How can we help patients manage their type 2 diabetes in the technology age? A good place to start is by addressing misconceptions about insulin and available technology to manage diabetes.
Addressing Misconceptions about Insulin
People with diabetes have been using insulin to treat their condition for nearly 100 years. Since the discovery and availability of insulin in 1921, insulin is the primary treatment for people with immune mediated diabetes (type 1, type 1.5, etc.) and is often an add-on medication in the treatment of type 2.1 Despite the 100-year evolution of insulin, there are still misconceptions related to its use.
Insulin use in type 2 diabetes is “the last resort.”
Not true. Insulin can be used at any time in the lifecycle of type 2 diabetes. It is common practice to use insulin when the A1c is above 10%, as insulin has the best A1c-lowering potential compared with other diabetes medications.1
Once a person (with type 2) starts insulin, they are on it for life.
Not true. Many people with type 2 diabetes may start insulin in combination with other non-insulin medications. As they modify and adapt a healthy lifestyle (nutrition, activity, stress reduction, sleep, and weight management), adjustments to medications can be done, including discontinuation of medications, such as insulin.
Insulin is the preferred diabetes treatment in the hospital setting.
True. The American Diabetes Association (ADA) Standards of Medical Care in Diabetes—2020 state “insulin is the preferred treatment for hyperglycemia in hospitalized patients.” The guidelines also support the use of insulin pens instead of vial and syringes with careful labeling and protocols “for single patient use only.”1
Hospitals should have a structured discharge plan when transitioning from the hospital to the ambulatory care setting.
True. Medication reconciliation is essential to optimal diabetes care and management, and the ADA standards of care have detailed guidance on this. In my practice, when a person with diabetes follows up for their first medical visit after hospital discharge (be it in person or telemedicine), we review their medications. It is very common to find the basal insulin the person was on before admission was not the same basal used while in the hospital. When the person gets home, they take both basal insulins: the original insulin they were using along with the new insulin prescribed at discharge. The duplication of therapy is also common with bolus insulin. Needless to say, this increases the risk of hypoglycemia, which can lead to an Emergency Department visit and possible readmission.
Improving Insulin Use Through Technology
Over the last few decades, the use of technology in managing diabetes has expanded, to the point in which the ADA Standards of Medical Care in Diabetes annual update now includes a designated section called, “Diabetes Technology.” This term is used to describe the hardware, devices, and software that people use to help manage their condition. Let’s address some common misconceptions related to the use of technology to manage diabetes.
Continuous glucose monitoring (CGM) devices are only for people with type 1 diabetes.
Not true. A person with any type of diabetes can find benefits with CGM use. The technology of CGM has evolved dramatically in the past 2 decades. Many of the new CGM devices use real time or intermittently scanned data that are transmitted to a smart phone or similar device. Several of the new devices no longer require calibration by the user and provide an abundance of information to better assess glucose management.1-2
The biggest barrier to CGM is third-party reimbursement. There are many restrictions for prescribing CGM. However, with the access and affordability to newer CGM devices, many people with diabetes are opting to pay for them out of pocket. People can visually see their glucose readings every 5 to 15 minutes. They can look at trends of highs and lows, as well as the amount of time (in a 24-hour period) that their glucose in “in range.”2 This knowledge empowers people to make healthy choices regarding food, activity, stress, etc. It can also help people know if their diabetes medication is working. For people taking insulin, CGM can help to tailor the correct dose based on the glucose levels and trends.
CGM devices should not be allowed in the inpatient setting.
Not true. The guidelines support allowing people with diabetes who are comfortable using their devices (including insulin pumps and CGM sensors/monitors) to be given the chance to do so in the hospital. It is very common for people with diabetes and solid self-management skills to be more knowledgeable and familiar with managing their glucose than the inpatient staff who do not know the person well.1 There are many people who can tell me exactly how much 2 slices of pizza will raise their blood glucose level. We need to listen to people, as they live with diabetes 24/7. Hospitals are encouraged to have policies in place for diabetes and device management, which include healthcare personnel supervision.
People taking bolus insulin often forget their mealtime doses and can omit or double their dose.
True. For people taking multiple daily insulin injections (e. g., 1-2 basal and 3 bolus), the injection burden can be overwhelming and annoying. It is very common in a busy day to forget or become distracted, such that a person may miss their mealtime insulin dose or mistakenly take it twice. This common problem led to the development of smart insulin pens. Using blue tooth or near field communication (NFC) technology, reusable insulin pens can transmit the time and amount of the bolus insulin injected to a person’s smart phone (app). This allows the person to know if/when they injected their bolus insulin. The smart phone app records the insulin doses, recommends bolus doses based on current blood glucose levels and carbohydrate intake, and provides the amount of insulin on board (IOB) – still active in the body. Knowing the IOB can reduce insulin stacking, thereby preventing or minimizing hypoglycemia.3
Insulin has come a long way in the past century. Through the integration and use of technology, people with diabetes have the tools to optimize their diabetes care and management. I cannot wait to see what the future holds.
- American Diabetes Association. Standards of medical care in diabetes – 2020. Diabetes Care. 2020; 43(suppl 1):S1-S206.
- Battelino T, Danne T, Bergenstal RM et al. Clinical targets for continuous glucose monitoring data interpretation: recommendations from the international consensus on time in range. Diabetes Care. 2019; 42:1593-1603.
- Klonoff DC, Kerr D. Smart pens will improve insulin therapy. J Diabetes Sci & Technol. 2018; 12:551-3.