BACKGROUND: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and basal insulin both lower blood sugar, but while insulin puts people at risk of hypoglycemia and weight gain, GLP-1 RAs do not. In addition, GLP-1 RAs have added cardiometabolic and renal benefits. For these reasons, when possible, many primary care providers prefer their patients with well-controlled type 2 diabetes to be transitioned from basal insulin to a GLP-1 RA. This transition process can be labor intensive, requiring multiple dosing adjustments and a watchful eye for hypoglycemia and hyperglycemia. The Mobile Insulin Titration Intervention (MITI)-GLP1 program uses SMS text messaging-based technology to support a streamlined and supervised transition process from basal insulin to a GLP-1 RA. This program takes place at a multilingual safety-net clinic.
OBJECTIVE: Our objectives were to assess program feasibility and acceptability to determine whether the intervention was doable, practical, and worthy of further investigation via a larger controlled trial. Preliminary clinical outcomes are also discussed in this paper.
METHODS: Patients were enrolled on a secure web platform that sent them a daily SMS text message asking the following: "What was your fasting blood sugar this morning?" Each weekday, texted responses containing patients' fasting blood sugar levels were checked for alarm values, and once weekly, patients were called and advised on whether and how to lower their basal insulin and increase their GLP-1 RA dose. The program was co-run by general internal medicine physicians and nurses and continued until the patient had their insulin stopped completely and/or their GLP-1 RA dose reached the maximum, or 16 weeks elapsed. All enrolled patients were included in the analyses.
RESULTS: A total of 72 patients completed the pilot program. Feasibility and acceptability were high. Of 3671 SMS text messages sent by the program, 3520 (95.89%) received a response from patients. Of 719 cumulative weeks in which Thursday titration phone calls were attempted, successful connections with patients were made in 649 (90.26%) instances. Preliminary clinical outcomes were promising. Insulin doses were meaningfully reduced (55/72, 76.39% had their basal insulin reduced by at least 50%; 45/72, 62.5% had their insulin stopped completely). GLP-1 RA doses were meaningfully increased (64/72, 88.89% had their GLP-1 RA dose increased by ≥1 level; 45/72, 62.5% were discharged on the maximum dose of their GLP-1 RA). There was minimal hypoglycemia (5/3520, 0.14% of the SMS text messages reported a value of <80 mg/dL) and hyperglycemia (1/3520, 0.03% of the SMS text messages reported a value of >400 mg/dL).
CONCLUSIONS: A general internal medicine-run MITI-GLP1 pilot program using SMS text messaging and interdisciplinary teamwork between internists and nurses is a feasible and acceptable intervention for safely and effectively transitioning people with well-controlled type 2 diabetes away from basal insulin and toward a GLP-1 RA.
