Lucia Novak MSN, ANP-BC, BC-ADM joined The Huddle to discuss the role of basal insulin in type 2 diabetes, when to initiate it, and how to have productive discussions about basal insulin with your clients that make them feel comfortable, informed and empowered. This episode was made possible with support from Lilly, A Medicine Company. Resources: American Diabetes Association Professional Practice Committee; 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes—2024. Diabetes Care 1 January 2024; 47 (Supplement_1): S158–S178. https://doi.org/10.2337/dc24-S009 Look AHEAD (Action for Health in Diabetes) study Pantalone KM, Misra-Hebert AD, Hobbs TM, et al. Clinical inertia in type 2 diabetes management: evidence from a large, real-world data set. Diabetes Care. 2018;41(7): e113-e114.
Lucia Novak MSN, ANP-BC, BC-ADM joined The Huddle to discuss the role of basal insulin in type 2 diabetes, when to initiate it, and how to have discussions about basal insulin with your clients that make them feel comfortable, informed and empowered.
This episode was made possible with support from Lilly, A Medicine Company.
Resources:
American Diabetes Association Professional Practice Committee; 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes—2024. Diabetes Care 1 January 2024; 47 (Supplement_1): S158–S178. https://doi.org/10.2337/dc24-S009
Look AHEAD (Action for Health in Diabetes) study. Look AHEAD (Action for Health in Diabetes)
Pantalone KM, Misra-Hebert AD, Hobbs TM, et al. Clinical inertia in type 2 diabetes management: evidence from a large, real-world data set. Diabetes Care. 2018;41(7): e113-e114.
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Jodi Lavin-Tompkins
Hello and welcome to ADCES's podcast, “The Huddle: Conversations with the diabetes care team”. In each episode, we speak with guests from across the diabetes care space to bring you perspectives, issues and updates that elevate your role, inform your practice and ignite your passion. I'm Jody Lavin-Tompkins, the Director of Accreditation and Content Development at the Association of Diabetes Care and Education Specialists. And I would like to thank Lilly for their support of this episode. My guest today is Lucia Novak, president of Diabesity, LLC in Bethesda, Maryland. She is a nurse practitioner, board certified in both adult health and advanced diabetes management, and her practice is with the Capital Diabetes and Endocrine Associates in Silver Spring and Camp Springs, Maryland. We're going to discuss the role of basal insulin in type 2 diabetes, where it fits and when to initiate it, as well as how to have a discussion with your patient and to make it a more positive experience for both of you. Welcome Lucia.
Lucia Novak
Thank you Jodi and thank you everyone for joining us today.
Jodi
Lucia, with all the newer medicines that we have these days, people with diabetes seem to be starting on insulin less frequently perhaps. So where do you think basal insulin fits and how is it positioned in the standards of care algorithm in the ADA guidelines?
Lucia
You know, that is a very good question because you're right with the newer players that we have or maybe not so new players, but the GLP-1 receptor agonists, the SGLP-2 inhibitors, we've really been successful with delaying the need for insulin for many people with type 2 diabetes. However, the guidelines are actually pretty clear on where insulin fits. So first and foremost, of course, we look at the patient clinically and anyone that is exhibiting the classic symptoms of hyperglycemia, which would be the polyuria, polydipsia, polyphagia, as well as unexplained or unintentional weight loss, just feeling really poorly, those patients are in a catabolic distress, and so they would require insulin, at least initially, to help with that glucose toxicity. Other signs for the clinician would be blood glucose levels that are typically over 300 milligrams per deciliter. An A1C that's above 10% would be another indicator that insulin might be needed in this particular patient.
But let's say a patient is not in crisis and their glucoses just aren't in the optimal range that we believe that they should be able to achieve given their comorbidities, their age, fragility, ability to integrate the therapeutic plan into place, then we need to look at how are they currently responding to their medications. So the ADA guidelines also state that if you are at a point with a patient with their diabetes that you believe that they can still achieve a lower A1C or better glucose management than where they are and they have not yet been on a medication from the GLP-1 receptor agonist class, the ADA guidelines actually recommend that for those patients who have never tried a GLP-1, if the option is between that and adding a basal insulin, the recommendation is actually to choose a GLP-1 receptor agonist. And the reason is, is that we can see as much of a A1C lowering with a GLP-1 as compared to basal insulin, but without the cost of hypoglycemia risk and without also the risk of additional weight gain, a lot of our patients do have comorbid obesity. So that's really where the guidelines state as far as when insulin must be added and then what you should be using before you're adding basal insulin.
