Managing diabetes requires good adherence to treatment

Dr. Gloria Canovas, endocrinologist at the University Hospital Fuenlabrada (Madrid) confirms that there is a very improved situation of glycemic control in patients with diabetes in Spain, a fact that has important implications for the health of these patients and that to reverse this it will be necessary to increase adherence with prescribed treatments.

Dr. Gloria Canovas, Endocrinologist at Fuenlabrada University Hospital (Madrid)

A question. What is the current status of diabetes control in Spain?

Response. First of all, we do not know exactly how many type 1 (DM1) diabetics are present in our country, because there is no patient registry, although there are plans to establish one. It is estimated that 0.2% of the population has diabetes, which represents about 90,000 patients. Regarding the degree of control of these patients, the SED1 study conducted by the Spanish Diabetes Association (SED) in which 647 patients from 75 hospitals in Spain participated, revealed that only about 30% of patients had an HbA1c less than 7%. In other words, a situation that could be greatly improved, although similar to what is happening in other Western countries.

s. And this poor control you mention is there, what implications could it have from a clinical point of view for these patients?

R was found. We have known for years that a person with poor DM1 control will live less and live worse, due to the onset of chronic complications. This is why it is so important that we all make an effort so that diabetes control and thus prevention of its related complications continues to improve.

s. What prevents us from getting better control?

R was found. Diabetes is a disease that requires a tremendous effort for the patient: every time he eats, he must measure the proportion of carbohydrates in food, he must take into account physical exercises, calculate the dose of insulin he needs and administer it before each meal … There are many variables every day, many times in a day. It is difficult to comply with all the instructions we give and learn everything you need to manage type 1 diabetes. Patients need a lot of education and we must be able to give them all possible tools to facilitate their control.

s. How important is adherence to treatment to achieve good control?

R was found. If there is insufficient adherence to treatment, there is no control because people with type 1 diabetes do not produce insulin. So they should give insulin without forgetting the basal or bolus before each meal. Thus it is an average of 4-5 injections of insulin per day. It is not uncommon for one of these doses to be missed or avoided for fear of hypoglycemia later on.

s. Are there differences in forgetfulness between basal and bolus?

R was found. We know that they forgot these two types. Endocrinologists used to think that it was common to miss doses, but studies say once in 4 doses are missed, basal doses can be forgotten by up to 36%. In the same study by Munshi MN, et al. 2019 The difference in blood glucose between the most forgetful and the least forgetful is 0.9% HbA1c difference. Forgetting insulin is associated with more variability, less time in the range (TIR), later hypoglycemia, and higher glycosylated hemoglobin.

s. What tools can we use to improve adherence to treatment?

R was found. Glucose sensors are very useful because they detect increases in blood glucose and allow you to assess with the patient if there are oversights. But the tools we have now serve only on suspicion of censorship. Sometimes a patient prefers not to take a forgotten dose for fear of hypoglycemia and is reluctant to admit it, or he has forgotten an administration and does not remember in the consultation whether it was really wrong or not. We miss a lot of information. We need a reliable record so that the patient can check whether the insulin dose has been forgotten, become more aware, and have all the information for consultations. At the moment, since we do not have this technology, we make decisions with information that is not completely reliable.

Another key piece of information is the moment the bolus is given, and we can’t control that now either. Taking it before meals, as we ought to do, is different from taking it during or after a meal, because if the dose of insulin is given during or after the meal, the patient will experience hyperglycemia and an increased risk of hypoglycemia.

In addition, the ability to share this information with the patient will help to clarify the behavior of the glucose level for patients depending on the time of the dose so that they understand the importance of all this. Studies have also been conducted on this topic that conclude that pre-meal dosing increases the time in the daily range by up to two hours and reduces the risk of hypoglycemia.

s. Taking all of the above into consideration, would you say that it takes a long time to talk to a patient just to try to get the necessary information about their adherence and treatment habits?

R was found. Effective way. It takes time to download the sensors and discuss what happened with them at each moment. Time deducted from other aspects to be taken in each visit

Sensors currently have an option for the patient to actively and manually note when and how much a dose has been delivered. However, this is an extra effort for all the effort the patient actually has to put in, and in practice we see that very few patients do, and those who do are more aware and have better adherence.

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Munshi Mn et al. Non-adherence to insulin therapy detected by Bluetooth pen cap is associated with poor glycemic control in diabetes care 2019; 42 (6): 1129–1131.
Ekberg NR, et al. Relationship between missed basal insulin injections and glycemic control in adults with type 1 diabetes. Diabetes 2021; 70 (Appendix_1): 727-P.
Gomez MB et al. Adherence to insulin regimens in patients with type 1 diabetes. National survey in Brazil. Clinical practice of diabetes. 2016; 120: 47-55
William V and others. Understanding the timing of the bolus insulin dose: characteristics and experiences of diabetic patients taking bolus insulin. Current Medical Research and Opinion, 2017; 33 (4): 639–645.
Adolfsson P, et al. Improved glycemic control observed in children with type 1 diabetes after introduction of insulin smart pens: a realistic study. Diabetes 2022; 13:43-56
Adolfsson P, et al. Increased time in range and fewer missed bolus injections after insertion of the connected smart insulin pen. Diabetes technology and its treatments. Diabetes Technol 2020; 22 (10): 709–718.
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