Clinical Inertia - How to Overcome injection Barrier.pptx

The barrier to the use of insulin can be from the patient or healthcare provider. Ensuring several factors can improve adherence to using insulin

1. Overcoming Injection Barriers in type 2 diabetes treatment Nanang Miftah Fajari Divisi Endokronilogi Metabolik dan Diabetes FK ULM/RS Ulin Banjarmasin

2. Case discussion Milestone of being seriously ill He doesn’t want to use insulin again How did you handle this reluctance? Clinical values HbA 1c : 7.5 % PATIENT PROFILE Male Age 58 Finance Director in business enterprise He had history of hypo’s Tx Basal insulin 18 U, SU, and Metformin

3. Case Discussion How did you handle this reluctance? Clinical values before HbA 1c : 8.2% BMI: 32 AMI 2 years ago PATIENT PROFILE Female Age 52 Secretary Metformin 3x850 mg DPP-4 I 2x100 mg Patient Concern about weight… What is The Best Deal Treatment for her? The Problem is she fear to injection and Avoid to Start Liraglutide ……..

4. Clinical Inertia The failure to initiate or intensify therapy when indicated or a failure to act despite recognition of the problem has become Worldwide phenomenon  delay of almost 3 years to intensify. The very reluctance to advance therapy may actually deter patients from accepting Therapy.

5. Cost of Inertia – it does matter For every 20 persons with diabetes whose… HbA1c value is 1% above the 7% target, one will suffer a microvascular complication within 5 years. LDL cholesterol level is 30 mg/dl above goal, one will have a myocardial infarction or stroke within 5 years Blood pressure is 10 mmHg above target, one will progress their microvascular disease within the same 5 years period of time Wiliam David Strain, Matthias Bluher, Paivi Paldanius , Diabetes Ther (2014) 5:347-354 Clinical Inertia in Individualising Care for Diabetes: Is There Time to do More in Type 2 Diabetes?

6. Physician-, patient- and healthcare-system-related factors contributing to clinical inertia. Failure to set clear goals Failure to initiate treatment Failure to titrate treatment to achieve goals Failure to identify and manage comorbidities (e.g. depression) Insufficient time Reactive rather than proactive care Underestimation of patient’s need Physician-related factors (50 %) Denial of having the disease Denial that the disease is serious Low health literacy High cost of medication Too many medications Medication side-effects Poor communication between physician and patient Lack of trust in physician Depression or substance abuse Lifestyle Absence of symptoms Patient-related factors (30%) No clinical guidelines No disease registry No visit planning No active outreach to patients No decision support No team approach to care Poor communication between physician and staff Health Care-related factors (20%)

7. Upfront discussion How often do you think an injection prevents diabetes patients from getting the most appropriate treatment?

8. Clinical Inertia Is Common: Time Course to Action Brown. Diabetes Care. 2004;27:1535. Slide credit: clinicaloptions.com 8 Mean A1C at Last Visit (%) 9 8.6% 9.1% 9.6% 8.2 yrs from diagnosis to initiation of insulin therapy 73.6% Diet and exercise 2.5 yrs 10 7 Sulfonylurea 2.9 yrs Combo oral agents 2.8 yrs 91.3% 87.7% Insulin therapy Patient moving to next therapy

9. Progressing From Oral Therapy to Insulin in Patients With Type 2 Diabetes ADA. Diabetes Care. 2018;41:S73. Garber. Endocr Pract. 2018;24:91. Slide credit: clinicaloptions.com Basal insulin therapy Combination of 2-3 oral agents Lifestyle management + metformin

10. So what about the injection? Many misconceptions about injectable treatment are based on experiences with insulin

11. DAWN summit 2004 Patient misconceptions (about insulin injection): More demanding Hypoglycaemia Mistaken concept (need to inject into vein) Don’t believe it’s necessary Fear loosing independence Employment concerns Suggests failure of self care to date BUT can learn to experiment/improve Pearson, TL. Insulin therapy in patients with type 2 diabetes: overcoming patient and physician barriers. ( http://www.medscape.org/viewarticle/590729 ) DAWN. Pract Diab Int 2004;21(5):201-208 HCP – attitudes to and misconceptions about insulin injections Use insulin as threat Believe patients don’t want it Injections are painful Difficult to dose Won’t improve diabetes control Patient needs more of my time Will need specialist referrals Not cost effective Patients often fear starting injection more than they fear injections themselves

12. Which, if any of the following were you concerned or afraid about when you were told you needed to start insulin ? UK Patient responses GAPP – concerns before starting insulin Global Attitudes of Patients and Physicians in Insulin Therapy (GAPP) survey results 2010; All UK patients n=205

13. Your beliefs about the injection get projected to the patient Source: http://yourbizstartup.com/2011/05/02/igniting-breakthrough-performance-part-two-setting-a-fresh-foundation/helping-hand/