And then of course is just in general when patients either are not good candidates for these medications, they've experienced too many side effects. Maybe it's cost that's holding them back from using these agents, then insulin becomes appropriate for just about any person with type 2 diabetes. It's a therapy that is safe and effective. It's not gonna harm the kidneys or cause other problems with drug interactions or end organ disease. It does come with the inherent risk of hypoglycemia and also with weight gain. But thankfully, if we're combining medications and using them appropriately, we can mitigate the risk for the weight gain, and we can also use the technology available to help us reduce the risk for the hypoglycemia.
Jodi
Lucia, that was a good overview of what the guidelines say about adding insulin and maybe how to think about adding it in our clinical practice. So when should we be having a discussion with the person about use of insulin? And how do you have that conversation in a non-threatening way?
Lucia
Another great question, Jodi. So with experience working with people with diabetes, I have found that as early in the process of their disease, the better to introduce. So for me, I will discuss therapeutic options that are available for our patients typically at the first or second visit, depending on how overwhelmed they are and what the reason is for them coming in to see me. But when we are eventually going to be discussing treatments for their diabetes, insulin is typically the first medication I discuss with them.
Jodi
Really?
Lucia
Yes. And I find that if you bring it up that way, there's no threat at all because you're discussing all of the therapies that are available and why you might lean toward one over the other. So a conversation might go something along the lines with, “hi, Mrs. So-and-so, we're going to be discussing the therapies that are available for managing the diabetes. So one that comes to mind in many people is the use of insulin. And insulin is always a safe and appropriate choice for many people with diabetes because it doesn't have any drug-drug interaction. It's safe to use during all stages of health in people with diabetes. There is a risk for low blood sugars and some weight gain, but if your blood sugars are really high and you're feeling poorly, insulin is one of the best ways that we can get those blood sugars into a more stable range and then introduce some other medications. But there may be other times during your career with diabetes where the glucoses just exceed what the medications can do. Perhaps you are put on prednisone to address your asthma or maybe you received an injection in your hip and your blood glucoses are now elevated. So there are different times that insulin may find its way both in and out of your diabetes management, but I'm here to work with you.
However, today I don't believe that that's where we're heading. We have some other medications that we can talk about. So it's something along those lines. They hear it from me upfront. So they know that if there's a problem and their non-insulin meds aren't working, that we do have something that is safe and effective. And I'm with them every step of the way. And I'm wondering if you show them the insulin or the needles or anything at that point, or you just talk about it.
At that point, I'm just discussing it and I don't typically show them everything unless we're actually going to be moving in that direction with using the medication. That's just a little bit overwhelming and it may not necessarily be appropriate. Now, if I knew they were going to be starting insulin, then of course I would be bringing out the pen and showing them how it works and always trying to get that initial injection with them in the office when possible.
Jodi
Okay. Well, let's move to a different area of discussion that's related to this. There's something called therapeutic inertia that exists out there. By that, I mean a hesitation to start basal insulin when it could be what the person needs to reach their targets. So what are some of the impacts of that?
Lucia
You just keep on asking the hard-hitting question. So yes, therapeutic inertia is a relatively newer term. I think a lot of folks are more familiar with clinical inertia. So therapeutic inertia is something that is actually the responsibility of the clinician to overcome. So by definition, therapeutic inertia is when a clinician, when seeing a patient, has an opportunity to intensify or de-intensify treatment, depending on the clinical scenario, and that opportunity comes and goes without anti-intervention being done. So that is the definition of therapeutic inertia. We know that inertia in general involves not just clinicians, but also the patients that are involved in that conversation about what to do next, and they have their own barriers as to why they may not want to move forward. But when we look at therapeutic inertia and try to determine what the impacts of that are, probably the most informational data that we have was a study that was done by Dr. Kevin Pontalone, which he's one of my favorites. But he did a study with several of his colleagues that looked at patients. They did like a retrospective chart review and they looked to see who in that chart review had an A1C of above seven. And then six months later, they went back to those same charts to see what the A1C was and what was done after that initial A1C six months ago. And unfortunately, what we saw was almost 63% of all of those patients had no change done in that six months despite having that elevated A1C above 7% at the beginning. And when you look a little bit more closely at who were significantly impacted, the folks that were between a 7 and a 7.9, almost 72% of those did not see a therapeutic adjustment. And I could see where that might happen because those folks are like, you know, if you work on what your exercise is, and maybe if I get you in to see a dietitian or we work on, you know, your nutritional habits, maybe we can make some impact there.
But what really concerned me was that the vast majority, there were over 50% with an A1C between eight and nine, and then another 44% above nine that did not have any intervention despite having those A1Cs for six months. And so that is where the impact comes in. Our patients fail to do well, and it's not that they are failing, it's that we are not working together to optimize their treatment and get their glucoses in a more safe and a more appropriate range.
