Chair:
Jaime Davidson, MD, FRCP, FACE
Faculty:
Francine Kaufman, MD
Luigi Meneghini, MD, MBA
Malcolm Nattrass, MD, PhD
Dr Jaime Davidson opened the program with his presentation entitled Matching the Right Insulin to the Right Patient. He discussed insulin secretion in healthy individuals, and followed it with a discussion of available insulin preparations, noting how insulin analogs more closely matched normal physiology. He next discussed strategies for initiating insulin, including basal insulin, biphasic insulin, basal therapy plus prandial injections at 1 or more meals. He noted that because not all people are the same, it is important for healthcare providers to familiarize themselves with all of the available options for insulin therapy. Next, he discussed patient characteristics that can affect choice of insulin regimen, including current blood glucose profile, cultural and psychosocial factors, age, presence of comorbidities, willingness to adhere to a regimen, and patient preference. Likewise, characteristics of insulin regimens can influence decisions, including ability to mimic endogenous insulin secretion, potential for adverse events, and cost and complexity of regimen. He ended with a discussion of therapy intensification, showing blood glucose fluctuations at various levels of A1C to again make the point that there is often great variability in patient glucose profiles, and healthcare providers need to be aware of all of the available treatment strategies available to help patients address glycemic fluctuations.
Next, Dr Luigi Meneghini discussed diabetes care in racial and ethnic minoritities. He began by presenting data showing that minorities are less likely to monitor blood glucose, less likely to use intensive insulin therapy, less likely to achieve glycemic targets, and more likely to have diabetic complications. He then presented a video case of a Latino patient poorly controlled with 2 oral medications. In the next section of his talk, Dr Meneghini discussed treatment options for this patient, with a focus on available data for basal insulin analogs. Dr Meneghini first showed data demonstrating that basal insulin analogs have less variability than NPH insulin, followed with a brief discussion of the treat-to-target studies, which showed that basal analogs have comparable efficacy but less hypoglycemia. Furthermore, insulin detemir was associated with less weight gain than either NPH or insulin glargine. Next, Dr Meneghini showed data that demonstrated the effectiveness of basal insulin analogs when added to oral agents in patients with type 2 diabetes. Additionally, when patients are switched from other therapies (oral agents only, oral agents plus NPH, or oral agents plus insulin glargine) to insulin detemir, they improved their glycemic control, reduced their hypoglycemia incidence, and lost weight. Next, Dr Meneghini showed data demonstrating that patients can safely titrate their own basal insulin analogs. Dr Meneghini ended his talk with some tips for culturally-competent diabetes care, including having an open discussion with patients regarding their beliefs, including other family members in healthcare decisions, helping patients to understand their medications, and recommending community resources. The presentation concluded with the video case outcome, which showed the patient being successfully treated with a basal insulin analog.
Dr Malcolm Nattrass next spoke on the topic of diabetes care in the elderly. He began his presentation by stating that life expectancy for elderly people is greater than most people realize, emphasizing the importance of tighter glycemic control in elderly patients. Older patients and patients with comorbid conditions are less likely to have their therapy advanced when they are not meeting targets. Next, Dr Nattrass presented a video case of an elderly woman with marked hyperglycemia who was inadequately treated with sulfonylurea therapy. Because of her marked hyperglycemia, basal insulin may not be sufficient to help her reach her target. Accordingly, he presented data from the 1-2-3 study, which demonstrated that some patients may reach target with a once daily injection of a biphasic insulin analog, and the majority of patients can reach targets with 2 daily injections of a biphasic insulin analog. The INITIATE study showed benefits for biphasic insulin analogs compared with basal insulin analog therapy with regard to A1C, especially among patients with marked hyperglycemia. Next, Dr Nattrass discussed the PREFER study, which demonstrated that biphasic insulin preparation may be as effective as basal/bolus therapy, especially among insulin naive patients. Dr Nattrass concluded his talk with a discussion of practical strategies for managing diabetes care in elderly patients, including polypharmacy management, hypoglycemia management, and strategies for improving medication adherence. The presentation concluded with the video case outcome of the patient being treated successfully with a biphasic insulin preparation.
The last presentation was given by Dr Francine Kaufman, who discussed diabetes care in adolescents. She began by noting that type 2 diabetes is increasing in children and that these children are burdened with diabetic complications at the time of their diagnosis. Dr Kaufman presented a video case of an active, African American teenage girl with marked hyperglycemia and polycystic ovary disease who was newly-diagnosed with type 2 diabetes. She discussed issues related to the proper care of this patient, including age, accurate diagnosis, lack of approved therapy, the influence of pubertal hormones, and the need to treat children with type 2 diabetes more aggressively to get them to goal. Dr Kaufman then turned her discussion to treatment for this patient, noting that metformin therapy, 1 of 2 approved agents for pediatric type 2 patients, would not help this patient to goal. Because of her marked hyperglycemia, basal insulin in conjunction with metformin would also not likely help her reach her target. In terms of available data discussion basal/bolus therapy in type 2 diabetes, the only available studies compare the basal insulin analog insulin detemir with the NPH insulin as the basal component. Efficacy and hypoglycemia risk were comparable between the 2 agents; however, there was a weight advantage seen with insulin detemir. Dr Kaufman ended her presentation with a discussion of how to manage the adolescent type 2 diabetes, focusing on the importance of parental involvement in diabetes care. The talk ended with the video case presentation showing the patient being treated with flexible basal/bolus therapy. Of note, prior to the presentation of the data, a majority of people in the audience reported that they would treat this patient with metformin only. By the end of the presentation, a majority of people indicated that they would treat her with basal/bolus therapy. |
