Activity Transcript

Peter has a 15-year history of T2D. His HbA1c is 8.7% and he’s being treated with metformin and basal-bolus insulin regimen [degludec + aspart]. He is overweight with a BMI of 27 kg/m2, and he has dyslipidemia (controlled on statin), hypertension (controlled on ACE inhibitor/diuretic). His eGFR is 78 mL/min, and he is showing early signs of retinopathy and peripheral neuropathy.

Patient: I enjoy fishing a lot. And, at the moment, I’m having trouble getting the bait on the line. There’s a numbness, like a tingling, in my fingers.

Physician: I see. Are you also feeling numbness or tingling in your feet?

Patient: Yeah, a bit. 

Physician: Have you noticed any recent changes in your vision? 

Patient: Yeah, sure. But that’s a byproduct of old age, I presume. My vision isn’t as crisp. And sometimes I have to blink a few times to get rid of the spots.

Physician: Have you seen an eye doctor in the past year?

Patient: No. Always had good vision. No glasses. No need.

Physician: In this case, I would encourage you to visit the eye doctor, at least for a quick vision test. But, in the meantime, let’s see if your test results give us any clues. Your blood pressure and cholesterol look good. Your A1c is 8.7, though.

Patient: Well, that’s not terrible. Down a bit from last time, I think.

Physician: Technically, yes, but at 8.7, your A1c is still too high, and putting you at risk for severe complications.

Patient: I know it’s supposed to be 7 or whatever, but I feel good. I’ve had diabetes forever: almost 15 years now. And for the most part, I’ve managed well.

Physician: Do you find it helpful to track how many insulin units you inject and when?

Patient: I don’t really need to do that. It’s always the same.

Physician: I see. And how do you know it’s the same?

Patient: Experience for the most part. I used to keep meticulous records. But I spent way too much time thinking about my diabetes. Thinking about insulin. How much? How little? Do I need more? Do I need less? I eat about the same every day, so I know how much insulin to give myself. And if I have some cake, I give myself a little more insulin.

Physician: And how often do you test your blood sugar?

Patient: Twice a day. Same time. Everyday. I know some people who don’t check theirs at all.

Physician: You’re absolutely right. There are some people out there who ignore their health entirely. And you, Peter, are not one of those people. But, here’s my concern. The numbness and tingling you’ve mentioned in your hands and feet. Those are early signs of nerve damage called diabetic neuropathy. And I’m afraid that the blurred vision you’ve been experiencing, and the floaters, could be early signs of diabetic retinopathy, which can lead to blindness. These things will likely progress unless you control your blood sugar. That means keeping it between 70 and 180. And getting your A1c to 7. Right now, with an A1c of 8.7, you’re in that target range less than 50% of the time.

Patient: Hmm. I can see that’s problematic.

Partha Kar, MBBS, MD, FRCP: Hello, my name is Professor Partha Kar. I'm a consultant in diabetes at Portsmouth Hospitals University NHS Trust in the United Kingdom. I'm also the national specialty advisor in diabetes with NHS England. Welcome to this program titled The Patient with Type 2 Diabetes on Complex Insulin Regimens, and the question is whether digital health can help us improve control. When we look at this particular scenario of the case, what we are looking at is the issue that a lot of patients have with concordance to complex insulin regimens. There are many issues at hand and in fact there are lots of studies which confirm this particular point of view. You'll see patients reporting from studies difficulties with taking insulin at prescribed times, as well as difficulty following instructions from healthcare professionals. And it's not just the patients who say that, physicians also share a very similar view with patients’ showing difficulty in taking them.

It is perhaps easy from one side of the table to give advice about what insulin regimens to take, but the evidence-base will tell us that it continues to be difficult. And in fact, the more complex the treatment regimen, the lower the concordance will be. The overarching principle being, complex insulin regimens may impede patient's glucose control. This is not surprising or new, yet with the advent of modern technology, what we want to look at is as to whether this can be tackled. There are further studies which confirm that the complexity of regimens, i.e. the number of injections, make a big difference to the concordance levels. And we know this from several studies, which show that as soon as the number of injections go up, it becomes even more difficult for people to stick to their regimens. It is not uncommon in our daily grind of life to see that the number of injections that people take do drop off, thereby compromising their control. And 58.5%, a high number of physicians, think that their typical diabetes patient will have difficulty with the number of daily insulin injections. So, the question is what we can do to help it going forward. We've seen how diabetes technology can foster diabetes self-management and improve diabetes care, and in fact, in today's modern world, we have got a plethora of new technology. There's continuous glucose monitors, insulin pumps that can be automated, connected insulin pens and apps. However, as ever, the most successful technology solution are the ones that fit into the patient's lives. And we’ll look into how that can fit into particular patients as well.

Physician: Peter, burnout managing diabetes is common. Especially after 15 years. The important thing is to get back on track. I notice you wear a smartwatch.

Patient: Yes, my wife gave it to me for our anniversary. She knows I love all sorts of gadgets. It’s great for fishing. It’s got GPS, barometers, altimeters. Monitors the weather.

Physician: That sounds fantastic. And you use that information to help you catch fish?

Patient: Yeah. Did a lot of fishing this summer. Caught some big ones. Made some people jealous.

Physician: Were they this big? Or this big?

Patient: Bigger.

Physician: Well, if you can use that we have things in the digital space that could help you manage your diabetes.

Patient: What do you suggest? I’m not interested in wearing a pump.

Physician: Honestly, whatever you think would fit nicely into your life is what I’d suggest. You have quite a few options. Wearable sensors check your blood sugar regularly, all day and night. You can wear them on your arm or your stomach. And you can read your blood sugar level anytime you want, without pricking your finger. They tell you if your glucose is trending up or down, and on some models, you can get alerts if your blood sugar goes too high or too low.

