Barriers to Traditional Insulin Therapy

Louis S. Christos, RPh: When you look at the ADA [American Diabetes Association] guidelines, they recommend, for anybody over 10% A1C, that you should initiate insulin therapy. I don’t think that really happens in the real world. There are a lot of issues around insulin—things that come up between a physician and a patient that limit the use of insulin. But when you also look at the number of patients who are on multiple oral therapies, whether they’re on 2 or 3 drugs, ideally, you would think that they would be candidates for insulin because they’re not getting enough subsequent A1C reduction as they add on additional orals. So, the proportion of patients that would require insulin—my perception is probably on the higher end, we just don’t see that in the real world because there are issues and stigmas associated with the use of insulin.

Use of insulin has always been an issue with patients because they think once they have to go to insulin that their disease is worse than they thought. They don’t want to understand or comprehend that they have a severe disease. That’s one issue, and I think that’s probably the main one. Use of insulins, the needles, is another concern. Patients just don’t want to self-inject. These patients are on, potentially, a basal mealtime therapy (3, 4 shots a day) and they can’t handle the number of injections. The other things are obviously the issues associated with the insulins themselves, in terms of side effects. They are notoriously associated with weight gain and high rates of hypoglycemia.

In hypoglycemia, obviously if it’s severe or life-threatening, the condition would require medical intervention, so that’s an additional cost and additional difficulty in managing those patients. And the weight gain is obviously a concern. These patients are already overweight to begin with, and the ADA has already had a policy in place in terms of addressing weight reduction. And that would be counterintuitive to treating somebody. Yes, you’re lowering your A1C, but if you’re causing that patient to gain weight, then you are also, maybe, contributing to some of the symptoms of the diabetes and some of the comorbidities that are associated with it.