Dispelling Myths and Removing Barriers About Insulin in Type 2 Diabetes T he burden that diabetes has placed on the health care system as a result of increased morbidity, mortality, and economic costs has continued to increase with each new decade. A review of data from the Third National Health and Nutrition Examination Survey (NHANES III; conducted 1988-1994) and the NHANES 1999-2000 shows that there is a smaller percentage of patients with diabetes that are at the American Diabetes Association glycosylated hemoglobin (A1C) goal of 7% than there was 10 years ago (35.8% today vs 44.5% 10 years ago). When looking more broadly at the 3 main outcome measures from NHANES 1999-2000, only 7.3% of the participants surveyed were within target goals for A1C levels, blood pressure levels, and total serum cholesterol levels, despite newer medications, technologies, and knowledge that developed during the past decade. 1 Of the 27% of surveyed patients with type 2 diabetes receiving insulin therapy, fewer than one half achieved the recommended A1C level of 7% or less. 1 These findings suggest that a concerted effort with all members of the diabetes care team is needed to achieve and maintain the goals that will decrease complications, reduce costs, and increase patient quality of life. Insulin is safe, effective, and the most potent drug available to achieve glycemic targets. Unfortunately, it is not used early enough, often enough, or aggressively enough to cause patients to achieve glycemic goals that have been proven to reduce morbidity and mortality. A major reason for this is the many myths and barriers held by patients and health care providers alike regarding insulin use that can present challenges to starting insulin therapy. Diabetes educators play a major role in helping to dispel these myths by having conversations with patients that allay fears and misconceptions. Conversations about the role of insulin in the successful treatment of type 2 diabetes could be one of the missing

As the number of people living with type 2 diabetes (T2D) continues to rise, managing their complex needs presents an increasing challenge to physicians. While treatment guidelines provide evidence-based guidance, they are not prescriptive—rather they emphasize individualization of management based on a patient’s clinical needs and preferences. Physicians, therefore, need to be fully aware of the advantages and disadvantages of the multiple and increasing treatment options available to them at each stage of the disease. The progressive nature of T2D means that treatment with basal insulin will become inevitable for many patients, while for some patients basal insulin alone will eventually be insufficient for maintaining glycemic targets. Recent guidelines recommend two basic approaches for intensifying basal insulin: the use of rapid-acting insulin, either as additional prandial injections or as part of premix (biphasic) insulin; and the addition of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) to the insulin therapy, which can be administered via subcutaneous injection once or twice daily, or weekly depending on formulation. More recently, two fixed-ratio combinations of basal insulin and a GLP-1 RA that allow for once-daily dosing have been approved. Each of these approaches has potential benefits and drawbacks, particularly in terms of risk for hypoglycemia, weight change, convenience, and side effects. Understanding these differences is central to guiding patient and physician choice. This article discusses the rationale, advantages, disadvantages, and implementation of currently available strategies for basal insulin treatment intensification in patients with T2D.Funding: Sanofi US, Inc.

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Despite the continued development of new pharmacologic agents, and the use of several existing drug therapies, almost two thirds of patients with type 2 diabetes mellitus do not reach the American Diabetes Association-targeted hemoglobin A(1c) level of less than 7.0%. Therefore, maintaining adequate metabolic control remains a primary concern for many clinicians and patients. It is now well recognized that in addition to defective secretion and action of insulin, other hormones also potentially play a role in the development and progression of type 2 diabetes. Glucagon-like peptide-1 (GLP-1) is a gastrointestinal hormone from the incretin family, which stimulates insulin secretion and plays an important role in regulating the enteroinsular axis. Incretin-based therapies are the newest class of glucose-lowering drugs for the treatment of type 2 diabetes and may help address some of the unmet needs in this therapeutic area. Liraglutide is a once-daily GLP-1 analog that has been recently approved by the European Union regulatory agency and is in late-stage review by the United States Food and Drug Administration for the treatment of type 2 diabetes. The pharmacokinetic and pharmacodynamic properties of liraglutide and mechanisms behind its protracted action, which in turn enables enhanced glycemic control, are reviewed.

Type 2 diabetes mellitus (T2DM) accounts for the vast majority of diagnosed diabetes cases and is a considerable burden to the US health care system. However, patients with T2DM often fail to adhere to treatment for numerous reasons including concerns about administration, mode, timing, convenience, adverse events, and cost. As the prevalence of T2DM and the complexity of therapeutic regimens increases, the role of pharmacists in educating patients about treatment benefits, administration techniques, dosage flexibility, and avoiding side effects is critical and may optimize care by increasing the likelihood of treatment adherence. In addition, pharmacists are in a unique position to assess which patients are not taking medications as they are prescribed and can therefore determine the most effective methods to promote adherence. This article will examine the causes of nonadherence in T2DM and the integral role that pharmacists can play in improving medication adherence and persistence. Strategies for improving adherence, such as patient education, motivational interviewing, medication therapy management programs, and collaborative management, will also be considered.