expert roundtables

Type 2 Diabetes: Current Treatment Challenges and Opportunities for Improved Patient Outcomes

by Serena Cardillo, MD; Rita Rastogi Kalyani, MD, MHS, FACP; and Marie E. McDonnell, MD

Overview

Challenges in the management of type 2 diabetes include patient adherence and therapeutic inertia, whereby the escalation of therapy appears to be indicated but does not occur. Other treatment challenges relate to costs, access to care, and special populations, such as older adults with type 2 diabetes.

Q:

In the ever-evolving field of type 2 diabetes, what are some key treatment challenges?

Rita Rastogi Kalyani, MD, MHS, FACP

Editor in Chief, Johns Hopkins Diabetes Guides
Director, Diabetes Management Service
Johns Hopkins Total Pancreatectomy Islet Auto Transplant Program
Associate Professor of Medicine
Johns Hopkins University School of Medicine
Baltimore, MD

“ . . . there are new challenges that are appearing as patients with type 2 diabetes age. For example, more and more, I think that we need to be considering geriatric syndromes, functional status, and quality of life in this patient population, as the goals of care change as these individuals age.”

Rita Rastogi Kalyani, MD, MHS, FACP

The prevention of type 2 diabetes and its complications, including the earlier identification of prediabetes, is an ongoing challenge for diabetes care specialists. In addition, there are new challenges that are appearing as patients with type 2 diabetes age. For example, more and more, I think that we need to be considering geriatric syndromes, functional status, and quality of life in this patient population, as the goals of care change as these individuals age. Unfortunately, there is an insufficient amount of robust evidence in this population because older patients have historically been—and continue to be—excluded from clinical trials, particularly those that evaluate the optimal glycemic targets for this population. The most appropriate therapies and specific treatment challenges of an aging diabetes population still need to be addressed.

Finally, therapeutic inertia continues to be a problem, as does the issue of medication-taking behavior, or patient adherence.

Marie E. McDonnell, MD

Chief, Diabetes Section
Division of Endocrinology, Diabetes and Hypertension
Director, Diabetes Program
Brigham and Women’s Hospital
Harvard Medical School
Boston, MA

“Therapeutic inertia and patient nonadherence are probably some of the most significant treatment challenges. And it is difficult to accurately measure clinical inertia because we can never really know all of the reasons why changes such as new medication additions, titrations, and insulin starts that appear to be indicated are not being made.”

Marie E. McDonnell, MD

Therapeutic inertia and patient nonadherence are probably some of the most significant treatment challenges. And it is difficult to accurately measure clinical inertia because we can never really know all of the reasons why changes such as new medication additions, titrations, and insulin starts that appear to be indicated are not being made. Some patient-related factors that are consistently associated with therapeutic inertia include ethnicity, race, and lower income. 

These underlying issues, particularly cutting through financial barriers, must be addressed as a nation. The health care system needs to acknowledge that, although there will be additional, initial, upfront costs for the cardioprotective drugs (eg, glucagon-like peptide 1 [GLP-1] receptor agonists and sodium-glucose cotransporter-2 inhibitors), money will be saved in the end due to the prevention of many other health care expenses, in addition to the prevention of heart disease. Overcoming these financial barriers would have an incredible impact on patient outcomes and would likely lower health care costs for the nation. 

With regard to treatment nonadherence, the health care delivery system does not really incentivize or enable diabetes care specialists to confirm that patients are taking the prescribed medication as directed. For example, there is no reimbursement for calls placed by nonproviders to patients to assess adherence after they begin a new treatment. Often, a patient goes to the pharmacy to pick up their medication only to realize that they cannot afford it, or they pick it up but stop taking it because of a side effect. Unfortunately, when this happens, you might not find out about it for several months. These are fundamental treatment challenges that need to be solved.

Serena Cardillo, MD

Fellowship Program Director and Director of Education
Professor of Clinical Medicine and Physician
Division of Endocrinology, Diabetes and Metabolism
Perelman School of Medicine
University of Pennsylvania
Philadelphia, PA

“In my experience, treatment costs and therapeutic inertia—especially when injectable therapies are involved—are 2 of the greatest hurdles for clinicians and for patients with type 2 diabetes.”

Serena Cardillo, MD

In my experience, treatment costs and therapeutic inertia—especially when injectable therapies are involved—are 2 of the greatest hurdles for clinicians and for patients with type 2 diabetes. There are times when we cannot prescribe the medication that we know would benefit our patient. 

Although there is a tremendous amount of excitement surrounding the newer medications that have a remarkable impact on cardiovascular risk reduction and comorbidities, these agents are costly. Because of this, it is often prohibitive to prescribe them for patients with Medicare, especially for more than a few months out of the year, due to the Medicare coverage gap. The same is true for insulin, a life-sustaining medication for patients with type 1 diabetes and for many patients with type 2 diabetes. Patients are often forced to ration their insulin analogs, which have an improved physiologic profile and carry a lower risk of nocturnal hypoglycemia. Diabetes care providers often need to prescribe suboptimal lower-cost formulations (eg, NPH insulin and regular insulin) for several months out of the year to avert the cost barrier. 

The second major treatment challenge is related to the injectable route of a number of these agents (both insulin and the GLP-1 receptor agonists), as many patients have a fear of injection therapy. Some individuals can be convinced to take an injection once per week, and the availability of a once-weekly GLP-1 agent helps to overcome this challenge for certain patients. Further, the availability of some devices that are engineered so that the patient never sees the needle is also beneficial in those with needle phobia. Importantly, a patient’s fear of injections has the potential to promote clinical inertia on the part of both the primary care physician and the endocrinologist if continued, time-intensive counseling and support cannot provide the reassurance that the patient needs to proceed with therapy. 

References

Ahad A, Raish M, Bin Jardan YA, Al-Mohizea AM, Al-Jenoobi FI. Delivery of insulin via skin route for the management of diabetes mellitus: approaches for breaching the obstacles. Pharmaceutics. 2021;13(1):100. doi:10.3390/pharmaceutics13010100

Al-Sofiani ME, Ganji SS, Kalyani RR. Body composition changes in diabetes and aging. J Diabetes Complications. 2019;33(6):451-459. doi:10.1016/j.jdiacomp.2019.03.007

Freeman J. Management of hypoglycemia in older adults with type 2 diabetes. Postgrad Med. 2019;131(4):241-250. doi:10.1080/00325481.2019.1578590

Huang Y-M, Shiyanbola OO, Chan H-Y, Smith PD. Patient factors associated with diabetes medication adherence at different health literacy levels: a cross-sectional study at a family medicine clinic. Postgrad Med. 2020;132(4):328-336. doi:10.1080/00325481.2020.1749499

Sharma SK, Kant R, Kalra S, Bishnoi R. Prevalence of primary non-adherence with insulin and barriers to insulin initiation in patients with type 2 diabetes mellitus - an exploratory study in a tertiary care teaching public hospital. Eur Endocrinol. 2020;16(2):143-147. doi:10.17925/EE.2020.16.2.143

Zhu NA, Harris SB. Therapeutic inertia in people with type 2 diabetes in primary care: a challenge that just won’t go away. Diabetes Spectr. 2020;33(1):44-49. doi:10.2337/ds19-0016

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