Insulin Access and Affordability Working Group: Conclusions and Recommendations

Cefalu, William T.; Dawes, Daniel; Gavlak, Gina; Goldman, Dana P.; Herman, William H.; Nuys, Karen Van; Powers, Alvin C.; Taylor, Simeon I.; Yatvin, Alan L.

doi:10.2337/dci18-0019

Cited by 229 publications

(201 citation statements)

References 18 publications

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“…Our findings that insulin use was significantly associated with higher CRN but it ranks at the bottom in dominance ranking suggest that non-adherence of insulin use may be related less to costs than to other factors such as injection site reactions, fear of hypoglycemia, and injections interfering with daily activities, meal planning and physical activity [34]. Recent report on the tripling of insulin price in 2002–2013 in the U.S., however, raises concerns about whether insulin costs may be an increasingly important issue for medication non-adherence in the future [35]. …”

Section: Discussionmentioning

confidence: 99%

Cost-related medication non-adherence among U.S. adults with diabetes

Kang

Lobo

Kim

2018

Diabetes Research and Clinical Practice

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Aims: To examine factors that affect cost-related medication non-adherence (CRN), defined as taking medication less than as prescribed because of cost, among adults with diabetes and to determine their relative contribution in explaining CRN. Methods: Behavioral Risk Factor Surveillance System data for 2013–2014 were used to identify individuals with diabetes and their CRN. We modeled CRN as a function of financial factors, regimen complexity, and other contextual factors including diabetes care, lifestyle, and health factors. Dominance analysis was performed to rank these factors by relative importance. Results: CRN among U.S. adults with diabetes was 16.5%. Respondents with annual income <$50,000 and without health insurance were more likely to report CRN, compared to those with income ≥$50,000 and those with insurance, respectively. Insulin users had 1.24 times higher risk of CRN compared to those not on insulin. Contextual factors that significantly affected CRN included diabetes care factors, lifestyle factors, and comorbid depression, arthritis, and COPD/asthma. Dominance analysis showed health insurance was the most important factor for respondents <65 and depression was the most important factor for respondents ≥65. Conclusions: In addition to traditional risk factors of CRN, compliance with annual recommendations for diabetes and healthy lifestyle were associated with lower CRN. Policies and social supports that address these contextual factors may help improve CRN.

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Section: Discussionmentioning

confidence: 99%

Cost-related medication non-adherence among U.S. adults with diabetes

Kang

Lobo

Kim

2018

Diabetes Research and Clinical Practice

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“…These include the rising prevalence of diabetes, as well as psychosocial, cultural, and economic factors that often limit access to insulin and outpatient medical care 131617. Diabetic ketoacidosis causes an estimated medical expenditure of $2.4bn (£1.9bn; €2.1bn) per year in the US 10.…”

Section: Epidemiologymentioning

confidence: 99%

“…Euglycemic diabetic ketoacidosis can result in delayed diagnosis and treatment, as well as potential for adverse metabolic consequences 17. Since the recent introduction of the SGLT2 inhibitors, several case reports and series describing euglycemic diabetic ketoacidosis in patients treated with these agents have been published 212223.…”

Section: Epidemiologymentioning

confidence: 99%

“…Insulin omission can be seen in patients of all ages and is more commonly observed in those with eating disorders, psychological distress, fear of hypoglycemia, and fear of weight gain 39. Other factors that are associated with insulin omission include inability to pay for insulin, the idea that insulin should be withheld when illness interferes with eating, inadvertent omission of an insulin dose, and, rarely, pump malfunction 173839…”

Section: Precipitating Causesmentioning

confidence: 99%

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Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients

French

Donihi

Korytkowski

2019

BMJ

135

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Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome (HHS) are life threatening complications that occur in patients with diabetes. In addition to timely identification of the precipitating cause, the first step in acute management of these disorders includes aggressive administration of intravenous fluids with appropriate replacement of electrolytes (primarily potassium). In patients with diabetic ketoacidosis, this is always followed by administration of insulin, usually via an intravenous insulin infusion that is continued until resolution of ketonemia, but potentially via the subcutaneous route in mild cases. Careful monitoring by experienced physicians is needed during treatment for diabetic ketoacidosis and HHS. Common pitfalls in management include premature termination of intravenous insulin therapy and insufficient timing or dosing of subcutaneous insulin before discontinuation of intravenous insulin. This review covers recommendations for acute management of diabetic ketoacidosis and HHS, the complications associated with these disorders, and methods for preventing recurrence. It also discusses why many patients who present with these disorders are at high risk for hospital readmissions, early morbidity, and mortality well beyond the acute presentation.

