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Translating the Science of Digital Insulin Titration into Practice

Mar 13, 2019 11:32:28 AM / by Barbara Eichorst, MS, RD, CDE

Years ago, when I was working as a dietitian at a diabetes clinic, part of my job was to help people with type 2 diabetes (PWD-T2) titrate their insulin. Being a dietitian, most of the adjustments were related to meal planning, like manipulating food to achieve desirable glucose goals. PWD and I were figuring out the carb to insulin ratio, the right amount of protein vs. fat, and meal/snack timing. Unfortunately, the insulin adjustment conversations always ended in “Talk to your doctor about your insulin adjustment.”

However, most PWD never followed up with their doctor; most continued to struggle with eating habits, activity levels, fear of hypoglycemia, omitting injections, confusion about injection frequency, pain, embarrassment, and the list goes on.  

Insulin titration was like a forgotten art, one that could make a difference in daily glucose levels and make people feel better. Despite the efforts to help PWD titrate, the majority of PWD taking basal insulin were not able to achieve desirable glycemic goals. Only a fraction of healthcare professionals (HCPs) were providing ongoing insulin titration instructions to PWDs.  

Insulin initiation and education on personalized titration.About fifteen years later, when I became a Certified Diabetes Educator (CDE), my job became completely focused on helping PWD titrate basal insulin. I was working with hundreds of doctors and their patients in the Chicago area to initiate insulin and provide them with necessary titration algorithms. It was good because we were educating PWD and HCPs about titration and setting up corresponding, personalized strategies. 

However, the way we did it was not ideal - pen and paper directions were complex and confusing. Since numeracy is a challenge for most PWD, the majority were not able to correctly calculate an insulin dose based on glucose levels, and errors in manually calculating their insulin were very common. 

Fortunately, so much has changed since then. Basal insulin titration is part of daily self-management and is a means to reach desirable glycemia sooner. The newest standards of care indicate the need to equip PWD with a self-titration algorithm. 

Now we have a choice when it comes to reliable and valid algorithms, like FDA cleared insulin titration apps that are types of digital therapeutics. These solutions allow PWD to self-adjust basal insulin doses based on instructions from their HCP. This new process can simplify the longstanding pen and paper method, as HCPs can access real-time data and empower PWD to self-regulate their treatment.  

Jeanne Jacoby, FNP-BC, CDE and Director, Medical Affairs – Diabetes at Voluntis, indicated, “There is no point in starting basal insulin without titrationBasal Insulin Titration Algorithm to get to the right dose - otherwise, it is like spitting in the ocean.”  

Jeanne says evidence indicates that A1C reductions correlate with daily insulin dosing. Consequently, each PWD who is taking basal insulin needs to focus on identifying the optimal daily dosage. There is no longer a reason for delaying the correct daily dosing of basal insulin as there are safe and accurate dosing algorithms available to help PWD and HCPs titrate effectively.  

My current professional practice is to help HCPs to utilize digital therapeutics to titrate basal insulin. Many PWDs lack confidence in their ability to self-titrate, fear hypoglycemia and feel overwhelmed with the complexities of insulin treatment. HCPs face challenges as well; uncertainties regarding initial dosing and corresponding increases, struggle with implementing titration protocols in a busy practice, and logistical challenges communicating effectively with PWD during and after initiation and titration. 

The good news is that there is now evidence that insulin self-adjustment can facilitate earlier, and effective, insulin use in routine medical practice. This helps HCPs and PWD adhere to the recommended standards of diabetes care.   

Listen to our podcast for the Top Five Actionable Tips to help your PWD with Titration:

 

Topics: titration, cde, hcp, pwd, insulin optimization, insulin affordability, insulin therapy, medication optimization, dsmes, digital insulin titration, insulin titration

Barbara Eichorst, MS, RD, CDE

Written by Barbara Eichorst, MS, RD, CDE

Barbara is the Diabetes Clinical Liaison at Voluntis. Previously, she has been a Vice President of Clinical Care responsible for leading a global patient-centric self-management education of 126 countries. Barbara’s experience from the last 20 years includes working with a national insulin titration initiative, directing provider and approver units at the American Association of Diabetes Educators, managing a diabetes education program at Rush University Medical Center, and providing patient care at Chicago based academic institutions such as Loyola University Medical Center and Northwestern Memorial Hospital. Barbara’s professional focus is on behavioral interventions in disease management, insulin titration, and digital therapeutics. She has contributed to multiple publications, public speaking, and key opinion leadership with her expertise in diabetes patient/provider engagement, self-management education, insulin titration and digital therapeutics.

Discussion Question: What challenges do you face when incorporating digital insulin titration into your practice?

Insulia® is a prescription-only software medical device intended for use by healthcare professionals and their type 2 adult diabetes patients treated with long-acting insulin analogs as an aid in the management of diabetes. Please carefully read product instructions before use. Insulia is only indicated for use with insulin detemir (Levemir® U-100) once or twice daily, insulin degludec (Tresiba® U-100) once daily and insulin glargine (Lantus® U-100, Toujeo® U-300 and Basaglar® U-100) once daily. Insulia should not be used for basal dose recommendations with intermediate-acting insulin (NPH – Neutral Protamine Hagedorn) nor with premixed insulin. Insulia is not intended for use by pregnant women, non-adult patients or patients that are treated with a basal-plus or a basal-bolus regimen (i.e. including multiple mealtime insulin injections per day or insulin pump therapy).
 
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