1. Barriers To Insulin Therapy
BY
KHALED EL SAYED EL HADIDY. MD
Head of Internal Medicine Department.
Head of Diabetes and Endocrinology Unit.
Beni-Suef University.
2. Diabetes is an increasing healthcare
epidemic throughout the world
3. Despite these guidelines few patients
are reaching HbA1c targets
1. Harris et al. Diabetes Res Clin Pract 2005;70:90-7 2. NCQA 2006 (Heidis measures);
3. UNIFESP and Fiocruz Study 2006; 4. EUCID 2008; 5. JDDM-CODIC 2007;
6. Nitiyanant et al. CMRO 2002;18(5):317-327;
7. http://www.glycomate.com/changingdiabetes/AUS
IDF Treatment Algorithm for People with Type 2 Diabetes. 2011
8. A1chieve Egypt sub-group
IDF (Global)
HbA1c <7.0%
NICE (UK)
HbA1c 6.5–7.5%
CDA (Canada)
HbA1c 7%
ALAD (Latin America)
HbA1c <6–7%
Canada1
51%
IDF (Western Pacific Region)
HbA1c 7.0%
Diabetes management guidelines worldwidePercent of patients reaching HbA1c target <7%
Brazil3
25%
UK4
40%
India6
22%
ADA (US)
HbA1c <7%
US2
42%
Japan5
61%
Australia7
52%
Australia
HbA1c 7%
Egypt8
32%
4. 4
37.3 36.0 36.0 36.4
0
10
20
30
40
50
Asia
(n = 3,438)
Eastern Europe
(n = 1,444)
Latin America
(n = 1,292)
All
(n = 6,346)
Patients*withHbA1c<7%(%)
*Patients with HbA1c test (36% of overall population)
Chan JC, et al. Diabetes Care 2009;32:227–33.
Only around one-third of patients* in
developing countries achieve HbA1c <7%
The International Diabetes Management Practice Study (IDMPS)
5. Diabetic
Retinopathy
Leading cause
of blindness
in adults1,2
Diabetic
Nephropathy
Leading cause of
end-stage renal disease3,4
Cardiovascular
Disease
Stroke
2- to 4-fold increase in
cardiovascular
mortality and stroke5
Diabetic
Neuropathy
Leading cause of
non-traumatic lower
extremity amputations7,8
8/10 individuals with
diabetes die from CV
events6
50% Type 2 diabetes has
complications at time of diagnosis
1UK Prospective Diabetes Study Group. Diabetes Res 1990; 13:1–11. 2Fong DS, et al. Diabetes Care 2003; 26 (Suppl. 1):S99–S102. 3The Hypertension in Diabetes
Study Group. J Hypertens 1993; 11:309–317. 4Molitch ME, et al. Diabetes Care 2003; 26 (Suppl. 1):S94–S98. 5Kannel WB, et al. Am Heart J 1990; 120:672–676.
6Gray RP & Yudkin JS. Cardiovascular disease in diabetes mellitus. In Textbook of Diabetes 2nd Edition, 1997. Blackwell Sciences. 7King’s Fund. Counting the cost.
The real impact of non-insulin dependent diabetes. London: British Diabetic Association, 1996. 8Mayfield JA, et al. Diabetes Care 2003; 26 (Suppl. 1):S78–S79.
6. Adapted from Stratton IM, et al. UKPDS 35. BMJ 2000; 321:405–412.
UKPDS: Decreased risk of diabetes-related
complications associated with a1% decrease in A1C
Any
diabetes-
related
endpoint
21%
Diabetes-
related
death
21%
All
cause
mortality
14%
Stroke
12%
Peripheral
vascular
disease†
43%
Myocardial
infarction
14%
Micro-
vascular
disease
37%
Cataract
extraction
19%
Observational analysis from UKPDS study data
†Lower extremity amputation or fatal peripheral vascular disease
*
7. HOMA=homeostasis model assessment
Adapted from Holman RR. Diabetes Res Clin Pract 1998;40(suppl 1):S21–5.
Decreasing -cell function as part of the
progression of T2DM
Normal -cell
function by
HOMA (%)
Time (years)
0
20
40
60
80
100
―10 ―8 ―6 ―4 ―2 0 2 4 6
Time of diagnosis
?
Pancreatic function
~ 50% of normal
9. Effectiveness of Antidiabetic Agent
Nathan DM. N Engl J Med. 2007;356(5):437-440.
1.5 1.5 1.0-1.5 0.5-0.9 0.8-1.0
≥2.5
SUs
Biguanides
(metformin) Glinides
DPP-4
inhibitors TZDs Insulin
0.0
0.5
1.0
1.5
2.0
2.5
3.0
HbA1cReduction(%)
Efficacy as
monotherapy
Antidiabetic
agents
Insulin is the most effective
glucose-lowering agent
10.
