BE-SMART (Basal Early Strategies to Maximize HbA1c Reduction with Oral Therapy): Expert Opinion

Abstract

The past three decades have seen a quadruple rise in the number of people affected by diabetes mellitus worldwide, with the disease being the ninth major cause of mortality. Type 2 diabetes mellitus (T2DM) often remains undiagnosed for several years due to its asymptomatic nature during the initial stages. In India, 70% of diagnosed diabetes cases remain uncontrolled. Current guidelines endorse the initiation of insulin early in the course of the disease, specifically in patients with HbA1c > 10%, as the use of oral agents alone is unlikely to achieve glycemic targets. Early insulin initiation and optimization of glycemic control using insulin titration algorithms and patient empowerment can facilitate the effective management of uncontrolled diabetes. Early glucose control has sustained benefits in people with diabetes. However, insulin initiation, dose adjustment, and the need to repeatedly assess blood glucose levels are often perplexing for both physicians and patients, and there are misconceptions and concerns regarding its use. Hence, an early transition to insulin and ideal intensification of treatment may aid in delaying the onset of diabetes complications. This opinion statement was formulated by an expert panel on the basis of existing guidelines, clinical experience, and economic and cultural contexts. The statement stresses the timely and appropriate use of basal insulin in T2DM. It focuses on the seven vital Ts-treatment initiation, timing of administration, transportation and storage, technique of administration, targets for titration, tablets, and tools for monitoring.Funding: Sanofi.

Keywords: Basal insulin; Degludec; Detemir; Glargine; Hypoglycemia; Titration; Type 2 diabetes mellitus.

Fig. 1

Recommended treat-to-target algorithm for the initiation and titration of basal insulin in basal insulin supported oral antidiabetic therapy (BOT). ^$Basal insulin analogues such as glargine and detemir are associated with a lower risk of hypoglycemia and are preferred. Where cost is a constraint, neutral protamine Hagedorn (NPH) can be used. In individuals at high risk of hypoglycemia, longer-acting insulin analogues such as degludec or Gla-300 should be considered. ^*While once-daily basal insulin is preferably administered at bedtime, it can be administered any time of the day depending on the sociocultural circumstances. NPH and detemir may have to be administered twice a day in some individuals

Fig. 2

Protocol for managing hypoglycemia. *Symptoms of hypoglycemia include excessive hunger, sweating, tremors, palpitations, irritability, blurring of vision, dizziness, difficulty concentrating, excessive tiredness, incoherent speech, and altered sensorium/seizures; symptoms of hypoglycemia are idiosyncratic. ^#15 g of glucose or sucrose or 150 mL of fruit juice or sweetened beverages such as cola (not diet cola) can be administered. ^$Complex carbohydrate snack can include 150 mL milk, 1 bread sandwich, 1 chapati, or 3 heaped tablespoons of cooked rice. When hypoglycemia occurs prior to a meal, the meal should be taken immediately