A new Health Ministry guide aims to train doctors in the use of insulin in type 2 diabetes.
FOR decades since its discovery, insulin has been used primarily to treat type 1 diabetes – a condition where a person’s body cannot keep his blood sugar levels from skyrocketing due to the destruction of insulin-producing pancreas cells by his own immune system.
Insulin use in type 2 diabetes is, however, not as common, as oral medications together with lifestyle modifications are still the main treatment option.
This is because in type 2 diabetes, the problem is not the lack of insulin. It is the inability of the insulin-producing cells to produce enough insulin to bring sugar levels down. It can also happen when cells become more resistant to the effects of insulin.
Therefore, in the early stages, patients with type 2 diabetes do not need to be supplemented with insulin because the body is still able to produce it. Oral medications and lifestyle modifications (like consuming less sugar and exercising) are already sufficient to help the body increase insulin production or reduce insulin resistance.
It is only when these oral agents “fail” completely to keep blood sugar levels within the normal range that doctors put their patients on insulin.
However, in recent years, this perception has changed as doctors realise that oral medications may not work as their patients’ disease progress over time.
“Many diabetics see insulin therapy as a last resort. They wait until their oral medication fail, and only then (will they be willing to) move to insulin, at the point when their disease is controlling their lives,” says president of the Malaysian Endocrine and Metabolic Society (MEMS) Prof Dr Nor Azmi Kamaruddin.
“The fact is, their oral medications have not failed, their disease has just progressed,” he adds.
Recognising this changing trend, the Health Ministry, together with MEMS have set out to produce a practical guide to insulin therapy in type 2 diabetes mellitus to train physicians in hospitals and clinics on the safe and effective use of insulin.
It is also to complement the 4th edition of the Clinical Practice Guidelines On The Management Of Type 2 Diabetes Mellitus launched last year.
“The Clinical Practice Guidelines On The Management Of Type 2 Diabetes Mellitus provides the overall picture on how to manage a patient with type 2 diabetes and its related problems, while this is specifically geared towards insulin therapy,” says Hospital Putrajaya senior consultant endocrinologist Dr Zanariah Hussein after the launch. Dr Zanariah is also the chairperson of the guide working committee.
The guide, supported by an educational grant by insulin pen producer sanofi-aventis, was launched last week at the opening of the 14th Asia-Ocenia Congress of Endocrinology.
Guide to address treatment barriers
Although many health authorities recognise that insulin may be a good addition to oral medications in the management of patients with type 2 diabetes, going by the numbers from the Third National Health and Morbidity Survey (third NHMS) in year 2006, and the nationwide audit by the Malaysian Institute of Health Management (IHM) in year 2005 and 2008, its use in Malaysia is still low compared to many developed countries.
According to the third NHMS, of the estimated 1.4 million Malaysians over 30 years old with diabetes, about 95% have type 2 diabetes. And of those with type 2 diabetes, 77% were treated with oral anti-diabetic medications. Only 7% were receiving insulin therapy. This is low compared to half the countries that reported the percentage of their insulin-treated type 2 diabetes (above 20% of all patients with type 2 diabetes).
While IHM audits showed an increase in the use of insulin therapy in Ministry of Health facilities (19% in 2008 compared to 13% in 2003), insulin is still mostly used in tertiary (or specialist) care compared to primary and secondary care, where most patients with diabetes are followed up.
“Seventy per cent of diabetes patients are, and can be, managed in the primary care (outpatient clinic) level,” says family medicine specialist Dr Mastura Ismail, one of the external reviewers of the guide. Usually, those who have complications or severe, uncontrolled diabetes need to be seen by a specialist.
“That’s why we have to train primary healthcare providers in the public and private sector so that they know how to use insulin safely and efficiently,” she says.
Not always the last resort
While insulin is prescribed, in many cases, when patients’ blood sugar levels are no longer adequately controlled, the guidelines indicate that it can be started upon diagnosis for those who are diagnosed late.