11. Healthy eating, weight control, increased physical activity & diabetes education
Metformin
high
low risk
neutral/loss
GI / lactic acidosis
low
If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
high
low risk
gain
edema, HF, fxs
low
Thiazolidine-
dione
intermediate
low risk
neutral
rare
high
DPP-4
inhibitor
highest
high risk
gain
hypoglycemia
variable
Insulin (basal)
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Metformin
+
Basal Insulin +
Sulfonylurea
+
TZD
DPP-4-i
GLP-1-RA
Insulin§
or
or
or
or
Thiazolidine-
dione
+
SU
DPP-4-i
GLP-1-RA
Insulin§
TZD
DPP-4-i
GLP-1-RA
high
low risk
loss
GI
high
GLP-1 receptor
agonist
Sulfonylurea
high
moderate risk
gain
hypoglycemia
low
SGLT2
inhibitor
intermediate
low risk
loss
GU, dehydration
high
SU
TZD
Insulin§
GLP-1 receptor
agonist
+
SGLT-2
Inhibitor
+
SU
TZD
Insulin§
Metformin
+
Metformin
+
or
or
or
or
SGLT2-i
or
or
or
SGLT2-i
Mono-
therapy
Efficacy*
Hypo risk
Weight
Side effects
Costs
Dual
therapy†
Efficacy*
Hypo risk
Weight
Side effects
Costs
Triple
therapy
or
or
DPP-4
Inhibitor
+
SU
TZD
Insulin§
SGLT2-i
or
or
or
SGLT2-i
or
DPP-4-i
If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add
basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i:
Metformin
+
Combination
injectable
therapy‡
GLP-1-RAMealtime Insulin
HbA1c
≥9%
Me ormin
intolerance or
contraindica on
Uncontrolled
hyperglycemia
(catabolic features,
BG ≥300-350 mg/dl,
HbA1c ≥10-12%)
Insulin (basal)
+
or
or
or
Diabetes Care 2015;38:140-149; Diabetologia 2015;10.1077/s00125-014-3460-0
12. Barriers to Initiation of Insulin Therapy
• Heath care providers
• Lack of consensus
• Limited local resources
• Inconsistent training
• Self-monitoring
• limited time for patient
education regarding proper
insulin administration
techniques
• Patient challenges
• Hypoglycemia
• Weight gain
• Self-monitoring
• Complexity of treatment
• Injection technique
• Perceived ‘failure’
13. Fear of Hypoglycemia
Insulin Therapy Barriers*
Many patients and physicians are reluctant to
begin insulin treatment*
Carlos Campos, MD, MPH, South Med J. 2007;100(8):804-811
14.
15. PIA KAISER, M.SC.,1 SEBASTIAN MAXEINER, M.SC.,1 ALEXANDER WEISE, M.SC.,1 FLORAIN
NOLDEN, M.SC.,1 ANJA BORCK, M.D.,2 THOMAS FORST, M.D.,1 AND ANDREAS PFÜTZNER,
M.D., PH.D.1
Assessment of the Mixing Efficiency of
Neutral Protamine Hagedorn Cartridges
16. Patients who improved their technique for insulin resuspension had
significantly Fewer Hypoglycemic episodes than those that did not
improve their technique.
Insuman the most efficient human insulin to resuspend to ensure accurate dosing*.
J Diabetes Sci Technol Vol 4, Issue 3, May 2010
17. Fear of Needles
Insulin Therapy Barriers*
Many patients and physicians are reluctant to
begin insulin treatment*
Carlos Campos, MD, MPH, South Med J. 2007;100(8):804-811
18.
19.
20. Initial Experience and Evaluation of Reusable Insulin
Pen Devices Among Patients with Diabetes
in Emerging Countries
Balduino Tschiedel • Oscar Almeida •
Jennifer Redfearn • Frank Flacke
T
o view enhanced content go to www.diabetestherapy-open.com
Received: July 30, 2014
The Author(s) 2014. This article is published with open access at Springerlink.com
CONCLUSIONS
As a result of interviews with individuals T2DM, it was identified that new and existing users of
insulin pens seek ease of injection, overall ease of use, and correct dose delivery as key
characteristics for an insulin pen device. Through hands-on use of these different pens, priming
the reusable insulin pens was the most difficult aspect of administering a dose; however, each
pen showed slight variation in the steps that posed difficulty with administration. The AS pen
was easiest to use overall compared with other reusable pens tested, and ranked highest by
uses in most of the characteristics identified as most preferred for a reusable insulin pen.
Selection of an appropriate reusable insulin pen may provide benefit and comfort for patients
starting or continuing insulin therapy; identifying those Diabetes Therapy characteristics that
are most preferred by patients may assist in overcoming barriers to appropriate dose delivery
and overall adherence with treatment.
21. Insuman
“Recombinant DNA technology”
“Unique 3-ball technology”
Proper Resuspension
Fewer Hypoglycemic
ALLStar
Easiest to use overall
compared with other reusable
pens tested*
Assist in overcoming barriers
to appropriate dose delivery
and overall adherence with
treatment
Why Insuman With AllStar?
