For providers treating people living with type 2 diabetes who are on insulin, the ability to make timely adjustments to therapy when a patient’s treatment goals are not met is key to optimal management. During the Friday, June 3, session, New Strategies for Insulin Use in Type 2 Diabetes, a panel of experts discussed how diabetes technologies, in conjunction with multidisciplinary care and support, can help address the factors that contribute to delays in implementing the most effective care.
The session was livestreamed and can be viewed on-demand by registered meeting participants at ADA2022.org. If you haven’t registered for the 82nd Scientific Sessions, register today to access the valuable meeting content.
Thomas W. Martens, MD, Medical Director, International Diabetes Center, HealthPartners Institute, began the session with discussion on the use of continuous glucose monitoring (CGM) to optimize glycemic management for people with type 2 diabetes on basal insulin or basal-bolus insulin regimens.
“If you look at the population in general, about 28% of people with diabetes overall fail to achieve an A1C less than 8%, but if you look at people managed with insulin, that number increases to about 38%,” Dr. Martens said. “And if you look at the number of individuals achieving an optimized A1C goal, you’re looking at about 70% of people on insulin who fail to get their A1C down below 7%.”
Addressing this “glycemic gap,” particularly in the primary care setting is a challenge, largely due to the time constraints of a busy primary care practice and a lack of training and comfort with insulin titration, he said.
“Overall, there are just too few touchpoints for titration—we simply don’t see people frequently enough,” Dr. Martens said. “Therapeutic inertia is the elephant in the room when we think about insulin management in primary care, and the task is to create a framework for success in primary care to help people with type 2 diabetes managed on insulin succeed.”
The application of CGM-guided titration in primary care can be an important element in creating that management framework and overcoming therapeutic inertia.
“Having the CGM or ambulatory glucose profile data easily available at every visit, at every touchpoint, and ideally available in the electronic medical record, along with team-based support for multiple daily dose insulin management, can help us build that framework for success,” Dr. Martens said.
Neda Rasouli, MD, Professor of Medicine in the Division of Endocrinology, Metabolism, and Diabetes, and Director of the Diabetes and Endocrinology Clinical Trial Program at the University of Colorado Anschutz Medical Campus, followed with a review of lessons learned on effective insulin management from Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE).
“GRADE was designed to help guide the choice of glucose-lowering medications that would be added to metformin based on the effect on A1C and duration of effectiveness, effects on complications, tolerability, and adverse events,” said Dr. Rasouli, one of the principal investigators for GRADE.
In comparing the four treatment groups in the study, she said insulin therapy was superior to glimepiride and sitagliptin and similar to liraglutide in achieving A1C below 7%.
“However, despite the attention paid to participants and the provision of free care, most participants failed to maintain treatment targets and A1C rose over time in all four treatment groups, including glargine insulin,” Dr. Rasouli said. “So, therapeutic inertia is real, even in the clinical trial setting.”
Viral Shah, MD, Associate Professor of Medicine and Pediatrics, Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, discussed the utility of connected insulin pen systems in improving glycemic management.
Missed insulin doses is one of the key contributors to therapeutic inertia, he said, citing data from various studies in which up to 30% of people with type 2 diabetes reported missing at least one basal insulin dose per month.
“If we can solve this problem, we can improve the A1C for many of our patients, and this is where the technologies, such as connected insulin pens, can help,” Dr. Shah said.
In conjunction with CGM, he said that connected insulin pens will allow providers to look at both glucose and insulin data.
“Insulin data without glucose data may not improve the outcomes, but if you use both data together, that’s where you can improve the outcome and move the needle further,” he said. “As the technology improves, I believe connected insulin pens will be beneficial in selective patients, particularly those patients who are missing their insulin often, or who have a higher A1C, or have problematic hypoglycemia and insulin stacking issues.”
Georgia M. Davis, MD, Assistant Professor of Endocrinology, Metabolism, and Lipids at Emory University School of Medicine, concluded the session with a discussion of the potential for automated insulin delivery in the management of type 2 diabetes.
“We have learned that automated insulin delivery is superior to other technologies for type 1 diabetes and that it may also be effective in type 2, as recent evidence shows a significant improvement in glycemic control with automated insulin delivery in diverse populations with type 2 diabetes,” Dr. Davis said.
While early data is promising, she said further clinical trial data is needed to understand the potential benefit of automated insulin delivery compared to conventional therapy in type 2 diabetes in both outpatient and inpatient settings.
“We need more studies to assess the effectiveness of automated insulin delivery, including cost analyses, in real-world settings,” Dr. Davis said. “Then we need to continue to develop algorithms for insulin adjustment that may be tailored to special populations, people at higher risk for hypoglycemia for example, and various clinical scenarios.”