Gordon Goodall

The consequences of delaying insulin initiation in UK type 2 diabetes patients failing oral hyperglycaemic agents: a modelling study

BackgroundRecent data have shown that type 2 diabetes patients in the UK delay initiating insulin on average for over 11 years after first being prescribed an oral medication. Using a published computer simulation model of diabetes we used UK-specific data to estimate the clinical consequences of immediately initiating insulin versus delaying initiation for periods in line with published estimates.MethodsIn the base case scenario simulated patients, with characteristics based on published UK data, were modelled as either initiating insulin immediately or delaying for 8 years. Clinical outcomes in terms of both life expectancy and quality-adjusted life expectancy and also diabetes-related complications (cumulative incidence and time to onset) were projected over a 35 year time horizon. Treatment effects associated with insulin use were taken from published studies and sensitivity analyses were performed around time to initiation of insulin, insulin efficacies and hypoglycaemia utilities.ResultsFor patients immediately initiating insulin there were increases in (undiscounted) life expectancy of 0.61 years and quality-adjusted life expectancy of 0.34 quality-adjusted life years versus delaying initiation for 8 years. There were also substantial reductions in cumulative incidence and time to onset of all diabetes-related complications with immediate versus delayed insulin initiation. Sensitivity analyses showed that a reduced delay in insulin initiation or change in insulin efficacy still demonstrated clinical benefits for immediate versus delayed initiation.ConclusionUK type 2 diabetes patients are at increased risk of a large number of diabetes-related complications due to an unnecessary delay in insulin initiation. Despite clear guidelines recommending tight glycaemic control this failure to begin insulin therapy promptly is likely to result in needlessly reduced life expectancy and compromised quality of life.

Evaluation of exenatide vs. insulin glargine in type 2 diabetes: cost‐effectiveness analysis in the German setting

Objectives: The objective of this analysis was to determine the cost‐effectiveness of exenatide vs. insulin glargine in patients with type 2 diabetes failing to achieve glycaemic control with oral antidiabetic agents, in the German setting, from a third‐party payer perspective.

Evaluating the cost-effectiveness of therapy conversion to insulin detemir in patients with type 2 diabetes in Germany: a modelling study of long-term clinical and cost outcomes

PurposeTo evaluate the long-term cost-effectiveness of transferring type 2 diabetes patients to an insulin detemir regimen after failure to achieve adequate control with oral antidiabetic agents (OADs) alone, or in combination with neutral protamine hagedorn (NPH) insulin, or with insulin glargine in Germany.MethodsA computer simulation model of diabetes was used to make long-term projections of future clinical outcomes and direct medical costs based on findings from a German subanalysis of the PREDICTIVE trial. The study analysed the impact of converting patients failing their current treatments to an insulin detemir regimen. Therapy conversion to insulin detemir ± OADs was associated with a significant reduction in glycosylated haemoglobin (HbA1c) compared with OADs alone, NPH insulin ± OADs, and insulin glargine ± OADs. Across all three groups, hypoglycaemia rates decreased by 80% and patients lost an average of 0.9 kg of body weight during treatment with insulin detemir ± OADs.ResultsTherapy conversion to insulin detemir ± OADs was projected to improve life expectancy by 0.28 years compared with OADs alone, and by 0.13 years compared with the NPH and glargine regimens. Transfer to insulin detemir was associated with improvements in quality-adjusted life expectancy of 0.21 quality-adjusted life years (QALYs) over OADs alone, 0.28 QALYs over NPH ± OADs, and 0.29 QALYs over glargine ± OADs. Insulin detemir was associated with savings over patient lifetimes due to reduced diabetes-related complications in all three comparisons.ConclusionsTherapy conversion to insulin detemir ± OADs in type 2 diabetes patients failing OADs alone, NPH or insulin glargine regimens was associated with improvements in life expectancy, quality-adjusted life expectancy and cost savings in all three scenarios evaluated.

Cost-effectiveness of insulin aspart versus human soluble insulin in type 2 diabetes in four European countries: subgroup analyses from the PREDICTIVE study

ABSTRACT Objectives: To evaluate the long-term health economic outcomes associated with insulin aspart (IAsp) compared to human soluble insulin (HI) in type 2 diabetes patients on basal-bolus therapy in Sweden, Spain, Italy and Poland. Methods: A published computer simulation model of diabetes was used to predict life expectancy, quality-adjusted life expectancy and incidence of diabetes-related complications. Baseline cohort characteristics (age 61.6 years, duration of diabetes 13.2 years, 45.1% male, HbA1c 8.2%, BMI 29.8 kg/m2) and treatment effects were derived from the PREDICTIVE observational study. Country-specific complication costs were derived from published sources. The analyses were run over 35-year time horizons from third-party payer perspectives in Spain, Italy and Poland and from a societal perspective in Sweden. Future costs and clinical benefits were discounted at country-specific discount rates. Sensitivity analyses were performed. Results: IAsp was associated with improvements in discounted life expectancy and quality-adjusted life expectancy, and a reduced incidence of most diabetes-related complications versus HI in all four settings. IAsp was associated with societal cost-savings in Sweden (SEK 2470), direct medical cost-savings in Sweden and Spain (SEK 8248 and €1382, respectively), but increased direct costs in Italy (€2235) and Poland (€743). IAsp was associated with improved quality-adjusted life expectancy in Sweden (0.077 QALYs), Spain (0.080 QALYs), Italy (0.120 QALYs) and Poland (0.003 QALYs). Conclusions: IAsp was dominant versus HI in both Sweden and Spain, would be considered cost-effective in Italy with an incremental cost-effectiveness ratio of €18 597 per QALY gained, but would not be considered cost-effective in Poland.

Biphasic insulin aspart 70/30 vs. insulin glargine in insulin naïve type 2 diabetes patients: modelling the long-term health economic implications in a Swedish setting

Objectives:  To evaluate the long‐term clinical and economic outcomes of biphasic insulin aspart 70/30 (BIAsp 70/30) treatment vs. insulin glargine in insulin naïve, type 2 diabetes patients failing oral antidiabetic drugs in a Swedish setting.

Anti-CD3 monoclonal antibody treatment in newly diagnosed Type 1 diabetes patients: a hypothetical modelling analysis

Diabet. Med. 27, 189–196 (2010)

The Impact of Obesity on Adverse Cardiovascular Outcomes in the General Population and in Patients with Type 2 Diabetes

Objectives There is an established causal link between obesity and cardiovascular outcomes. The aim of this review was to determine whether an independent relationship exists between anthropometric measurements of weight (typically body mass index [BMI]) and cardiovascular outcomes (e.g. angina, myocardial infarction, congestive heart failure, stroke, and mortality due to cardiovascular disease) in the general population and in patients with type 2 diabetes. Methods A review of the medical literature published between 1988 and May 2008 was conducted using the PubMed, EMBASE, Cochrane and Center for Review and Dissemination databases. Studies longer than 12 months, with ≥500 adult subjects and published in English were included. Results In studies conducted in general populations there was an overall trend towards increased risk for adverse cardiovascular outcomes with increasing BMI. The nature and strength of this relationship varied according to the measurement used (e.g. BMI, waist circumference, waist-to-hip ratio) and the population studied, with notable differences observed in Asian/Asia-Pacific compared with European or North American-based studies. However, data from diabetes-specific populations are limited. Conclusions In general, the degree of being overweight or obese was associated with an elevated risk of adverse cardiovascular events and mortality. Although inextricable links exist between obesity, type 2 diabetes and cardiovascular disease in the general population, the extent to which findings can be extrapolated to a diabetes-specific population is limited.