When Insulin Intensification Is Needed

Serge Jabbour, MD, and Jasmine D. Gonzalvo, PharmD, discuss the need for insulin intensification in patients who are not reaching their glycemic targets on their current regimen.

Serge Jabbour, MD: When we see patients with type 2 diabetes, one thing I explain to them all the time is that by the time they see me for the first time, they probably had diabetes for many years and they’ve lost at least 80% of their beta cell function—which means at some point in the next 5 to 10 years, their beta cells are going to burn out completely. That’s why many patients with diabetes would end up needing insulin. So, it’s a disease where you have progressive destruction of the beta cells, and insulin is something many patients with diabetes will need at some point. Insulin works all the time, most of the time, as long as you use the right combination and you titrate the insulin the right way.

The problem is, when patients end up on basal insulin at mealtime, which typically is 4 injections a day, sometimes more—it depends on how many times they eat per day—compliance can be a factor. Patients don’t want to inject that many times a day. If they adopt noncompliance, their A1C level will never be at goal. And high A1C, as we know, is linked to many complications like retinopathy, nephropathy, and, over time, also CV events like heart attack and stroke. That’s why finding a way to give the insulin in fewer injections per day will improved compliance and achieve the goal of an A1C level of less than 7%, as defined by the ADA [American Diabetes Association] guidelines.

Jasmine D. Gonzalvo, PharmD: The barriers for increasing insulin, or really taking insulin as prescribed, most often relate to the cost of insulin and cost of diabetes medications or diabetes supplies. Weight gain is another obstacle or barrier for people who would maybe need to increase their insulin doses. Oftentimes, patients know that weight gain comes along with insulin dose increases. And so, weight gain can be a very common barrier for patients who want to increase their dose or who even just decide not to increase their insulin dose. From there, the only other barrier that I really see is this idea that patients think increasing insulin doses are too high, and it feels like too much medication. Not wanting to take so much medication is another barrier to insulin intensification or dose increases.

Serge Jabbour, MD: When we start insulin therapy and we titrate the insulin dose—that could be basal, mealtime—to get the sugars down to goal, we find that there are patients who may need high doses of insulin. Sometimes, it’s a high dose for 1 injection, where the pen cannot give you the full dose in 1 single shot. For example, there are mealtime incidents where, when you dial the dose in the pen, it doesn’t go above 60 units. With basal insulin, it could be up to 80 units. So, when a patient needs more than that amount for 1 injection, they have to inject twice at the same time. There are patients who may end up not only on 4 shots a day but even on 6 or 7 shots a day. That can affect compliance, which can lead to higher blood sugars or high A1C levels over time. That’s why there was a need at some point to find ways to improve compliance and make sure patients get a higher dose of insulin per injection, getting less volume when it comes to injecting insulins.