Clinical
Diabetes 19:146-147, 2001 © American
Diabetes Association ®, Inc., 2001
Insulin
Therapy for Diabetes: Is the Future Now?
Irl B. Hirsch, MD,
Editor
On
a recent consultation for the inpatient
endocrine service, we were asked
to see a 38-year-old woman with a 22-year
history of type 1 diabetes. Her
admission had nothing to do with diabetes,
but she was on dialysis for end-stage
renal disease, and she was blind
from retinopathy. She was receiving a
fixed-mixed ratio of twice-daily
insulin but noted that for most of her life
with diabetes she was prescribed once-daily
insulin.
Are
these stories ever going to go away, or will
they continue until there is a
"cure"? My concern is that this
all-too-common scenario will not
disappear for many years.
At
a recent meeting with more than 100
endocrinology fellows in the
audience, I asked the group how many of them
received formal training in the
use of insulin therapy. To my surprise,
fewer than 10 raised their hands.
Several years ago, another endocrine
fellow told me that during his 2-year
fellowship, he did not manage
even one patient with diabetes. These
diabetes experts of the future
are not receiving the critical training
or learning about the "clinical
pearls" they must know in order to
make the best use of insulin to help
patients achieve HbA1c targets
while minimizing the risk for hypoglycemia.
I
have thought for many years that most
endocrinologists do not really
learn how to manage insulin therapy until
their formal training is
completed and they are out in the "real
world." This, of course,
includes insulin pump therapy. By the same
token, it is safe to say we need to
take a long, hard look at the way
we train primary care residents in the use
of insulin.
One
problem with insulin therapy is that there
is no standard for how best to
use this medication. This is very different
from, say, the treatment of
hypertension in patients with diabetes.
For the latter, there is not only
consensus for treatment target goals,
but also agreement about which agents to use
first and which combinations work
best. A similar situation exists for the
treatment of hypercholesterolemia in
patients with diabetes. However,
with insulin therapy, it almost seems that
there are as many different
strategies as there are experts.
To
me, the confusion and lack of consensus is
quite understandable. Truly
understanding issues such as when to use
regular insulin, when it would be
better to use insulin lispro (Humalog) or
aspart (Novolog), when it would
be reasonable to use morning NPH without
lunchtime insulin, and what the
differences are between ultralente insulin
and insulin glargine (Lantus) simply
requires a great deal of
experience. Perhaps that is why many
endocrinology fellows note that
their best opportunity for learning insulin
use is to work at camps for
children with diabetes. This
"real-world" scenario
vastly differs from the often sterile
clinics of their training
programs.
The
problem of teaching students and young
physicians about insulin therapy
is not new, but it seems magnified now
because of the recent
introduction of two new insulin preparations
into the United States. And what
about physicians who are already in
practice and have been so for perhaps
several decades? How do these
doctors learn about emerging strategies for
insulin therapy?
The
answer is that many of them don’t. At one
recent conference, an internist
mentioned that this was the first
diabetes-related program he had
attended in more than 10 years. Ten years
with no continuing medical
education (CME) related to diabetes—think
of all of the changes we have seen in
diabetes treatment in the past
decade! The Diabetes Control and
Complications Trial; the United
Kingdom Prospective Diabetes Study; the
effects of angiotensin-converting
enzyme inhibitors, aspirin, and statins;
the elimination of animal-species
insulin; and the introduction of
metformin, insulin lispro,
thiazolidinediones, alpha-glucosidase inhibitors,
minimally invasive glucose monitoring,
insulin aspart, and insulin
glargine are only a few of the recent
advances in diabetes care. With
no formal training for the past 10 years,
how can physicians keep up? They can’t.
More
training is required, and I believe that, of
all of the areas of diabetes, the
need for further education about insulin
therapy should be a priority. In my
experience, very few physicians feel
comfortable with insulin therapy, especially
those who have recently completed
their training. This is particularly concerning
because it has been predicted that an
estimated 26% increase in insulin
use among type 2 diabetic patients in the
United States will occur over the next
5 years.1 Given
the epidemic proportion of type 2
diabetes in younger patients, especially
women of child-bearing age, I wonder
if this is actually an underestimate.
So
how do we go about improving this situation?
One obvious answer is to place
more emphasis on insulin therapy in both
graduate and postgraduate medical
education. The 45-min medical student
lecture or 30-min dinner lecture before a
baseball game or Broadway show
has not worked. More time is needed because
no matter how simple we try to make
it, insulin therapy is more complicated
than most other treatments in medicine.
Half-day or day-long CME seminars
are required, perhaps as part of a national
program.
Furthermore,
it would be ideal if there were more
standardization in how to best
use insulin. This may be more difficult to
accomplish. Still, the new
insulin analogs that are specifically
designed for prandial needs and
basal replacement may do more toward building
a consensus on how best to use insulin than
anything else since its
discovery.
One
concern already described since the
introduction of insulin glargine
is the inappropriate use of this basal
insulin for prandial replacement.
It needs to be emphasized that patients
with type 2 diabetes already doing
well on twice-daily injections of
NPH and regular (or NPH and insulin lispro)
should not be switched to
once-daily insulin glargine. Patients
already requiring both prandial
and basal insulin rarely are able to alter
the natural progression of b-cell
deficiency so that only basal insulin
will be required. The more likely scenario
is that maintaining target HbA1c
concentrations over time will require a
multi-component insulin regimen
with both prandial and basal elements. The
concept of switching patients
from two injections to one shot, or from
three injections to two is a message
many patients would like to hear.
But it is not consistent with our current
understanding of the pathogenesis
and natural history of type 2 diabetes.
Again, this is all remediable with
better education.
During
the next few years, we will likely see the
introduction of more new basal
and prandial insulin analogs, including
different preparations of
pulmonary inhaled insulin. Perhaps this will
remove some of the stigma of insulin
therapy in the minds of both
physicians and patients.
The
potential future of insulin therapy in this
country should be quite bright.
We now need to better train ourselves and
our patients to use this
important peptide in the best possible ways.
REFERENCES
1
Sylvester CJ: UBS Warburg Research Note.
Generex Biotechnology, July 9, 2001
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