A successful management indicates persistent achievement of glycated hemoglobin (HbA1c) level < 7%. Since diabetes is a progressive disease, maintaining the prescribed HbA1c level with lifestyle control alone or along with pharmacotherapies often become difficult. Persistent hyperglycemia leads to several complications in the diabetic patients. Dyslipidemia and elevated blood pressure in these patients (especially T2DM patients) becomes a risk factor for cardiovascular diseases (CVDs) in long run. Moreover, microvascular complications like neuropathy, retinopathy and nephropathy and macrovascular complications such as high risk for stroke and acute coronary syndrome are significantly associated with chronic hyperglycemia and glycemic variability. Thus, overall management of the disease and comorbidities gradually become a burden over time.m dolor sit amet, consectetur adipiscing elit. Ut elit tellus, luctus nec ullamcorper mattis, pulvinar dapibus leo.
Poor adherence: Adherence to the therapy is one of the most significant factors that decide the success of the management of chronic diseases. Unfortunately, a significant number of patients cannot remain adhered to the prescriptions for diabetes management. It has been estimated that 15-39% of the patients do not adhere to oral antidiabetic drugs. Increased economic burden and poor affordability, multidrug regimen, multiple doses of medications, and persistent complications are some of the major reasons for non-adherence.
Advantages: Marked benefits are observed when patients undergo insulin therapy. Improvements in fasting and post-prandial blood glucose level are observed in patients with insulin therapy. Because of the progressive nature of the disease insulin therapy becomes obligatory to maintain the optimal glycemic levels. Regular use of insulin has also been associated with HbA1c reduction. The dose of insulin can be finely adjusted leading to precise dosing and adequate control of blood sugar. Although human insulin and its analogs vary in cost, however, they are generally less expensive than newer antidiabetic medications. Reduced cost increases patient adherence for a prolonged Since insulin also has anti-inflammatory properties, it provides protection against atherosclerosis development, thus further reduces the risk for CVDs in diabetic patients.
Barriers and approaches: According to Global Attitudes of Patients and Physicians in Insulin Therapy study (GAPP), 72.5% doctors reported that the patients did not take the insulin as per prescription and average per month omissions were 4.3 days for basal insulin and 5.7 days for prandial insulin. This is due to some of the preventable complications of insulin therapy as discussed below:
Since insulin therapy is a self-injectable therapy, fear of the needle poses significant barrier the adherence to the prescription. IDMPS study revealed that more patients preferred oral therapy than injectable therapy. Since insulin is often indispensable in diabetes management, physicians play an important role in proper patient education and relieving anxiety among patients. Insulin pen needles have now become shorter making them relatively painless and more convenient to use. India has already become the global hotspot for diabetes. Besides lack of health consciousness, inadequate information about the disease and its treatment options and increased cost significantly reduces the adherence. Hence physician plays a great role in prescribing the most suitable insulin (or its analog) and properly educating the patients about its use so that patients achieve long-term euglycemia and better quality of life.
Current scenario of diabetes in India In 2017, India ranks second with 72.9 million diabetes patients preceded by China (114.4 million) and followed by the USA (30.2 million). The IDF Diabetes Atlas indicates that the prevalence of diabetes will increase to 134.3 million by 2045. India has the second highest prevalence of adult diabetes in South East Asia. It also ranks second in paediatric Type 1 diabetes with 128,500 children and adolescents aged between 0-19 suffering from it. There are nearly 42.2 million undiagnosed cases of diabetes in India. Worldwide, India ranked fourth in the total healthcare expenditure on diabetes in 2017.
Challenges in diabetes management Uncontrolled hyperglycemia and diabetes complications: Persistently elevated blood glucose level despite medications is one of the biggest challenges in diabetes management.
Cost: Since diabetes progressively becomes unmanageable, more than one pharmacoactive agent (or more than a single dose of the agent per day) is required. Besides that, diabetes being a chronic disease, patients need periodic consultations with the physician. Micro- and macrovascular complications also increase the cost of care for the patients. Hence cost for medications gradually increases. In fact, International Diabetes Management Practice Study (IDMPS) revealed micro- and macrovascular complications are predominant factors for the increased cost. that Moreover, for obese T2DM patients, morbidity becomes a significant issue and healthcare expenditure increases with the frequency of hospitalization.
Lack of awareness: According to the Chennai Urban Rural Epidemiology Study (CURES), only 41% Indian adults are aware of risks of diabetes and about the fact that the disease can be prevented. Moreover, 92% of the patients visit general physicians instead of a diabetologist for the treatment. Thus, a severe lack of awareness poses a further challenge in diabetes management.
Insulin therapy: advantages and barriers Unlike T1DM, patients with T2DM may not need insulin therapy initially if the HbA1C level is not greater or equal to 8-9%. For most cases, initial management depends on oral antidiabetic drugs and modifications of diet and lifestyle. However, such primary modalities are often inadequate, and patients are required to receive insulin therapy for effective control of hyperglycemia.
Hypoglycemia is one of the major barriers to insulin therapy. T1DM patients are more likely to experience hypoglycemia than that of the T2DM patients. Moreover, such events are more likely to occur with prandial fast-acting insulin than long-acting basal insulin. However, proper patient education regarding consumption of meal and self-injection of insulin can significantly reduce the rate of hypoglycemia. Another concern of insulin therapy is weight gain. This causes more problem to T2DM patients since T2DM is more of a lifestyle disorder and significantly more patients are either overweight or obese. However, adequate physical exercise coupled with dietary restrictions can keep weight gain at bay.