Emerging Trends in Insulin Therapy
Boston, MA—Many individuals with diabetes have suboptimal HbA1c control. Adding more than 2 to 3 oral medications may not achieve glycemic targets, and adherence is not always optimal.
Clinicians from San Diego-based Scripps Health highlighted the latest concepts in the treatment of diabetes. They focused on strategies for advancing basal insulin therapy, addressing patient and physician barriers to insulin, and new basal insulin options. The symposium was supported by an educational grant from Sanofi Aventis.
Patients remain poorly controlled on oral antidiabetic drug treatment for prolonged periods of time. One study that examined insulin use throughout the world found there is a 4- to 6-year delay in insulin initiation, according to Jeffrey Sandler, MD, senior endocrinologist, Scripps Mercy Hospital San Diego. He cited the CDC’s 2011 Diabetes Fact Sheet that looked at the percentage of adults diagnosed with diabetes receiving treatment with insulin or oral medication in the United States (2007-2009). The data showed 12% take insulin only, 14% take both insulin and oral medication, 16% take no medication, and 58% take oral medication only.
Dr Sandler, highlighted the practical challenges that may play a role in determining what type of insulin to use. The challenges include treatment complexity and the need for patient flexibility, deteriorating glycemic control, hypoglycemia, weight gain, clinical inertia, and patient denial that they need insulin.
The majority of patients have an HbA1c of ≥7%, which is above the ADA and American Association of Clinical Endocrinologists (ACCE) guidelines. The ADA’s recommended HbA1c target is <7%, while the AACE recommended target is ≤6.5%. Therefore, there is a disparity between glycemic targets and the actual glucose levels in patients with diabetes, according to Daniel Einhorn, MD, senior endocrinologist, Scripps Memorial Hospital La Jolla. Patient and physician barriers may be a contributing factor in the delay of insulin initiation and intensification.
Dr Einhorn said a study by Peyrot et al included patient-cited insulin issues among 1530 patients [Diabet Med. 2012;29(5):682-689]. They found:
• 66.7% said insulin-treated diabetes controls their life;
• 59.8% said insulin regimen can be restrictive;
• 54.4% said it is hard to live a normal life while managing diabetes;
• 81.4% wished the insulin regimen would fit daily life changes; and
• 23.1% cited the number of daily injections as an issue.
Tools in the guidelines can help overcome patient barriers to insulin. For example, the AACE/American College of Endocrinology diabetes management algorithm addresses all aspects of diabetes using 7 color-coded graphics, including a glycemic control algorithm, an algorithm for adding/intensifying insulin and profiles of antidiabetes medications [Endocr Pract. 2015;21(4):438-447].
Considering patient attitudes and beliefs, as well as providing early education can help, too. Dr Einhorn stressed the importance of explaining the reasons for starting insulin therapy. Further, devices such as insulin pens offer ease of use and improve adherence. A study by Asche et al found greater medication adherence, less hypoglycemia, and de- creased health care utilization associated with insulin pens, compared with vials/ syringes [Clin Ther. 2011;33(1):74-109].
Athena Philis-Tsimikas, MD, corporate vice president, Scripps Whittier Diabetes Institute, continued the symposium with a discussion on basal insulin. While basal insulin maintains normal glucose levels between meals and overnight, she highlighted several limitations.
The ideal initial insulin therapy would provide effective and stable glycemic control for 24 hours with minimal hypo- glycemia and weight gain. Basal insulin alone is usually the optimal initial regimen, she said. However, not all patients reach target with a single injection. There are several options for them, but they have to be willing to take >1 injection [Diabetes Care. 2015;38(1):140-149]. One is adding a glucagon-like peptide-1 (GLP-1) receptor agonist. Dr Philis- Tsimikas said that the combination of basal insulin plus a GLP-1 receptor agonist is being well-received after several studies confirmed that its efficacy is on par with more complex multidose insulin regimens, but with less hypoglycemia and with weight loss.
Alternatively, consider advanced insulin regimens. These include adding 1 injection of rapid-acting insulin analogue before the largest meal, or adding ≥2 injections of a rapid-acting insulin analogue before meals.
“When using combination medications with insulin, consider new insulin options that lower the risk of hypoglycemia and weight gain and minimize other side effects,” she said.
George Dailey, MD, senior consultant, Scripps Clinical Medical Group, concluded the symposium highlighting a new basal insulin option for glycemic control. The FDA has approved long-acting insulin glargine, 300 U/mL. Dr Dailey reviewed its attributes compared with 100 U/mL. For example, 300 U/mL showed a more constant and prolonged pharmacokinetic and pharmacodynamic profile, lower glycemic variability, and stable blood glucose beyond 24 hours. It also demonstrated flexibility to adapt the timing of injections to either morning or evening dosing and with a 24±3-hour window.—Eileen Koutnik-Fotopoulos
