Challenges and unmet needs in basal insulin therapy: lessons from the Asian experience

Abstract

Basal insulin therapy can improve glycemic control in people with type 2 diabetes. However, timely initiation, optimal titration, and proper adherence to prescribed basal insulin regimens are necessary to achieve optimal glycemic control. Even so, glycemic control may remain suboptimal in a significant proportion of patients. Unique circumstances in Asia (eg, limited resources, management of diabetes primarily in nonspecialist settings, and patient populations that are predominantly less educated) coupled with the limitations of current basal insulin options (eg, risk of hypoglycemia and dosing time inflexibility) amplify the challenge of optimal basal insulin therapy in Asia. Significant progress has been made with long-acting insulin analogs (insulin glargine 100 units/mL and insulin detemir), which provide longer coverage and less risk of hypoglycemia over intermediate-acting insulin (Neutral Protamine Hagedorn insulin). Furthermore, recent clinical evidence suggests that newer long-acting insulin analogs, new insulin glargine 300 units/mL and insulin degludec, may address some of the unmet needs of current basal insulin options in terms of risk of hypoglycemia and dosing time inflexibility. Nevertheless, more can be done to overcome barriers to basal insulin therapy in Asia, through educating both patients and physicians, developing better patient support models, and improving accessibility to long-acting insulin analogs. In this study, we highlight the unique challenges associated with basal insulin therapy in Asia and, where possible, propose strategies to address the unmet needs by drawing on clinical experiences and perspectives in Asia.

A Practitioner’s Toolkit for Insulin Motivation in Adults with Type 1 and Type 2 Diabetes Mellitus: Evidence-Based Recommendations from an International Expert Panel

“…Studies indicate that the rate of hospitalizations and mortality is higher in nonadherent patients with T2DM than in adherent patients. Also, significantly higher HbA1c levels were observed in patients with T2DM who missed insulin injections compared with those who never missed a dose [29].…”

“…• Delay in Initiation of Insulin Therapy: Delay in initiating insulin therapy has been a major challenge in real-world clinical practice. Many Asian and international studies have shown that even when there was no significant improvement in glycemic control, initialization of insulin therapy was always delayed [29]. • Insufficient Dose Titration: Timely initiation of insulin therapy is not the only factor that provides optimal glycemic control.…”

“…Insufficient dose titration, even after timely insulin initiation, may also contribute to inadequate glycemic control. The International Diabetes Federation guidelines recommend a self-titration regimen of initiation of a low-dose insulin (usually 10 U/day) and increasing the start dose by two units every 3 days until the target of \ 6.0 mmol/l (\ 108 mg/dl) premeal blood glucose has been achieved [29]. • Uncertainties Regarding Insulin Titration: In routine clinical practice, titration of the insulin dose is determined based on patient characteristics.…”

“…Based on the physician's clinical judgment about an individuals' condition, a decision is made about the titration regimen. In developing countries like Asia, lack of support and inappropriate use of titration algorithms may contribute to dosing errors or insufficient dose titration [29]. • Adherence and Persistence to Therapy: Adhering to insulin therapy is a key determinant of glycemic control.…”

Effectiveness of Insulin Degludec in Thai Patients with Diabetes Mellitus: Real-World Evidence From a Specialized Diabetes Center

“…Insulin degludec has been available in Thailand since October 2016. Although the clinical trial results revealed less nocturnal hypoglycemia, the data from real-world settings is limited especially in Asian patients [11,12]. To gain further knowledge on clinical effectiveness, treatment patterns, satisfaction with new insulin treatment and quality of life (QOL) among Thai patients with diabetes (both T1DM and T2DM) initiating insulin degludec in a real-life clinical setting, we conducted a 12-month, prospective non-interventional study in a single specialized diabetes center in Bangkok, Thailand.…”