Diabetes control requires good adherence to treatment

Dr. Gloria Cánovas, endocrinologist at the University Hospital of Fuenlabrada (Madrid) assures that there is a very improvable situation in the control of blood sugar in diabetic patients in Spain, a fact that has important repercussions on the health of these patients and which to reverse it would be necessary to increase adherence to prescribed treatments.

Dr. Gloria Cánovas, endocrinologist at the University Hospital of Fuenlabrada (Madrid)

QUESTION. What is the current situation of diabetes control in Spain?

ANSWER. To begin with, we do not know exactly how many patients with type 1 diabetes (DM1) there are in our country, because there is no patient registry, although there are plans to create one. . It is estimated that 0.2% of the population suffers from diabetes, which represents approximately 90,000 patients. Regarding the degree of control of these patients, the SED1 study carried out by the Spanish Society of Diabetes (SED) in which 647 patients from 75 hospitals in Spain participated, reveals that only about 30% of patients had an HbA1c lower at 7%. In other words, a situation that could be greatly improved, although it is similar to what is happening in other Western countries.

P And this poor control that you speak of exists, what implications does it have from a clinical point of view for these patients?

R It has been known for years that a person with poorly controlled DM1 will live less and live worse, as chronic complications appear. And that’s why it’s so important that we all make an effort to keep improving diabetes control and, therefore, the prevention of diabetes complications.

P What prevents us from having better control?

R Diabetes is a disease that represents a considerable effort for the patient: each time he eats, he must measure the carbohydrates in the food, he must take into account the physical exercise, calculate the dose of insulin he needs and administering it before each meal…are many variables every day, many times a day. It is difficult to follow all the instructions we give and to learn everything it takes to manage type 1 diabetes. Patients need a lot of education and we must be able to give them all the tools possible to facilitate their control.

P How important is adherence to treatment to achieve good control?

R If there is no adequate adherence to treatment, there is no control because people with type 1 diabetes do not produce insulin. They must therefore administer insulin without forgetting the basal or the bolus before each meal. It is therefore 4 to 5 injections of insulin on average per day. It is not uncommon for one of these doses to be missed or avoided for fear of hypoglycaemia later.

P Are there differences in forgetting between basal and bolus?

R We know they forget both types. Endocrinologists thought it was more common to forget boluses, but studies indicate that boluses are missed 1 in 4 times but basal can be missed up to 36%. In this same study by Munshi MN, et al. 2019 the difference in blood sugar between those who forget the most and those who forget the least is measured and the difference in HbA1c is 0.9%. Forgetting insulin is associated with more variability, less time in interval (TIR), greater and later hypoglycemia, and higher glycosylated hemoglobins.

P What tools can be used to improve adherence to treatment?

R Glucose sensors are very useful because they detect increases in blood sugar and allow you to assess with the patient if there has been an oversight. But the tools we have now only serve to suspect that something has been forgotten. Sometimes the patient prefers not to take a forgotten bolus for fear of hypoglycaemia and is reluctant to admit it, or he has forgotten an administration and cannot remember in consultation whether it was really an error or not. We are missing a lot of information. We need a reliable file so that the patient can check if an insulin dose has been forgotten, become aware and have all the information for consultations. Right now we don’t have that technology, we make decisions with information that is not entirely reliable.

Another fundamental piece of information is when the bolus is delivered, and we don’t control that either at this time. It is not the same to administer it before meals, as one should do, than during or after the meal, because if the bolus of insulin is administered during the meal or after, the patient will have more hyperglycemia and a greater risk of hypoglycemia.

Also, being able to share this information with the patient would help show patients how their sugar levels behaved based on when they took it so they understand the importance of it all. Studies have also been carried out on this subject which have concluded that the administration of boluses before meals increases the time of autonomy per day by up to 2 hours and reduces the risk of hypoglycemia.

P Given all of the above, would you say it takes you a lot of time to talk with the patient just to try to get the necessary information about their adherence and treatment habits?

R Indeed. It takes time to download the sensors and discuss with them what happened every moment. Time that is deducted from other aspects that could be covered on each visit

The sensors currently have the ability for the patient to actively and manually note when and how much of a dose has been delivered. However, it is an additional effort to all the effort that the patient already has to make, and in practice we see that few patients do it, and those who do it are those who are the most aware and have the best compliance. .

References:
Gomez-Peralta F, et al. Clinical characteristics and management of type 1 diabetes in Spain. SED1 Endocrinology, Diabetes and Nutrition Study 2021; 68(9):642-653
Munshi MN, et al. Nonadherence to insulin therapy detected by Bluetooth-enabled pen cap is associated with poor glycemic control Diabetes Care 2019;42(6):1129–1131.
Ekberg NR, et al. The association between missed basal insulin injections and glycemic control in adults with type 1 diabetes mellitus. Diabetes 2021;70(Supplement_1):727-P.
Gomes MB et al. Adherence to therapeutic insulin regimens in patients with type 1 diabetes. A national survey in Brazil. Diabetes Res Clin Pract. 2016;120:47-55
William V et al. Understanding bolus insulin timing: characteristics and experiences of people with diabetes who take bolus insulin. Current medical research and opinion, 2017;33(4):639-645.
Adolfsson P, et al. Improved glycemic control observed in children with type 1 diabetes following the introduction of smart insulin pens: a real-world study. Diabetes Ther 2022;13:43–56
Adolfsson P, et al. Increased time in range and fewer missed bolus injections after the introduction of a smart connected insulin pen. Diabetes technology and therapy. Diabetes Technol Ther 2020; 22(10):709-718.
Edwards S, et al. Using the connected pen as a diagnostic tool to assess missed bolus dosing behavior in people with type 1 and type 2 diabetes. Diabetes Technol Ther. 2022;24(1):61-66
Steenkamp D, et al. Adherence and perseverance to insulin therapy in people with diabetes: impact of the distribution ecosystem of connected insulin pens. J Diabetes Sci Technol. 2021; 1932296821997923. [online ahead of print]
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