Patient: Does it tell you how much insulin you need?

Physician: No, it doesn't calculate doses, and you still have to give injections throughout the day. Its main advantages are fewer finger pricks, helping to prevent highs and lows, and the information it can give you on how well your diabetes is being managed overall. Like, it can tell you how much time you’ve spent in target range -- or above it -- over a day. Or a week. Even a few months.

Patient: Hmm. Interesting.

Physician: There are apps that calculate bolus dosing that you can download. And smart insulin pens that help you keep track of the amount and timing of insulin injections. Some pens also show you the amount of active insulin on board. The data from smart pens are stored, so there’s none of the manual reporting you used to do.

Patient: I hated that. Do you use the pen to give yourself the insulin too?

Physician: Yes, they are reusable and use prefilled cartridges

Prof Kar: As we look at the whole scenario around patients on insulin, on the background of diabetes, we also need to remember that the non-concordance, according to a study done by Munshi at all in 2019, showed that they were as high as 24% for bolus insulin administration and 36% of basal insulin administration.

We need to look at what available digital tools we have, and if we take a step back, what we are trying to here see is whether we can help with modern technology, the importance of self-management. As a clinician, we can give advice about what regimens they should take, what insulin they should take, but the people with diabetes are the ones living with diabetes all the time. And thereby, what can modern technology offer in the way of making that self-management journey a bit easier? And that's what we need to look at. What we do know, that two-thirds of patients with type 2 diabetes have got poor concordance to treatment. Again, that is not surprising with modern pressures of life, living with it, social issues, additional burdens of medications, living with stigma, all of them contribute to living with type 2 diabetes and concordance issues going forward.

So the question is, whether modern technology has a place in trying to improve that. Technology certainly has made life better for us in different spheres of life, whether it be booking our airline tickets, banking sector, or you name it, any other sector we can think of. And it's a question of whether we can bring that approach as standard care into healthcare going forwards. If you look at the first clinical outcome study, which is using a smart insulin pen done by Adolfsson et al in 2020, a very important point comes through is that it shows a fewer missed bolus doses and improves time and range, both of them very important factors. They do go hand in hand, but it goes back to the fundamentals of improved self-management. Why? Because technology is giving people the remit, the means to try and look at their diabetes care, try and look at what insulin they're taking, when they're taking it, and thereby making those adjustments as needed.

Most importantly, improvement of concordance, not surprisingly, helps in increasing the time in range, which further translates into improved HbA1c, as we do know from major studies. And further on, extrapolated onto long-term outcomes benefits, which is what we are trying to do with diabetes care. In this particular scenario, we are now looking at the patient being started now on a glucose monitor and a smart pen going forward, as part of the modern technology input into helping improve their diabetes control.

(6 weeks later)

Physician: How are things going, Peter? Any problems wearing the flash glucose monitor?

Patient: No, it’s been good. Well, it fell off one time, but I got a replacement quickly.

Physician: And how about the smart pen?

Patient: No problems. I’ve been using it for about 6 weeks now.

Physician: Excellent. And what have you learned?

Patient: I can tell my blood sugar is up overnight. But I’m not sure what to do about it. I don’t want to go hypoglycemic while I’m sleeping, either.

Physician: All right. Let’s have a look at the data together. But first, I want to point out that you’ve captured what your blood sugars are doing 75% of that time. This tells me you’re getting in the habit of scanning. And that’s exactly what you need to be doing. Also, your time in range is near 60%. This is a great improvement, Peter. You should be very proud of yourself.

Patient: Yeah, thanks. It’s encouraging. I’m having less trouble with the numbness in my hands. And I’ve started to notice that my eyesight isn’t as blurry.

Physician: That’s wonderful. Now, we’re aiming for at least 70% within the target range. Let’s look at the pen report and see what we can do to get you there, shall we?

Prof Kar: What do we now have? We have looked at the practical aspects of initiating treatment. We are trying to look at what can we do using digital solutions? Do we include connected smart pens in the clinic? And I think this is an evolution of care, whereby we are slowly but surely inserting technology more and more into people's lives just as we have done in many, many walks of life. Healthcare needs to also make this standard care going forwards.

Talking about smart pens, talking about continuous glucose monitors, flash glucose monitoring or insulin pumps should be part and parcel of what we offer to everybody. The importance is that we offer that to everybody irrespective of their background, deprivation, or ethnicity. And that is something which will only happen when we take technology as standard care for diabetes. A fundamental part of that is also training needs. Training that needs to be done not only by patients, but also by physicians as part of their continuous professional development. Just as we learn about newer insulins, we learn about newer drugs, we learn about newer ways of remission in type 2 diabetes and all the dietary modifications. Technology should also be part of our continuous professional development. Once again, we need to look at technology becoming standard care in type 2 diabetes and type 1 diabetes.

We need to think of it not as niche care, not to think of it as added-on care or something special, but as basic care. Just like glucose monitoring is, just like insulin administration is. As part of that, physicians need to do their continuous professional development, learning about these technologies and thereby also helping setting up programs in conjunction with people living with diabetes so they can have training in this as well, just as we would have for insulin initiation.

In summary, thereby to say it's important that we all take away the lessons, what this particular case has shown us. Improvement in concordance, improvement in helping quality of life, improvement in basically making self-management easier. Living with diabetes is never easy, yet with modern technology, we could perhaps make it a little bit easier. And if we look at technology being a standard part of our care, then it is also our responsibility as professionals to update ourselves as part of our continuous professional development and introduce and offer it to all patients living with diabetes.

Thank you very much for participating in this activity. Please do carry on to answer the questions that follow and complete the evaluation. Thank you very much for your time.

This transcript has not been copyedited.

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