“There’s a treatment algorithm in the guide. When a patient comes (for the first time) with severe elevations in blood sugar, we will start insulin right from the beginning, because that is the most potent drug to bring the blood sugar down,” says Dr Zanariah.
“However, if you are one of the majority of patients who have been treated effectively with oral tablets over the years ... and we have exhausted the combination of tablets, we will ask you to consider insulin. The insulin we use will also be gradually increased,” says Dr Zanariah.
The amount of time from the start of oral medications to the need to start insulin varies because there is often a huge delay of diagnosis. “It is not uncommon to see people who may need insulin after a year or two, or at most, five years into their disease,” Dr Zanariah notes.
For patients, one of the barriers is the idea that once they are on insulin, they are at the end stage of the disease, says Dr Nor Azmi. “That’s the most prevalent barrier that we see, but of course, there are also problems like the fear of injection and fear of injecting in public,” he says. As a result, patients skip doses or fail to take their insulin as prescribed.
On top of that, patients who are put on insulin also have to be a little more diligent in checking their sugar levels (you need to know your blood sugar level to know how much insulin to take).
For doctors, the lack of resources (drug costs, staff or skills), time, experience, and guidelines to administer treatment (treatment algorithms) may play a part in their reluctance to adopt the use of the therapy. Their lack of knowledge about the ways to initiate, monitor, and intensify insulin therapy may also cause another problem: ineffective insulin therapy.
To address these issues, the guideline covers almost everything from the rationale for insulin therapy in type 2 diabetes, to the ways to overcome treatment barriers, and a step-by-step guide on how to start and optimise insulin therapy using different types of insulin.
Guidelines to manage problems that may arise during insulin therapy, including low blood sugar (hypoglycaemia), weight gain, injection site problems, and allergy are also discussed.
To date, 30 primary care physicians have been trained using the guidelines. The Ministry hopes to train over 200 physicians through workshops and roadshows over the next 12 months.
However, educating physicians is only the first step. “We hope we would be able to come up with a guide for patients as well,” says Dr Zanariah.
The guide will be available for download on the MEMS website at www.mems.my (under the CPG tab on the left panel) in two weeks’ time.
FOR decades since its discovery, insulin has been used primarily to treat type 1 diabetes – a condition where a person’s body cannot keep his blood sugar levels from skyrocketing due to the destruction of insulin-producing pancreas cells by his own immune system.
Insulin use in type 2 diabetes is, however, not as common, as oral medications together with lifestyle modifications are still the main treatment option.
This is because in type 2 diabetes, the problem is not the lack of insulin. It is the inability of the insulin-producing cells to produce enough insulin to bring sugar levels down. It can also happen when cells become more resistant to the effects of insulin.
Therefore, in the early stages, patients with type 2 diabetes do not need to be supplemented with insulin because the body is still able to produce it. Oral medications and lifestyle modifications (like consuming less sugar and exercising) are already sufficient to help the body increase insulin production or reduce insulin resistance.
It is only when these oral agents “fail” completely to keep blood sugar levels within the normal range that doctors put their patients on insulin.
However, in recent years, this perception has changed as doctors realise that oral medications may not work as their patients’ disease progress over time.
“Many diabetics see insulin therapy as a last resort. They wait until their oral medication fail, and only then (will they be willing to) move to insulin, at the point when their disease is controlling their lives,” says president of the Malaysian Endocrine and Metabolic Society (MEMS) Prof Dr Nor Azmi Kamaruddin.
“The fact is, their oral medications have not failed, their disease has just progressed,” he adds.
Recognising this changing trend, the Health Ministry, together with MEMS have set out to produce a practical guide to insulin therapy in type 2 diabetes mellitus to train physicians in hospitals and clinics on the safe and effective use of insulin.
It is also to complement the 4th edition of the Clinical Practice Guidelines On The Management Of Type 2 Diabetes Mellitus launched last year.
“The Clinical Practice Guidelines On The Management Of Type 2 Diabetes Mellitus provides the overall picture on how to manage a patient with type 2 diabetes and its related problems, while this is specifically geared towards insulin therapy,” says Hospital Putrajaya senior consultant endocrinologist Dr Zanariah Hussein after the launch. Dr Zanariah is also the chairperson of the guide working committee.