14. So what about the injection? Techniques on how to identify and overcome barriers

15. 50% pts fearful of needles 40-50% pts difficult to use insulin <10% pts of perceive a benefit of insulin 50% pts associate insulin with personal failure Identify and address a patient’s personal obstacles Introduce Insulin as a brief experiment Educate patients on Hypo’s Consider the use of insulin pens Focus on glycemic outcomes Explain the progressive nature of DM Do not refer to insulin as a threat Introduce the possible need for insulin therapy early in treatmen Managing Fears and Barrier Related to injection Therapy Polonsky WH, Jackson RA. Clin Diabetes 2004, 22 147,150 SOLUTION

16. Presenting and discussing information: Setting patient expectations in type 2 diabetes care Consider each case individually, e.g. history of “failures” Advise on progressive nature of the disease and the progressive nature of therapy Diminish self-blame by explaining likely course at diagnosis Consider showing patients injectable devices early – before they might need them Pearson, TL. Insulin therapy in patients with type 2 diabetes: overcoming patient and physician barriers. ( http://www.medscape.org/viewarticle/590729 ) Starting injectable treatment in adults with type 2 diabetes. RCN guidance for Nurses, 2012 Ideally – preparation for the move to injectable therapy should start early following diagnosis

17. “Injectable does not mean a more severe stage of disease” “Your friends or relatives will not notice that you use an injectable for treating your diabetes” “You only have to inject once a day and you can inject at any time of the day to suit your lifestyle” What conversation was effective in providing the patient with confidence to start the injection

18. UK Patient responses GAPP – responses from patients who have started on taking insulin Global Attitudes of Patients and Physicians in Insulin Therapy (GAPP) survey results 2010; All UK patients n=205 What would you say are the biggest challenges you face in effectively managing you diabetes with insulin?

19. Intensifying to injectable therapies

20. Intensifying to injectable therapies

21. Summary Many patient barriers are based on myths and insulin therapy HCP and patient perceptions not always aligned Once on injectable therapy – patients’ fear drops

22. Clinical use of Tresiba ® Safety Hypoglycaemia reductions across phase 3 trials No new adverse event profile Convenience Flexible dosing Effective and predictable glucose- lowering profile Available in FlexTouch ® Minimal injection-site reaction Simple initiation and titration Once-daily dosing Simplicity No increase in risk of adverse CV outcomes versus glargine U100 CV, cardiovascular; glargine U100, insulin glargine 100 units/mL

23. Tresiba ® device comes with Flextouch IDeg, insulin degludec Tresiba ® [summary of product characteristics]. Bagsværd, Denmark: Novo Nordisk A/S; 2012; Hemmingsen et al. Diabetes Technol Ther 2011;13:1207–11; Vora et al. Diabetes Res Clin Pract 2015;109:19–31 100 U/mL formulation 80-unit maximum-dose pen Pen contains 300 total units Delivers up to 80 units in a single injection Dial exact dose (1-unit dose adjustments) No push-button extension Less pressure for injection IDeg FlexTouch ® can deliver 80 units or 160-unit per injection depending on dose needed U100 Easy to use Confidence in Insulin delivery Preferred by patients The benefit of Flextouch

24. Which patient will benefit from Tresiba ® Varying stages of beta-cell dysfunction Patients who need to start insulin or switch from another basal insulin When hypoglycaemia, multiple injections and lack of flexibility are barriers to glycaemic control Patients with irregular lifestyle When FPG and HbA 1c are not at target FPG, fasting plasma glucose; PPG, postprandial glucose; T1D, type 1 diabetes; T2D, type 2 diabetes Thalange et al. Pediatr Diabetes 2015;16:164–76; Meneghini et al. Diabetes Care 2013;36:858–64; Mathieu et al. J Clin Endocrinol Metab 2013;98:1154–62; Lane et al. JAMA 2017;318:33–44; Wysham et al. JAMA 2017;318:45–56; Tresiba ® March 2018 ( https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/203314s008lbl.pdf ) Tresiba ® November 2017 ( http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/002498/WC500138940.pdf )

25. Simpan pen Anda di lemari pendingin Pen yang Anda gunakan sekarang dapat disimpan di suhu ruangan dengan temperature hingga 30ºC atau di suhu lemari pendingin (2ºC hingga 8ºC) selama 8 minggu. For full instructions, please see the Instructions for Use that came with your pen. How to use Insulin Degludec pen

26. Initiation of Tresiba ® in T2D BB, basal–bolus; BID, twice daily; GLP-1RA, glucagon-like peptide-1 receptor agonist; glargine U300, insulin glargine 300 units/mL; OAD, oral antidiabetic drug; OD, once daily; T2D, type 2 diabetes Tresiba ® November 2017 ( http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/002498/WC500138940.pdf ) START SWITCH FROM OTHER BASAL INSULIN Degludec + − OAD GLP-1RA Bolus OR OR Recommended 10 U daily Recommended 20% reduction in degludec dose when adding GLP-1RA Basal BID Degludec Basal OD Basal component of BB/premix 1:1 Degludec Degludec 1:1 1:1 Consider 20% reduction in insulin dose when switching from BID insulin or glargine U300 Insulin naïve

