Therapeutic inertia is a multifactorial challenge for all of us in diabetes care. It relates to so much more than just failure to initiate or escalate therapy, and it involves many players - people with diabetes (PWD), healthcare providers (HCPs), health systems and payers.
Recently, the American Diabetes Association (ADA) started a movement with an initiative called Overcoming Therapeutic Inertia: Accelerating Diabetes Care for Life. This supports the fact that treatment intensification in the real world is not meeting the ADA Standards of Care.
Here are 10 things to know about insulin use that inspired this dialogue:
- In the last two decades, despite more therapies being available, the number of PWD with A1C over 9% has increased.
- There is a gap in what PWD are willing to do to improve A1C and what HCP believe that PWD are willing to do.
- The vast majority of people with T2DM remain uncontrolled at six months following initiation.
- The dose tends to increase only slightly from date of initiation to six months.
- Treatment intensification typically occurs after the first follow-up.
- There is a need for HCP awareness about basal insulin treatment inertia.
- Despite attempts to increase their basal insulin dose, most PWD are not able to achieve glycemic goals.
- Current insulin intensification strategies are not effective in bringing PWD to goal.
- More effective, patient-centered titration strategies are needed.
- Self-titration technologies are available; there is a need to use them because they can result in similar glycemic target achievement compared to physician-led titration.
Achievement of glycemic goals early in the course of diabetes is indicated with a growing body of evidence of “metabolic memory.” This theory supports the need to intensify treatment and get to the glycemic goals as soon as possible. Also, achieving targets sooner is associated with maintaining lower A1C for a longer time and a shorter time to goal attainment.
FDA-cleared digital therapeutics could be one of the technology solutions that help with therapeutic inertia relating to insulin use. HCPs and PWDs have the opportunity to use these technologies in real-time, with contextual coaching that can generate actionable steps needed to adjust therapy. The HCP can generate reports to guide insulin titration, and support engagement needed to minimize therapeutic inertia.
As most insulin initiation and titration takes place in primary care, it makes sense to introduce FDA-cleared titration technologies during those visits. It will require the HCP and PWD to have a productive discussion about the need for insulin intensification/titration at the time of initiation; addressing short-term vs. long-term glycemic control goals; utilizing available educational resources including titration apps and software; taking time to help build skills that are needed to explain the efficacy and safety of insulin; involving not only patients, but family members, and corresponding caregivers; creating a multidisciplinary, institutional/system-level process that makes basal insulin titration part of standards of care; addressing the reasons insulin has been recommended and why titration is part of the treatment; focusing on the availability of easy delivery devices, cost and dose flexibility; educating and re-assess injection skills and techniques; and addressing fears, side effects and weight gain associated with insulin use.
I am optimistic about the future of overcoming therapeutic inertia among the six million PWD that use insulin. Existing and new technologies have the potential to help the 14% of PWD who take insulin, and the 14.7% who take both insulin and oral medication, to maximize their potential in managing their diabetes!
- Blak BT, Smith HT, Hards M, Maguire A, Gimeno V. A retrospective database study of insulin initiation in patients with type 2 diabetes in UK primary care. Diabet Med. 2012;29(8): e191-98.
- Dalal MR, Grabner M, Bonine N, Stephenson JJ, DiGenio A, Bieszk N. Are patients on basal insulin attaining glycemic targets? Characteristics and goal achievement of patients with type 2 diabetes mellitus treated with basal insulin and physician-perceived barriers to achieving glycemic targets. Diabetes Res Clin Pract. 2016; 121:17-26.
- Michelle Mocarski, MPH; Jason Yeaw, MPH; Victoria Divino, BA; Mitch DeKoven, MHSA; German Guerrero, MD; Jakob Langer, MSc; and Brian Larsen Thorsted, Slow Titration and Delayed Intensification of Basal Insulin Among Patients with Type 2 Diabetes
- MSc Journal of Managed Care & Specialty Pharmacy JMCP April 2018 Vol. 24, No. 4 jmcp.org
- Strojek K. et al; Self- vs. Physician-Led Titration of Insulin Glargine 300 U/mL (Gla-300)—Improved or Comparable Efficacy at Week 24 without Increased Risk of Hypoglycemia, Irrespective of Age (<65 or ≥65 Years)—TAKE CONTROL. Diabetes Jul 2018, 67 (Supplement 1) 303-OR; DOI: 10.2337/db18-303-OR
- Mauricio D.et al; Glycaemic control and hypoglycaemia burden in patients with type 2 diabetes initiating basal insulin in Europe and the USA Diabetes, Obesity and MetabolismVolume 19, Issue 8, August 2017, Pages 1155-1164