Your T2D Patient Needs Mealtime Insulin: Counsel on Options, then Move Ahead

The type 2 diabetes patient you are about to see needs to add a mealtime dose of insulin and the conversation needs to happen today. For primary care clinicians who feel the weight of that chat as they approach exam room 3, NYU endocrinologist Brian Levy, MD, offers 3 tips: "A1c, A1c, A1c."

The change can mean more complex management for the PCP and increased disease burden for the patient, but it is also the next opportunity to reduce the risk of long-term diabetes complications.

In a recent conversation wtih Patient Care, Levy offered guidance for easing the transition from a basal insulin regimen to mutliple daily injections with a focus on keeping it simple for both parties involved.

Brian L. Levy, MD, is an endocrinologist and clinical assistant professor of medicine at New York Univerity Grossman School of Medicine in New York, NY.

The following transcript has been lightly edited for clarity and style.

Patient Care Online. So how do you approach a patient and counsel them through the need to introduce mealtime insulin? You're the physician with the limited time. This is the person who has a lot of concern about it. And what are what are some of the treatment options that you can offer?

Brian Levy, MD. First you have to work with the patient to help them understand it's not their fault. Advancing insulin is going to help them and keep them healthier over time. Once you get that education established, one has to work with the patient to figure out the best way to intensify their insulin. Now, one approach, is to begin with “basal plus,” which means the basal insulin regimen is not working. You choose the one meal a day that by glucose monitoring, whether it's finger sticks, or continuous glucose monitoring, you see the patient’s glucose is highest. You start mealtime insulin just with that meal. And you show the patient that by taking mealtime insulin, let's say at supper, if that's the biggest meal, you can prevent their glucose from going as high as it was. That helps to convince them.

But then what about breakfast? And what about lunch? And people with type 2 diabetes as we know often have snacks, or the equivalent of a fourth meal a day where their glucose goes high. Basal plus is a way of introducing mealtime insulin and teaching the person that, “Hey, I really need it at all my meals.” Basal plus typically doesn't work very well, long term. I prefer to educate them correctly in that I monitor their blood glucose and show them after all their meals that their glucose levels are high and then do the right thing. And that's initiate mealtime insulin at all the meals where they likely need it.

We talked about the barriers to multiple injections. One of the newer products available, the Simplicity patch, is a wearable patch that can administer insulin for up to 3 days, mealtime or bolus only. Patients take the insulin on demand by clicking the patch. This infuses the insulin instead of having to take a shot each time. It's really a small patch. It's wearable; it’s placed on the abdomen and re-inserted every 3 days. The reservoir holds enough insulin to provide mealtime insulin for 3 days. For example, if a patient were to need 10 units of insulin at lunchtime, the patch delivers 2 units per click, and so with 5 clicks, they administer their insulin, and it can be done through their clothing. It’s discreet; the patient can stay seated; they don't have to excuse themselves to take a shot in the restroom. This means that instead of 9 mealtime injections over 3 days, the patient inserts the patch once. It is a painless insertion. And also, if a patient eats an extra snack or meal, they can click, whereas they're less likely to take out their insulin pen and take another shot to correct for eating more than 3 meals a day. The patch is waterproof. So, the patient showers with it. If they swim, they swim with it. If they exercise, they exercise with it. The adhesive is such that it doesn't fall off. It is an easy solution.

There are other solutions, of course. There are insulin pumps. What we are discussing here is that people with type 2 diabetes often are looking for a simple approach. Pumps are complex; they have a lot of bells and whistles and settings that just might be too complex for the patient with type 2 diabetes. Importantly, and this is my opinion, but I think a lot of endocrinologists will agree. Patients and their primary care doctors love their basal insulin. They love their Lantus. They love their Detemir. And they're comfortable using it. If you switch to a pump, you're going from a once daily basal insulin, to converting everything to rapid acting insulin, including the basal insulin, which increases the complexity for the primary care doctor on how to manage their patient's diabetes. So, they like the Lantus and the Detemir, as examples, and then they like giving shots—rapid acting insulin at meals, or something simpler, like the Simplicity patch as a way of avoiding all of those injections.

You're never used to the routine. What I love to say is we all have really busy lives and to put type 2 diabetes on top of that, where you have to monitor your blood sugar, you have to monitor what you're eating both quantity and amount of carbohydrate, monitor how things like exercise or illness, like a cold or a virus or COVID-19 in today's time, affects your blood sugar. You never forget about the disease, unfortunately. You want simple ways to manage the disease. And one of those, as we've talked about, for type 2 diabetes patients is the Simplicity patch. Other things that have revolutionized management in type 2 diabetes include continuous glucose monitoring, so that you don't have to stick your finger each and every time to see what your blood sugar is. Although it is still indispensable to stick your finger in some cases. And it's also affordable compared to CGM, which may be less affordable based on healthcare plans. We’re always looking for things [to simplify diabetes care.] Years back, it was the invention of the insulin pen, as opposed to using a vial and syringe, which was yet more complexity and more steps and more social barriers than just taking a pen, dialing the dose, and injecting. We've come a long way with type 2 diabetes and we still have a long way to go. But we're looking for things to simplify. And I think this is one way to simplify mealtime injections.

PCO. Could you offer 3 practical tips on recognizing and moving through clinical inertia for the clinician—recognizing it themselves as well as in the patient.

Levy. So, 3 tips. The simple answer is A1c, A1c, A1c.

We have to follow the A1c and the patient's glycemic control. If you're not meeting the goals of management, you have got to advance care. You can’t remain stagnant and tell a patient to follow their diet and lose weight. Second, we have got to move the patient through guideline- approved treatment paradigms. Even before insulin, you got to move them through these outstanding noninsulin classes that are available. We need to use them and be familiar with them. If the A1c is not improving, you’ve got to advance care. And the third thing is working with the patient to find a plan or a treatment option that is more appealing and simpler for them to follow. Because if they don't follow it, they're not going to do as well as if they do follow it.