27. Once-weekly titration based on the average of two preceding FPG measurements 3 FPG target should be individualised ADA/EASD recommend an FPG target of 4.4 to 7.2 mmol/L (80 to 130 mg/dL) for many adult patients with diabetes 4 * If above target, + 2 units Suggested titration schedule T2D 1,2 *Individual patient goals may vary. This is a suggested once-weekly titration schedule. FPG goal should be individualised. If average FPG levels are more than 1 mmol/L below or 2 mmol/L above FPG goal, larger dose changes (e.g., 4, 6, or 8 units) can be considered ADA, American Diabetes Association; EASD, European Association for the Study of Diabetes; FPG, fasting plasma glucose; T2D, type 2 diabetes 1. Endocrinologic and Metabolic Drug Advisory Committee. Insulin degludec and insulin degludec/insulin aspart treatment to improve glycemic control in patients with diabetes mellitus: NDAs 203314 and 203313 briefing document. Published November 8, 2012; 2. Vora et al. Diabetes Res Clin Pract 2015;109:19–31; 3. Philis-Tsimikas et al. Adv Ther 2013;30:607–22; 4. ADA standards of medical care in diabetes – 2016. Diabetes Care 2016;39(Suppl. 1):S39–S46 + – If at target, maintain dose If below target, - 2 units

28. BE PROACTIVE – START YOUR PATIENTS ON TRESIBA ® Ultra-long-acting Basal Insulin 42 hours TRES Insulin Basal Benefit: WILL YOU START YOUR NEXT PATIENT WITH TRESIBA ® ? Tresiba ® provides blood sugar control beyond 42 hours Tresiba ® give patients flexibility when needed Tresiba ® significantly reduces hypoglycaemia risk vs glargine U 100

29. Getting patients started on Liraglutide injection therapy Clinical benefits helps lower blood sugar levels helps reduce weight lowers blood sugar when needed, so the risk of hypoglycaemia is low nausea is a common side effect of liraglutide that usually subsides after a few weeks Little to no pain Thin needle – 2 human hairs Noninsulin Once daily, independent of meals, at the same time every day Once daily, any time of the day. Once most convenient time is chosen, it should be taken that time every day. Liraglutide SmPC http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/001026/WC500050017.

30. Exercise: Using the Liraglutide injection pen An opportunity to experience the delivery device Use patient information leaflet as guidance Own experience can be useful when showing patients starting liraglutide therapy

31. Injection technique Insert the needle at ~90º (or 45º if a longer needle is used) Push needle all the way in Push the button to inject Leave the needle in place for at least 6 seconds Remove the needle Getting your grip on skin ‘pinch up’ right Correct Incorrect Needle insertion If required, pinch skin before inserting the needle: Squeeze skin between your thumb and two fingers Insert the needle Hold the pinch Inject Leave the needle in place for a count of 10 Release Remove the needle Royal College of Nursing http://www.rcn.org.uk/__data/assets/pdf_file/0009/78606/002254.pdf (Accessed October 2011) The Forum for Injection Technique (FIT). The First UK Injection Technique Recommendations. Oct 2010

32. Principles Motivational interviewing: 5 key principles Express empathy through active listening Roll with resistance Avoid arguing with the patient Resolve the patient’s ambivalence Support self-efficacy by emphasizing autonomy

33. Motivational interviewing: OARS Mitchell SE. Motivational interviewing in the management of type 2 diabetes O pen-ended questions A ffirmations R eflections S ummaries Letting patients tell their stories Acknowledging the patient’s struggle Simple reflections – eg telling patients what you heard them say without repeating their comments word for word Let you and the patient reflect on your discussion and helps identify next steps

34. Motivational interviewing: Some other useful tips Mitchell SE. Motivational interviewing in the management of type 2 diabetes “Change talk” Humans tend to believe what they hear themselves say rather than simply taking advice from others Encourage Support patient in finding the solution on ways to overcome barriers Overcome The “Readiness ruler” Ask questions about importance of a behaviour change Ensure they understand the benefits of their treatment Follow up Probe

35. Choose from one of these patient barriers—or others you have identified—and adopt these characteristics in your role play Scared of weight gain and hypos Scared of needles and associated pain Doesn’t believe he is that sick Think its inconvenient Doesn’t want to inject in public Travels often Role play: motivational interview techniques Working in groups of 2, decide who will take the role of HCP or patient Situation: Patient uncontrolled on metformin HbA 1c : 8.7 BMI 29 – you suggest on GLP-1RA therapy/Insulin