InsulinInsulinElixir of lifeElixir of life

Dr. Sergio Diez AlvarezDr. Sergio Diez AlvarezStaff Specialist PhysicianStaff Specialist Physician

The ChallengeThe Challenge Mr XL has type 2 diabetes and has Mr XL has type 2 diabetes and has

been on Oral Hypoglycemic Agents been on Oral Hypoglycemic Agents (metformin + glibenclamide) for 8 (metformin + glibenclamide) for 8 months, his HbA1c is 8.3% and you months, his HbA1c is 8.3% and you have decided to offer him the option have decided to offer him the option of going on to insulin.of going on to insulin.

In theory, there is no difference between theory and practice.

In practice, there is a big difference.-Unknown

Understand the StakeholdersUnderstand the Stakeholders The Willing PatientThe Willing Patient The Willing ClinicianThe Willing Clinician The Insulin type and RegimenThe Insulin type and Regimen The Delivery DeviceThe Delivery Device Safety AccessoriesSafety Accessories Other factorsOther factors

The PatientThe Patient Insulinopaenia – beta cell reserveInsulinopaenia – beta cell reserve Insulin Resistance – mainly hepatic, Insulin Resistance – mainly hepatic,

muscle, and adipose tissuesmuscle, and adipose tissues

Type 1 – complete insulin deficiency Type 1 – complete insulin deficiency Type 2 – Insulin dependent (LADA) Type 2 – Insulin dependent (LADA)

vs. insulin requiringvs. insulin requiring

DAWN StudyDAWN Study Resistance to Insulin Therapy Resistance to Insulin Therapy

Among Patients and ProvidersAmong Patients and Providers Results of the cross-national Results of the cross-national

Diabetes Attitudes, Wishes, and Diabetes Attitudes, Wishes, and Needs (DAWN) studyNeeds (DAWN) study

Diabetes Care November 2005 vol. 28 no. 11 2673-2679Diabetes Care November 2005 vol. 28 no. 11 2673-2679

PatientsPatients Patients rate the clinical efficacy of insulin as Patients rate the clinical efficacy of insulin as

low and would blame themselves if they had low and would blame themselves if they had to start insulin therapy. to start insulin therapy.

Self-blame is significantly lower among those Self-blame is significantly lower among those who have better diet and exercise adherence who have better diet and exercise adherence and less diabetes-related distress. and less diabetes-related distress.

Patients who are not managing their diabetes Patients who are not managing their diabetes well (poor perceived control, more well (poor perceived control, more complications, and diabetes-related distress) complications, and diabetes-related distress) are significantly more likely to see insulin are significantly more likely to see insulin therapy as potentially beneficial. therapy as potentially beneficial.

The ClinicianThe Clinician Most nurses and general practitioners (50–55%) delay Most nurses and general practitioners (50–55%) delay

insulin therapy until absolutely necessary, but insulin therapy until absolutely necessary, but specialists and opinion leaders are less likely to do so. specialists and opinion leaders are less likely to do so.

Delay of insulin therapy is significantly less likely Delay of insulin therapy is significantly less likely when physicians and nurses see their patients as when physicians and nurses see their patients as more adherent to medication or appointment more adherent to medication or appointment regimens, view insulin as more efficacious, and when regimens, view insulin as more efficacious, and when they are less likely to delay oral diabetes they are less likely to delay oral diabetes medications. medications.

Resources were considered barely adequate currently Resources were considered barely adequate currently and there were concerns about worsening problems and there were concerns about worsening problems with increasing numbers of patients with diabetes, with increasing numbers of patients with diabetes, and increased use of insulin and increased use of insulin

Clinicians ShiftingClinicians Shifting 1980s - clinicians tended to be more 1980s - clinicians tended to be more

pessimistic than patients and pessimistic than patients and overestimate the barriers complying overestimate the barriers complying with treatment. with treatment.

Insulin was seen as efficacious but Insulin was seen as efficacious but there was resistance because of a there was resistance because of a lack of support, a skills deficit, and a lack of support, a skills deficit, and a lack of confidence and experience in lack of confidence and experience in starting insulin. starting insulin.

