Optimizing Insulin Intensification in Diabetes Care

Robert Hood, MD: It’s all about the patient. We clearly have to consider the patient’s preferences and convenience. A lot of nonadherence or noncompliance with insulin therapy has to do with how the patient tries to live their life. This is not as simple as just taking a pill. You’ve actually got to pull out an invasive device and give yourself insulin. Pens certainly help out a bunch, as opposed to a vial and syringe. But when you think about it, put yourself in the patient’s shoes. When is it going to be easiest for you to give injections? The easiest time is in the morning. You’re always home in the morning. You’re usually home in the evening. You’re least likely home at lunchtime. So when we start using more complex regimens that require more injections, especially injections when we’re not at home, it becomes more difficult for the patient to comply with that therapy.

Adherence is an issue not just for diabetes but for other disease states. The worst thing we can do is think of the patient in negative terms from the standpoint of adherence. I think it’s wise to assume that everybody’s nonadherent. I know I certainly have been with some of my therapy over the years. This is important when you’re changing insulin therapy. If you go into that therapeutic adjustment assuming someone’s taking all their insulin, you might be overestimating how much insulin they’re actually taking. So I think a really great thing to do when you’re adjusting therapy with a patient is saying to them, “Over the past week, how many injections of insulin did you miss?” as opposed to saying, “Do you miss your insulin injections?” “No.” Be nonthreatening, nonjudgmental. Try to bring out from the patient how often they’re not taking their injections. That will allow you to more accurately assess what’s going on and make a more judicious transition to therapy.

It also gives you the opportunity of understanding why they’re missing an injection. You’re not slapping their hand. We need to understand why they’re missing that injection. Maybe it’s because they’re at work. Maybe they’re fearful of hypoglycemia because it’s bedtime. Understanding what drives patients will improve adherence. Don’t just put a label on them: Understand it and try to improve their outcomes.

The history of insulin therapy has been typified by progressively more concentrated insulins. The point there is to try to improve the lives of patients with diabetes. When we concentrate insulin, there are several things that can happen. One thing that can happen is you can change the pharmacodynamics of the insulin, the time action of the insulin. For example, if you look at U-500 insulin compared with U-100 regular insulin, U-100 insulin is primarily a mealtime insulin and usually has to be combined with something else. With U-500, the time action is changed to the point where it can provide both a basal and a prandial component and reduce the number of insulins you have to take and the number of injections.

If you have patients who are on high doses of insulin, concentrating that insulin again will reduce the number of injections because it becomes a more manageable volume. There are also data to suggest that you do reduce injection site pain, and if you reduce pain, then you’ll improve compliance.

Finally, even with patients who are not very insulin resistant, you can get a benefit from decreasing volume. That pen device will last longer. Concentrated insulins are not just for the insulin-resistant patient; they also have utility in people who are less insulin resistant. For example, if you look at the U-200 lispro pen, they’re going to be changing that out half as frequently, even when they’re not on a high-dose insulin. When you think about it, if you’re someone with diabetes, you’re supposed to get 30 units of insulin right now, you dial your pen, and it stops at 20 units. What’s going to happen? Are you going to throw the 20 units out, get another pen, and give 30 units? Or are you going to give the 20 units and get another pen and give a second injection? Or are you just going to give the 20 units?

None of those things are good outcomes. The less often we have to change out our delivery systems, the better. This also goes for some patients with insulin pumps who require large amounts of insulin. It just becomes difficult changing out reservoirs so frequently. Using more concentrated insulin makes pump therapy more livable. So we can get improvements in PK/PD [pharmacokinetics/pharmacodynamics] or time action of the insulin. We can give large doses to the insulin-resistant patients with fewer injections and less discomfort. In patients who are not so insulin resistant, we can even change out our delivery systems less frequently to improve their lives.

Transcript edited for clarity.