Jodi
That's really interesting and it's a little disappointing, but I'm sure there's a lot of factors that go into that data. I'm wondering if some of that is due to making decisions on what the clinician believed the patient was capable of doing, perhaps.
Lucia
We all have it. We all have an inherent bias and our biases will color our conversations with the patients and will color our decision when we are thinking about what is an optimal choice for the patient. And so I have come to appreciate, and I'm sure you have too, that the more that you work with people in different types of care settings, chronic disease management, patients oftentimes surprise you. You cannot judge a book by the cover. And I think that patients need to hear from the clinician that you have confidence that they can do it so that they will hope that they will have the confidence. And then that's where the conversation happens. And then again, that's where you say, well, let's take out a pen. Let's look at what it is and how it works and what you're going to do. A lot of times I will hear, that wasn't so bad. That needle's not as big as I thought it was. This is easier than I expected it to be. This is nothing like how my mom used to give herself insulin. So again, if we come at it with a voice of empowerment, encouragement, and not doubting what the patient is able to do, but perhaps setting the seed of what I believe you can do with the right tools and the right support, I think you're more likely to get buy-in. But to answer your question, yes, I do believe that some providers, many healthcare providers will think, okay, my patient's in this kind of a situation. This is what's going on at home. These are their finances. There's a lot going on emotionally with them. I don't think they're gonna handle it. And then therefore may not want to move forward with treatment because they believe the patient is overwhelmed with many other things. But again, the patient's not going to be able to cope or handle all of those other things if their glucoses are not in an optimal safe range. If they're running too high, they're going to be sick. If they're running too low, we're going to have issues with hypoglycemia. So we have to kind of put that into perspective and talk with the patient, what are you able to do? Based on what I'm seeing and my interpretation of your blood glucose is, this is what I am thinking is going to best help you, at least right now, while we can get your blood sugars to be in a safer place. Tell me what your thoughts are on how you would be able to implement this. What would get in the way? Is there something that I can do to assist? And then you're allowing the patient to kind of think about, okay, how is this gonna fit in? Can I do it? Can I not do it? And what are the safe options if injecting insulin is not something that they tell you they don't think they can do?
Jodi
You know, you make so many great points about how it's so important to give that person in front of you the confidence that they need to be able to carry out these instructions and also to kind of have a voice and to have a discussion about it. And without the bias of the clinician, those are all super important points. So another way to make this happen is to make it easy. We always hear that, right? So what do you do in practice to make it easy for the person to start insulin? And how can that be translated to other clinicians, other healthcare professionals?
Lucia
So that is a real tough question, because it's not necessarily easy, but we can make it perhaps less burdensome and easier for the patient. Again, what they are thinking and what they are believing is going to happen is oftentimes very different from the reality. And some patients may actually think it's gonna be easy. And then when you discuss it with them, they think, my gosh, this is overwhelming. So it really depends on where the patient is during that conversation. Most of the time when I have to initiate insulin, I don't always have the option to say, go home and think about it and come back. Because nine times out of 10, they may not come back and never want to send them out without making sure that they're safe with whatever they need to go home. And so when I don't have anything but that moment right in front of me, I'm talking with the patient, will involve my support staff, my medical assistants that I know have the ability to teach patients because I have personally trained them kind of thing. And I will use my support staff to help me because now that appointment is going to be a little bit longer, a little bit more involved. And I may not have the time to actually sit there and complete the appointment with them as far as introducing them to the insulin, calculating their doses for that insulin, and then getting them started. It just depends on everything that's going on with the patient. Some of my patients are coming in, they don't feel very well, they're eager to feel better, they are okay with starting insulin. Some just don't want another pill because they have the buy one get three free that come with diabetes and they're on a whole host of medications. And so if they could do something that is not another pill, sometimes they welcome it. And for those patients, that can become seamlessly part of the conversation during that appointment. And I'm able to get them started and get them going. And they will have that first injection in the office with me. Other times, if they need a little bit more support, if my particular time does not allow for that, I will have my assistants come in and kind of take over and then I can always touch back with the patient between other appointments if they're still there and make sure everything is okay. There have been times where I had patients get certain labs because I was trying to determine, you know, what type of diabetes do they have and do we really need to be moving into an insulin regimen, where I've called them about the labs and have said, you know, it looks like we're going to need to start insulin. And I want you to come into the office and I will set aside time for that. That's not a luxury that most providers have. I understand that, but I am working in the realm of endocrinology. And so my scheduling will allow for those kinds of appointments. And I will encourage the patient to bring somebody that lives in the home with them, whether that be their spouse, their partner, their brother, their sister, whoever is going to be that support person for the patient, if for no other reason, to just be another set of ears, to take notes and to ask questions so that when the patient leaves, they have all of the information and less likely that they're going to run into problems, forget something, what have you.
