Addressing Inadequate Glycemic Control in Diabetes

Robert Hood, MD: Roughly half of patients in the United States have hemoglobin A1C levels less than 7%. Unfortunately, that has not changed over several years, despite advancements in treatment. There are various reasons why we’re not getting patients to goal, and clinical inertia is certainly a factor here. Clinical inertia is driven by many factors. Often patients are deemed noncompliant, but their compliance is often affected by third-party coverage for medication, complexity of regimens, or how much time is spent on education. In a busy clinical office, all too often some of these issues are not well addressed.

Obviously, lifestyle modification can have a huge impact on people with diabetes, especially those who are more insulin resistant. Unfortunately, it’s hard to have sustained effect on lifestyle modification in the majority of our patients. So, we should all start with lifestyle modification, but we often have to resort to escalating pharmacotherapy.

With pharmacotherapy, patients are taking medications that don’t make them feel better, and often there’s cost and complexity involved. When we talk about insulin injections, we’re talking about taking injections and having to do blood sugar monitoring. You may actually make the patient feel worse by causing hypoglycemia. Also, patients tend to perceive insulin therapy as a negative thing. They often relate insulin therapy to having bad diabetes or complicated diabetes. In some cultures, they relate diabetes requiring insulin to people going blind or having kidney failure. So, there’s a lot of emotional baggage that goes along with diabetes therapy, especially insulin therapy, and a lot of outside forces make it difficult for us to get adequate adherence out of our patients.

Serge Jabbour, MD: When we see patients on high-dose insulin and A1C is still not at goal, many times we think it’s a compliance issue. We maybe start thinking outside the box to try to come up with another option that could improve compliance and get A1C to goal. Patients basically remain on 4 injections a day. We say, “Let’s keep going up,” and we just stop from being proactive. That’s why I think when we see those patients, we need to think outside the box and try to come up with an option that can help compliance and help that A1C come down. One thing I do myself when I see these patients is start thinking about other agents I could add, which could help the insulin work in a more efficient way, or switching insulin to something more concentrated, which can work better based on some studies we have done.

Transcript edited for clarity.