Optimizing Insulin Therapy in Diabetes - Episode 13
Davida F. Kruger, MSN, APN-BC, BC-ADM: When you’re working with patients, you want to simplify the regimen so that adherence is improved. And so, we really do work with the patients to figure out what their schedules look like and when they can take a basal insulin. “What time do you go to bed? Can we give it to you at 9 o’clock? What’s going to help you remember?” I always joke with my patients and say that I can’t sleep without brushing my teeth, so I would put my basal insulin right next to my toothbrush. What are the cues that are going to help patients remember? They have busy schedules. If we’re asking them to take insulin 10 to 15 minutes before their meals, which is really important in terms of how that insulin works, what are we going to do to help those patients remember to take the insulin?
We talk to them about the craziness in their life, and ask who’s going to support them to be able to take all of their insulin injections. We really want to simplify any programs. If we have a patient on 5 or 6 injections and we can simplify it down to 2 or maybe 3 injections a day, the patient’s more apt to be able to follow through and be more adherent and have a better outcome. Including their lifestyle and asking them how they want to do it is really important.
Serge Jabbour, MD: To really become adherent and compliant when it comes to insulin, teaching is key and so is the number of injections per day. Why teaching? If we start insulin without telling patients why it is really important, patients may start it after a week. Why should they inject? Patients have that fear of insulin. But we tell them, “It’s a natural hormone we all make. You don’t make it because your beta cells burn out completely. We know the insulin is safe; it’s going to bring your sugars down. By having an A1C [glycated hemoglobin] less than 7%, you will have fewer complications; you will not end up on dialysis.” By educating patients—either us or our diabetes educators—patients become more compliant.
The second thing, the number of injections per day, is really important. If we try to use insulins where we give 2 injections as opposed to 4 or 5, that will improve compliance significantly. That’s why in the patients who are on so much insulin, when I switch them to U-500, compliance is much better. Now they are on 2 shots a day as opposed to 4 or 5 shots a day.
Robert Hood, MD: When you look at the time action of U-500 insulin, it doesn’t look terribly physiologic. It looks a lot like what you would see with Humulin 70/30 insulin. That’s far different, though, from what we see with these beautiful analogs, where you get a discrete mealtime peak with a rapid-acting, very flat basal insulin. They do a great job of matching insulin with food.
So, why did these patients on U-500 drop their A1C levels? In the past, some people thought that maybe they just use the insulin better. But in de la Peña’s clamp study, the action of the insulin was no different than that of U-100. The area under the glucose infusion curve that looks at the glucose-lowering effect was no different than for U-100 at doses of 50 and 100 units. So, there’s nothing magical about U-500 lasting longer under the skin.
It all very much suggests that compliance is an issue, and we’re vastly simplifying the regimen for these patients. There are population studies using databases where propensity matching suggests patients on U-500 are more compliant than U-100 patients at high doses. This trial’s initial drop of A1C during the lead-in period, then a rapid drop of A1C in the face of a dose reduction of insulin, speaks about better compliance, and then these measures of compliance that were done with questionnaire testing really validates it.
Going back to the patient, put yourself in the shoes of a patient. How would you comply with a 5-, 6-, 7-, 8-, or 10-injections-a-day regimen, plus 4-finger-sticks-a-day blood sugar monitoring? What’s more, you’re looking at 2 copays. With U-500, it’s a single copay, a single insulin used in monotherapy, and a simple 2-injections-a-day regimen or 3-injections-a-day regimen.
Transcript edited for clarity.