Special guest blog from Jennifer N. Clements, Pharm.D., BCPS, CDE, Associate Professor of Pharmacy Practice, Presbyterian College School of Pharmacy
Patients with diabetes have an increased risk of macrovascular complications such as heart disease and stroke. As supported in the American Diabetes Association (ADA) guidelines, there is evidence that suggests adequate glycemic control can reduce the risk and progression of cardiovascular disease. The ADA and the European Association for the Study of Diabetes (EASD) recently published an update on the management of hyperglycemia, which stated that basal insulin remains an option for initial therapy in severe hyperglycemia or add-on therapy with oral agents when glycemic control has not been achieved. The benefits of basal insulin include effectiveness, lack of a maximum dose, and ability to titrate to response. However, basal insulin can cause hypoglycemia and weight gain. In addition, numerous studies have shown that basal insulin – particularly insulin glargine – has been associated with reports of cancer risk.
Recently, the Outcome Reduction with an Initial Glargine Intervention (ORIGIN) trial released results comparing insulin glargine to standard treatment in The New England Journal of Medicine (N Engl J Med 2012; 367: 319-28). The patient population included adults over the age of 50 year with high risk of cardiovascular events and diagnosis of type 2 diabetes or at high risk of diabetes based on criteria for impaired glucose tolerance/impaired fasting glucose (IGT/IFG). Insulin glargine was given at 2, 4, or 6 units and self-titrated to fasting blood glucose level of 95 mg/dL or below. Patients were followed for approximately 6 years after initiation of insulin glargine.
The ORIGINS trial found that insulin glargine only had a neutral effect on cardiovascular events with a risk of weight gain and hypoglycemia. While insulin glargine is a safe option, it is essential to control for conventional risk factors, such as blood pressure and cholesterol levels, along with promotion of smoking cessation and aspirin therapy. Additional evidence is necessary to determine the role of basal insulin among high-risk patients.