The guide, supported by an educational grant by insulin pen producer sanofi-aventis, was launched last week at the opening of the 14th Asia-Ocenia Congress of Endocrinology.
Guide to address treatment barriers
Although many health authorities recognise that insulin may be a good addition to oral medications in the management of patients with type 2 diabetes, going by the numbers from the Third National Health and Morbidity Survey (third NHMS) in year 2006, and the nationwide audit by the Malaysian Institute of Health Management (IHM) in year 2005 and 2008, its use in Malaysia is still low compared to many developed countries.
According to the third NHMS, of the estimated 1.4 million Malaysians over 30 years old with diabetes, about 95% have type 2 diabetes. And of those with type 2 diabetes, 77% were treated with oral anti-diabetic medications. Only 7% were receiving insulin therapy. This is low compared to half the countries that reported the percentage of their insulin-treated type 2 diabetes (above 20% of all patients with type 2 diabetes).
While IHM audits showed an increase in the use of insulin therapy in Ministry of Health facilities (19% in 2008 compared to 13% in 2003), insulin is still mostly used in tertiary (or specialist) care compared to primary and secondary care, where most patients with diabetes are followed up.
“Seventy per cent of diabetes patients are, and can be, managed in the primary care (outpatient clinic) level,” says family medicine specialist Dr Mastura Ismail, one of the external reviewers of the guide. Usually, those who have complications or severe, uncontrolled diabetes need to be seen by a specialist.
“That’s why we have to train primary healthcare providers in the public and private sector so that they know how to use insulin safely and efficiently,” she says.
Not always the last resort
While insulin is prescribed, in many cases, when patients’ blood sugar levels are no longer adequately controlled, the guidelines indicate that it can be started upon diagnosis for those who are diagnosed late.
“There’s a treatment algorithm in the guide. When a patient comes (for the first time) with severe elevations in blood sugar, we will start insulin right from the beginning, because that is the most potent drug to bring the blood sugar down,” says Dr Zanariah.
“However, if you are one of the majority of patients who have been treated effectively with oral tablets over the years ... and we have exhausted the combination of tablets, we will ask you to consider insulin. The insulin we use will also be gradually increased,” says Dr Zanariah.
The amount of time from the start of oral medications to the need to start insulin varies because there is often a huge delay of diagnosis. “It is not uncommon to see people who may need insulin after a year or two, or at most, five years into their disease,” Dr Zanariah notes.
For patients, one of the barriers is the idea that once they are on insulin, they are at the end stage of the disease, says Dr Nor Azmi. “That’s the most prevalent barrier that we see, but of course, there are also problems like the fear of injection and fear of injecting in public,” he says. As a result, patients skip doses or fail to take their insulin as prescribed.
On top of that, patients who are put on insulin also have to be a little more diligent in checking their sugar levels (you need to know your blood sugar level to know how much insulin to take).
For doctors, the lack of resources (drug costs, staff or skills), time, experience, and guidelines to administer treatment (treatment algorithms) may play a part in their reluctance to adopt the use of the therapy. Their lack of knowledge about the ways to initiate, monitor, and intensify insulin therapy may also cause another problem: ineffective insulin therapy.
To address these issues, the guideline covers almost everything from the rationale for insulin therapy in type 2 diabetes, to the ways to overcome treatment barriers, and a step-by-step guide on how to start and optimise insulin therapy using different types of insulin.
Guidelines to manage problems that may arise during insulin therapy, including low blood sugar (hypoglycaemia), weight gain, injection site problems, and allergy are also discussed.
To date, 30 primary care physicians have been trained using the guidelines. The Ministry hopes to train over 200 physicians through workshops and roadshows over the next 12 months.
However, educating physicians is only the first step. “We hope we would be able to come up with a guide for patients as well,” says Dr Zanariah.
The guide will be available for download on the MEMS website at www.mems.my (under the CPG tab on the left panel) in two weeks’ time.
