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.

Diabetes is an increasing healthcareepidemic throughout the world

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. 20118. 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%

AustraliaHbA1c 7%

Egypt8

32%

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)

Pa

tie

nts

* w

ith

Hb

A1

c<

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)

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.

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

*

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

Treatment options in type 2 diabetes

1960s 1970s 1980s 1990s

Sulphonylureas

Thiazolidinediones

DPP-4i, dipeptidyl peptidase-4 inhibitor; GLP-1RA, glucagon-like peptide-1 receptor agonist; SGLT2i, sodium glucose co-transporter-2 inhibitor

Metformin

1950s

Insulin

GLP-1 RAs

DPP-4is

SGLT2is

2000s 2010s

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

Hb

A1

cR

ed

uct

ion

(%

)

Efficacy as monotherapy

Antidiabeticagents

Insulin is the most effectiveglucose-lowering agent

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-RA Mealtime Insulin

HbA1c≥9%

Me orminintoleranceorcontraindica on

Uncontrolledhyperglycemia

(catabolicfeatures,BG≥300-350mg/dl,HbA1c≥10-12%)

Insulin (basal)

+

or

or

or

Diabetes Care 2015;38:140-149; Diabetologia 2015;10.1077/s00125-014-3460-0

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’

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

PIA KAISER, M.SC.,1 SEBASTIAN MAXEINER, M.SC.,1 ALEXANDER WEISE, M.SC.,1 FLORAINNOLDEN, 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

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

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

Initial Experience and Evaluation of Reusable Insulin

Pen Devices Among Patients with Diabetes

in Emerging Countries

Balduino Tschiedel • Oscar Almeida •

Jennifer Redfearn • Frank FlackeT

o view enhanced content go to www.diabetestherapy-open.com

Received: July 30, 2014The Author(s) 2014. This article is published with open access at Springerlink.com

CONCLUSIONSAs 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.

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?

Insuman

Thank you