Psychological ResistancePsychological Resistance Remember – at time of Diagnosis 50% Remember – at time of Diagnosis 50%

of of --cell function is already lost.cell function is already lost. Insulin must be regarded asInsulin must be regarded as

““expectedexpected therapytherapy”.”. Not Not “Failure”“Failure” Not Not “Last Resort”“Last Resort” NotNot “End-stage therapy” “End-stage therapy”AND SHOULD BE STARTED MUCH AND SHOULD BE STARTED MUCH

EARLIEREARLIER

Innovators vs. Conservative CliniciansInnovators vs. Conservative Clinicians

History of InsulinHistory of Insulin Insulin first isolated 1921 by Banting and BestInsulin first isolated 1921 by Banting and Best Insulin first used as a treatment for diabetes in Insulin first used as a treatment for diabetes in

1922 1922 Had short duration period and required several Had short duration period and required several

daily injectionsdaily injections Had to be given through reusable glass syringes Had to be given through reusable glass syringes

with large often blunted needleswith large often blunted needles

The Insulin TypesThe Insulin Types Human vs. AnalogsHuman vs. Analogs Long Acting Insulin (Basal)Long Acting Insulin (Basal) Short Acting Insulin (Bolus)Short Acting Insulin (Bolus) Pre-mixed InsulinsPre-mixed Insulins

http://en.wikipedia.org/wiki/Image:Insulin.jpg

24-hour plasma glucose and insulin 24-hour plasma glucose and insulin profiles in healthy individualsprofiles in healthy individuals

Owens DR et al. Lancet 2001;358:739–746

The Lancet, 2001, Vol 358, pages 739–746.

Insulin RegimensInsulin Regimens There is NO best Insulin – there There is NO best Insulin – there

is only the Right Insulin for the is only the Right Insulin for the Right PatientRight Patient

Daily Bolus (in combination with OHA's)Daily Bolus (in combination with OHA's) Twice daily Twice daily Basal bolus Basal bolus Basal plus 1,2,3Basal plus 1,2,3 CIISCIIS These can all be used in combination with OHAs These can all be used in combination with OHAs

( especially insulin sensitizing agents)( especially insulin sensitizing agents)

Delivery DevicesDelivery Devices SyringesSyringes Pen-sets – disposable or RefillPen-sets – disposable or Refill Continuous Insulin Infusion PumpContinuous Insulin Infusion Pump

Glucose MonitoringGlucose Monitoring Standard (simplified) GlucometerStandard (simplified) Glucometer Blood Ketone measuring (for Insulin Blood Ketone measuring (for Insulin

dependent patients)dependent patients) Continuous Glucose Monitoring Continuous Glucose Monitoring

DeviceDevice

Other (important ) FactorsOther (important ) Factors

FamilyFamily Friends (peers or colleagues)Friends (peers or colleagues) Co-morbiditiesCo-morbidities Diabetic Complications e.g. Diabetic Complications e.g.

retinopathyretinopathy Media (including internet)Media (including internet)

After Sales StrategyAfter Sales Strategy

Match the regime to the patientMatch the regime to the patient What is the target HbA1c?What is the target HbA1c? How avidly should hypos be avoided?How avidly should hypos be avoided? How many injections is the patient How many injections is the patient

willing to give?willing to give? Fasting or postprandial the greater Fasting or postprandial the greater

problem?problem? What device can the patient use?What device can the patient use?

%

con

t ribu

ti on.

40

60

80

100

0

Relative contribution of FPG & PPG to hyperglycaemia.

65

17

31

FPG contribution.

PPG contribution.

83

69

35

<7.3% 7.3%-8.0% >8.0%HbA1c tertiles :

20

p=0.048

p=0.001

(12 hour profile)

Peter R, Owens DR et al- Diab Med- 2004

ComplicationsComplications LipodystrophyLipodystrophy Lipoatrophy & lipohypertrophyLipoatrophy & lipohypertrophy