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Optimizing Treatment Strategies for Diabetes - Episode 8

Barriers to Optimal Treatment for Patients With Diabetes

Dr Meece navigates insulin therapy education and ensuring patient adherence.

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Jerry Meece, RPh, CDCES, FACA, FADCES: A study [that was published] in Diabetes & Metabolism in 2021 showed a 1% decrease in patients over 60 years old. There was a 1% decrease in A1C [glycated hemoglobin] in people who were using the pen vs the vial and syringe. If you go back to the practicality of it, if you’ve ever watched someone draw up a vial of insulin in their syringe, very often they’re missing it. Ten units isn’t quite 10 because of that little rubber stopper—it’s 9 or 9½. They found out that when this population dialed up 10 units in a pen, it was 10 units. That’s nice. What you see is what you get.

[There are also] new connected pens that are so good. They remind us when we should be injecting. They give us data we can download and follow. It’s an even greater argument for improved control. We finally jumped that hurdle. Everything is going the way of insulin pens, but we still need to know the proper way to use them as far as the needle fitting a pen. In your experience, can we answer this question? Are most pen needles universal? Do they fit most insulin pens?

Jennifer D. Goldman, RPh, PharmD, CDCES, BC-ADM, FCCP: They do now. Ten years ago, that wasn’t the case, but now the majority available are interchangeable. We’re able to provide needles that are covered on someone’s insurance, but the 4-mm needles are universal across all different pens.

Jerry Meece, RPh, CDCES, FACA, FADCES: Good to know. To that point, and developing it a little further, when a patient is starting insulin and is given [insulin] glargine and we’ve talked about the dose, how do you go about initiating insulin therapy? How do you prepare someone for the first time they’re going to start using insulin? What steps do you take? How are you going to instruct them? What are you basing what you’re telling them on? Take us through the process of talking with a patient about their insulin.

Jennifer D. Goldman, RPh, PharmD, CDCES, BC-ADM, FCCP: I make sure to have the conversation about insulin very early when I meet a patient. Even if they aren’t going to use insulin right then, lots of people need to have insulin, and we need to create a positive message.

When I talk with pharmacists about insulin, I remind them to stay positive and remind patients that this is a good thing. Nothing is worse than a patient talking to the pharmacist and saying, “My doctor wants me to start insulin, but I don’t want to,” and the pharmacist going along with that conversation and saying, “That’s terrible. I’m sorry to hear that.” They need to switch it to: “That’s great news, because [that means] you’re going to feel better.” I’ve been focusing on diabetes for 25 years. There isn’t 1 person whom I started insulin on who didn’t feel better once they started insulin. We need to remind people that this isn’t a punishment. It is what it is. We’re replacing a hormone that they need, and they’re going to feel better.

The other thing that pharmacists need to know is to start low and go slow. It’s very important to do that. The other reason that we need to start low is because if somebody has been walking around with high blood sugar and we bring them down quickly, they’re going to feel like they have hypoglycemia even if their blood sugar numbers aren’t numerically low. If they’re used to walking around at 300 mg/dL and we bring them down to 150 mg/dL, they aren’t going to feel well.

The American Diabetes Association guidelines also have specific steps and recommendations for initiating insulin. For most people with type 2 diabetes, we start a GLP1 receptor agonist as the first injectable. That’s what’s recommended. But there are people who need insulin. That might be someone who’s newly diagnosed with a high A1C or someone who has had diabetes for years and now their blood sugars are going up. If either one is symptomatic, they might need insulin.

The recommendation is that you can start with 10 units of basal insulin or you can do 0.2 units per kg once a day then increase by 2 units every 3 to 4 days to target a specific blood sugar. [If the goal is] tight control, we might target 80 to 130 mg/dL and then stay at that dose. If someone has a higher goal, we might target 100 to 130 mg/dL. But what’s most important is to give them the instructions on how to empower themselves to self-titrate at home and not give them 10 units and say, “We’ll see you in 3 months” or “We’ll see you in 6 months.” They have to be titrated to that target. We want to do that, but we also have to make sure they’re prepared to prevent hypoglycemia and that we’re having that conversation if we’re starting insulin, because the biggest concern patients have when they’re starting insulin is hypoglycemia. Make sure they’re prepared and that they have glucagon for an emergency.

Jerry Meece, RPh, CDCES, FACA, FADCES: There are 2 or 3 really good guidelines out there for starting insulin. You’re right. Especially when Lantus [insulin glargine] started out, we were titrating by appointment. The doctor would prescribe 10 units, see [the patient] 3 months later, and then move to 14 units. Now we do this much more rapidly. It’s where pharmacists could play a huge role with things like collaborative practice agreements. If you send someone into my pharmacy with glargine, and we’re going to start them at even 10 units, we’ll move them up X number of units every few days, according to our agreement, until they’re at goal 50% of the time. We can do that. It takes a huge burden off the practitioner, in which they can almost write insulin and move up in dosage as easy as they can write an oral medication. It’s important to be able to do that.

Transcript edited for clarity.

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