Another piece of that is following up with the patient. So once you've initiated the insulin, if I personally am not reaching back out to the patient within a day or two, just to make sure they didn't have any problems with that initial injection, that they felt comfortable, that they didn't experience any problems, you know, they forgot to take the cap off the needle, that happens quite a bit, just touching base with them. If I can't do it, then one of my medical assistants will do that for me and contact the patient. And that kind of builds on that village that we need to surround our patients with, the support. They again, feel less alone. And believe it or not, when you reach out to the patient like that, they are less likely to be panic calling you because we are kind of nipping things in the bud as we go along. Of course, there are things that happen. Sometimes you're teaching a patient over the weekend and it's a long weekend and you're not able to get in touch with them right away. But I always have a backup plan. know, when you need to call the on-call person, you know, if there's a reason that you should just go to the emergency room, these would be those reasons, that kind of thing. You know, if you invest the time either yourself or using the support system around you, as well as the support system around the patient, you actually will save yourself time in the long run with the management of that patient.
Jodi
So Lucia, you did mention the support that you have in your office for doing these kinds of things. What about a diabetes care and education specialist? Do you have any of those in your practice or do you refer to them? Tell us more about that.
Lucia
We don't have diabetes education and support in our particular office. So I will refer them to diabetes education through our local hospitals. We have several in the area where they offer outpatient diabetes classes. They can be in person. They can be virtual. But absolutely, that is a must have. I am fortunate that in addition to myself and two other clinicians that are also board-certified advanced diabetes managers working in the office with me. We also have a registered dietitian that, she's not part of the practice, but she provides services in our offices to our patients, which is really nice. And so that's another person that needs to be involved in the management of the patient is making sure their nutritional plan is sound, that they understand different types of foods. We have quite a diverse population in the practice setting. Again, I'm in Maryland. So in one area of Montgomery County, we have a pretty affluent, but we also have a very high Hispanic population. Hispanics come from all over. And so not everyone that is of a Hispanic ethnicity is going to have the same food choices or cultural behaviors. And so being able to take that into consideration is important as well. So Jodi, you are absolutely correct. We can't do this alone and nor should we. We have those folks around us. And I believe if you're not sure where or who your closest CDCES is, your certified diabetes care and education specialist, who is that person and where are they located, you can actually find that out through our website. Am I correct?
Jodi
Yes, there'll be a link to the map in the show notes. Lucia, this has been a great conversation. We've covered a lot of good information and we appreciate your telling us how you do things and your expertise on this topic. And I'm wondering if you have any closing thoughts for our audience.
Lucia
Well, you know me, Jodi. I always have thoughts. And I'm not afraid to share them. First of all, thank you for having me on your program today, it was a great honor. For closing thoughts, I think it's really important that clinicians out there don't forget that insulin is still a very important and at times necessary treatment for our patients. The less scary we make it sound, the more receptive our patients will be, and we shouldn't delay using it when we need to use it. So if patients are just not doing well on their current non-insulin regimen, their glucoses just can't seem to get into a safe range, we have the luxury now of CGMs that are just available in so many ways at a very low cost. Many of us that have access to our reps can get some complimentary sensors in the office which will help us to kind of have this conversation with the patient. The important thing is for us not to delay initiating treatments that are needed by our patients. So while the guidelines state when we absolutely need to use it, when patients are just not doing well, hyperglycemia and having symptoms, or, you know, we have that option to start with a GLP-1 if they've never been on it. But we have many patients that despite GLP-1 and perhaps also using an SGLP-2 inhibitor are still going to need insulin. And I have many patients where insulin is actually the safest choice. So again, the important thing is recognizing where our patients are in their disease career of diabetes, what their support system looks like and how we are part of that support system and how we can empower them to move forward with their diabetes management.
Jodi
Well, thank you so much Lucia for sharing your expertise on this topic with us. Your experiences and tips are very helpful to hear. And for our audience, we've put more resources in the show notes if you want more information. And again, I would like to acknowledge Lily's support for this podcast.
Thank you for listening to this episode of The Huddle. And remember, being an ADCES member gets you access to many resources, education, and networking opportunities. Learn about the many benefits of ADCES membership at adces.org/join. The information in this podcast is for informational purposes only and may not be appropriate or applicable for your individual circumstances. This podcast does not provide medical or professional advice and is not a substitute for consultation with a health care professional. Please consult your health care professional for any medical questions.