Advances in Insulin Delivery Systems - Episode 2
Drs Diana Isaacs and Natalie Bellini discuss selecting the right insulin delivery method for patients with diabetes, and the challenges that arise with insulin injectables.
Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: One of the things I wanted to mention is the ICC framework, which stands for “identify, configure, and collaborate.” This is a way to individualize therapy. In the identify step, it is identifying the right medication, or the right technology for the right person at the right time, taking into consideration person-centered needs and features. For example, not everyone loves giving themselves injections. We have the wearable insulin devices, insulin pumps, and inhaled insulin, which offer a way to not have to give quite so many injections. Then, the configure step is making sure that we provide the education; that we don’t just throw a drug or throw a technology on a person. We spend that time setting it up and explaining how it works and customizing it. Lastly, collaborate is then assessing how it is working, going through the data, going through the glucose values, continuous glucose monitoring [CGM] values, and adjusting things as needed. Natalie, are there any other methods in terms of the need to select the right technology, or the right medication, for the right person at the right time?
Natalie Bellini, DNP, FNP-BC: Talking to each other as colleagues, we both have started using a website called Diabetes Wise, [which is] specifically targeted both for patients and providers. There are 2 separate entities, 1 for patients and 1 for providers, because we all get confused after a while and think, “What is the best thing for my patient right now? Am I thinking of everything? Is there something that I’m missing?” When we use the ICC framework, it is something that we need to use every time a patient walks in the door. Is there something new? Is there something different? Has an indication changed where we can use something in a patient that we couldn’t before? Diabetes Wise is a website that brings that together for us so that we can go there and say, “How do I do this, what do I need to do, and what options are available for my patient?” One of the things I like is that I can go to the website and say, I’m looking to prescribe this, and based on their patient insurance, tell me how to get it done. And you can do it by state. You want to use whatever it might be, a CGM, a pump, or inhaled insulin for a patient. They have this kind of insurance, private, Medicaid, or Medicare. How do I get it done? It gives you a stepwise approach to help you answer those questions.
Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: That’s such a great resource. I love that there’s…the Diabetes Wise for patients, and there’s the Diabetes Wise for professionals. We can have people with diabetes look through it, and it helps with the health care professional side. Then there’s one other resource I found great as well. It’s called Danatech and is available through the Association of Diabetes Care and Education Specialists…. It used to be that you had to be a member, but now it’s totally free. It has a similar feature where you can look up what’s covered by the type of insurance. I recently looked through it, and it was very up-to-date. It’s another great way to stay informed, but we encourage people to stay up-to-date with what’s out there because the options are exploding, and we just want to make sure that we’re offering choices. Unfortunately, most of the individuals who are on mealtime insulin are using vials and syringes, or standard insulin pens. I don’t think that’s because they said, “This is what I want to be on” or “I think this is the best.” It’s because no one told them that there are other options like inhaled insulin, wearable insulin, connected insulin pens that help you calculate your doses, and insulin pumps. Nobody told them, especially in type 2 diabetes where a lot of times they’re not as likely to be offered new options.
Natalie Bellini, DNP, FNP-BC: I agree with you wholeheartedly. The other side of it is that the patient feels guilty. The patient is forgetting mealtime insulin, or skipping it because they’re embarrassed or they don’t want to carry it with them, or they don’t know how to do those things, or they simply forget. Our patients are people, and we all need to continually remember that. They have lives to live just like we do. There’s a point we get to where instead of blaming a patient for forgetting mealtime insulin, we need to remind, or help them to remember and take that ICC framework and say, “What will help my patient do this better?”
Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: There are so many challenges to taking mealtime insulin—like you said, it’s easy to forget it. Another scenario can be that someone doesn’t remember if they already took it or not. Then, that person must make the difficult decision: do they double dose, or do they just completely skip it? Some people have challenges with calculating their doses, or just knowing how much they should take for certain food, or complications and obstacles. What adverse effects have you seen with insulin injections?
Natalie Bellini, DNP, FNP-BC: The number one adverse effect is hypoglycemia. What if a patient thinks that they might have done it, but they’re worried that their blood sugar’s going to get high? They feel guilty when they show up back at their provider, so they take 2 doses by mistake. They say, “I must not have done it.” Then, the biggest side effect is hypoglycemia. Another one is if a patient continues to give injections in the same area, they can get lipohypertrophy, or lipoatrophy. Insulin isn’t absorbed in the same way that we expect it to consistently absorb. Their blood sugars can fluctuate from that, and we can have all kinds of other issues.
Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: Absolutely. Even though we advise to rotate sites, unfortunately, a common thing is that people will rotate on each side of their abdomen, but they go to the same 2 spots all of the time. Then, they end up developing nodules and things that can then make it difficult to actually absorb the insulin. Also, what we’ve seen in thin people, or people using needles that are too long, is that they end up injecting into the muscle, which causes erratic insulin absorption and can contribute to hypoglycemia. There are a lot of potential effects.
Transcript edited for clarity