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“…19 We reported that only 10% of patients were treated with a basal-bolus regimen, probably for reasons of patients' acceptability to multiple injections, patients' fear of hypoglycaemia, lack of support systems, and high treatment costs, especially if the treatment is paid out-of-pocket. [27][28][29] The high treatment cost is in part due to the complexity of pricing, procurement, and supply chain of insulin. 28 F I G U R E 3 Modifying effects of gender, young-onset diabetes (YOD), and diabetic kidney disease (DKD) at baseline on the impact of intensive insulin regimens in the entire cohort For each subgroup, the respective reference groups were: premixed -DKD -; basal-bolus -, YOD -; and basal-bolus -, women.…”

Section: F I G U R E 1 Multivariable Linear Regression Analyses Of Thmentioning

confidence: 99%

Real‐world data reveal unmet clinical needs in insulin treatment in Asian people with type 2 diabetes: the Joint Asia Diabetes Evaluation (JADE) Register

Kong

Lew²,

Lau

et al. 2020

Diabetes Obesity Metabolism

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Aims To explore the pattern of insulin use and glycaemic control in Asian people with type 2 diabetes, stratified by gender, young‐onset diabetes (YOD; diagnosed before age 40 years), and diabetic kidney disease (DKD; estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73m2). Materials and methods We conducted a cross‐sectional analysis of 97 852 patients from 11 Asian countries/regions (2007–2017) included in the prospective Joint Asia Diabetes Evaluation (JADE) Register. Results Among 18 998 insulin users (47% women, mean ± SD age 59.2 ± 11.7 years, diabetes duration 13.2 ± 8.3 years, glycated haemoglobin [HbA1c] 72 ± 21.4 mmol/mol [8.74 ± 1.95%], median total daily insulin dose [TDD] 0.27–0.82 units/kg), 25% and 29.5% had YOD and DKD, respectively. Premixed (44%) and basal‐only (42%) insulin were the most common regimens. Despite being more commonly treated with these two regimens with higher insulin dosages, patients with YOD had worse HbA1c levels than their late‐onset peers (73 ± 20.5 vs. 71 ± 21.2 mmol/mol [8.82 ± 1.87% vs. 8.66 ± 1.94%]; P < 0.001). Fewer women than men attained an HbA1c level < 53 mmol/mol (7%; 15.7% vs 17.1%; P = 0.018). Adjusting for age, diabetes duration, TDD, HbA1c, eGFR, and use of oral glucose‐lowering drugs at baseline, the odds of self‐reported hypoglycaemia were higher in women (vs. men: adjusted odds ratio [aOR] 1.16, 95% confidence interval [CI] 1.05–1.28) and in patients with DKD treated with a premixed regimen (1.81 [95% CI 1.54–2.13] vs. 1.34 [95% CI 1.16–1.54] in non‐DKD; Pinteraction < 0.001). Compared to basal‐only regimens, premixed and basal‐bolus regimens had similar HbA1c reductions but were independently associated with increased odds of hypoglycaemia (1.65 [95% CI 1.45–1.88] and 1.88 [95% CI 1.58–2.23], respectively). Conclusions In this Asian population, there were varying patterns of insulin regimens with suboptimal glycaemic control, despite relatively high TDDs, which were influenced by gender, DKD, and YOD status.

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Insulin Access and Affordability Working Group: Conclusions and Recommendations

Cited by 229 publications

References 18 publications

Cost-related medication non-adherence among U.S. adults with diabetes

Cost-related medication non-adherence among U.S. adults with diabetes

Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients

Real‐world data reveal unmet clinical needs in insulin treatment in Asian people with type 2 diabetes: the Joint Asia Diabetes Evaluation (JADE) Register

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