current smoking, body mass index, hyperten-
sion, the presence of macrovascular and microvascular compli-
cations, number of antihyperglycemic drugs, family history of
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-
cluding assessment of efficacy, hypoglycemia risk, impact on
weight, side effects, costs, and patient preferences^.
lin initiation may be appropriate for some but not all patients.
Pilla et al. are unable to explain the extent to which the differences
they identified in insulin initiation may be explained by appro-
priateness of insulin initiation because their analysis did not
account for all of the factors included in the decision-making
process. In particular, hypoglycemic risk may play a critical role
in the decision to initiate insulin given increased recognition of
the significant negative impact of hypoglycemia on long-term
outcomes of patients with type 2 diabetes
but it was not ad-
dressed in this study.
As stated by the authors, the racial/ethnic differences in
insulin initiation identified in this study are especially note-
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
racial/ethnic variation identified in this study represents differ-
ences or disparities would greatly inform efforts to ensure
equitable treatment of type 2 diabetes for all patients.
Corresponding Author: Rosette J. Chakkalakal, MD, MHS; Vander-
bilt University Medical Center, Nashville, TN, USA (e-mail: Rosette.j.
Compliance with Ethical Standards:
Conflict of Interest: The author declares that she does not have a
conflict of interest.
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Published online February 22, 2018