DSM: Have you seen changes in how
doctors or patients view insulin therapy
in recent years? Has the role of insulin
changed due to the wider range of drug
treatments for Type 2 diabetes?
Lee: In general, I would say that there has
been a paradigm shift in terms of when we
think about initiating insulin, particularly basal
[long-acting] insulin. We used to wait until all other
options were exhausted, but insulin does not have to be
the last-line option.
If you’ve ever seen a pen needle, you can hardly see
it because it’s so tiny. And because you can carry this
pen in your pocket, and the ease of use, I would say the
barriers to starting basal insulin have been lowered on
both the clinician and patient sides.
Nathan: [I’ve seen] more willingness to use
insulin by clinicians in Type 2 diabetes and,
with appropriate discussion, by patients as well.Vella: I still get the perception that patients
perceive insulin as a last resort or punish-
ment for misbehavior and lack of compliance
with lifestyle modification. People are often surprised
when I point out that diabetes is a disease and that
even in people with medically complicated obesity,
diabetes is only present in about one third.
This is to point out that the loss of the ability to
make insulin, and the need for insulin therapy, dif-
fers between patients. What endocrinologists are
interested in is achieving good glycemic control
safely and effectively.
DSM: There’s a growing number of diabetes-
management apps and ways to sync diabetes
devices to phones and tablets. In your experi-
ence, have these developments had a meaningful
impact on diabetes care and self-management?Lee: We have all these fancy apps and differ-
ent interface options, but at the end of the
day, it matters how the patient is using it, how
the clinician is using it.
For example, with glucose values, some glucometers
can sync directly to the clinic and provider, and I think
we’re just beginning to investigate that option. So many
patients forget to bring their glucometer to an appoint-
ment. But how do we systematically allow this type of
web-based exchange of data? We’re still working out the
kinks; it’s kind of clunky at this point.
Especially with a CGM, where you’re generating tons
of data, artificial intelligence may come into play to help
make sense of it. Manufacturers should also agree on a
universal format in which clinicians can easily read the rel-
evant data, regardless of the brand of CGM. It certainly is
not easy at this point to zoom in on an episode of hypogly-
cemia, for example. I think it remains a challenge.Nathan: [Diabetes-oriented] apps, in my
opinion and experience, are likely to be most
useful for patients who are “tech savvy.” The
feedback information, reminders and help with dose
selection and even meal and activity selection, only pro-
vide information and perhaps [lead to] better choices
than patients would make on their own. None of these
work unless patients are paying attention and ready to
carry out the changes recommended.
Simple, relatively stable diabetes treatments that aren’t
changed frequently—such as an oral agent or a single
dose of daily insulin in Type 2 diabetes—are not likely to
benefit. Alternatively, better, “more educated” recommen-
dations for Type 1 diabetes that patients will use frequently
may help modestly to achieve lower HbA1c levels, reduced
frequency of hypoglycemia and reduced patient burden.Vella: I think these are tools, in much the
same way as pen and paper, for recording glu-
cose [readings] in a systematic manner. The
key to their effective use is discipline and education.
This is what makes the tools effective or ineffective—
not some design tweak.
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