Finding Value in Today's New Insulin - Episode 8
Kenneth Snow, MD, MBA: I think that raises, though, one challenge that the payer side faces—whether it’s in 1 syringe or 2 (the therapeutic options that are available, and they’re available as separate agents), the opportunity to combine them into 1 syringe, of course, is better for a patient. It’s easier. It’s only 1 injection versus 2, and that most likely (we don’t definitely have data on that specific issue), leads to improved adherence, which of course is very important. But at what cost does that convenience come? It’s not medically going to be any better, so it is, in a way, a convenience issue, but a very important convenience issue if they’re not adherent.
Zachary Bloomgarden, MD: This is where you guys have to work with each other. Pharmaceutical, managed care, physicians, and patients all have to be on the same page and say, “Okay, if it exists as 1 shot, and it’s so much easier for the human being with diabetes to accept 1 injection than 2, let’s all strive to make that 1 injection be available because it will pay off.”
Dennis P. Scanlon, PhD: Would you agree with that, Bob? Or do you sort of try to profile patients and think about who’s the best candidate for the combination therapy?
Robert Gabbay, MD, PhD, FACP: Certainly, profiling and choosing the right person is important. I think convenience is sometimes used as a reason to say, “Well, that’s therefore not important.” I think, framing it in terms of adherence as you did, it is really the issue. Any medicine only works if people are adherent to it. They’re more likely to be adherent to a once-a-day dosing than a three-times-a-day, or whatever the comparator drug is. That said, what’s the right kind of patient for this?
There are a lot of patients that are started on basal insulin, and I think, particularly in primary care, they’ve gotten very comfortable with using basal insulin and titrating the dose up. What often has happened is there’s a large group of patients that are not well controlled, that are on basal insulin. And many of them are not controlled, not because they need more basal insulin, but they’re not able to make meal-time insulin. That’s where the GLP-1 (glucagon-like peptide-1) agonist comes in and, essentially, it becomes a choice between adding a GLP-1 agonist, which is going to have less effect on weight, less hypoglycemia, and could be the same number of injections that the patient is already on, or going to a basal bolus, which would be 3 additional injections and more weight gain. And, if you frame that to most patients, they’re going to choose door number 1 over door number 2.
Dennis P. Scanlon, PhD: Do we also need to factor in the clinician time in terms of various treatments, or the education time?
Zachary Bloomgarden, MD: This is another part of the fallacy of the Treat-to-Target Trial, based on fasting blood sugar, because, at a certain point, if you just hit the person over the head with more and more and more basal insulin to drive down the FBG (fasting blood glucose), you’re not accomplishing much.
Dennis P. Scanlon, PhD: Except hypoglycemia.
Zachary Bloomgarden, MD: Right. Except nocturnal hypoglycemia.