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Dr. Mathieu:
This is CME on PACE CME and ReachMD, and I'm Chantal Mathieu, an endocrinologist from Leuven, Belgium, and I'm joined today by Dr. Melanie Davies from Leicester in the UK. Hello, Melanie.

Dr. Davies:
Hi, Chantal. 

Dr. Mathieu:
So, when we're talking about daily basal insulin injections, we realize that there's a big issue of taking these injections. What does the real-world evidence tell us on this topic?

Dr. Davies:
So, Chantal, I think there's a couple of things that we know from real-world evidence, and I think one of the big things is that insulin initiation is often delayed. And we know that that delay puts people living with diabetes at an increased risk of complication. So, that delay in starting can worsen glycemic control and that level of hyperglycemia can lead to complications, it can lead to increased hospitalization, it can lead to increased diabetes-related complications in the future. So, it’s really important that we try and be more proactive in the initiation of insulin.

So, about one-third of people initially decline insulin, and only about a third of those decliners eventually do start insulin. We know, also, from big global trials that this clinical inertia exists across many different countries, that there's a delay and that often we've let HbA1C go to quite high levels.

So, and the other thing is that even once we start insulin, we know that people can miss their injections. So, about a third of people don't take their insulin regularly, and also we know that people tend to discontinue insulin therapy relatively early. 

We need to be better at explaining to people the benefits of insulin. We need to have regimens that work more effectively in people and are simpler for people to take, and we need to find strategies that help people continue on their insulin for a longer time-point.

Dr. Mathieu:
Thank you, Melanie. So, very important points, first of all. The delay in initiation, then, the fact that people sometimes discontinue, stop for certain periods of time their insulin. But also, I believe that you and the people in Leicester have demonstrated that there's also an inertia in intensification of insulin therapy, in titration of the basal dose or adding meal-time insulins. Can you comment on that? 

Dr. Davies:
Yes. It’s at every stage that there's a problem. So, there's a problem initiating insulin. There's a problem in terms of adequate titration of basal insulin. And there’s also this lack of intensification. So, in people where we up-titrate basal insulin but the A1C remains high, there’s also a delay in intensification. So, all of these things are compounded so that we don't end up using insulin therapy adequately and properly titrating both the basal insulin and the prandial insulin, if it's required. 

Dr. Mathieu:
And is this a worldwide problem, Melanie? Or is it limited to specific geographic areas?

Dr. Davies: 
So, the UK doesn't do amazingly well, and there have been a number of studies where they've looked at different countries. But actually, although there's some variability, this is a global issue. Therapeutic inertia, and this delay in starting and intensification appears to be a problem the world over.

Dr. Mathieu:
Thank you very much, Melanie, for this interesting discussion.

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