There is no question in our mind that over the next 18 to 24 months we are going to see some major advancements for insulin using patients. Thanks to Dexcom and Abbott CGM technology has become not just more patient friendly but also more patient accessible. Thanks to Medtronic and Tandem insulin pump technology is advancing ever closer to a true closed loop insulin delivery system. Thanks to TypeZero and others insulin dosing algorithms will go beyond insulin pumps and extend to patients who use “smart”insulin pens.
Although we would never claim that insulin therapy is easy with these technological advancements it’s about to become much, much easier for all involved. We would almost go as far to state that in many respects it will be easier to be a patient on insulin than a patient who’s therapy regimen is oral medications alone. We know that sounds a little crazy but patients on oral therapies alone are the last to adopt technology like a CGM. They have the least control over what happens to their body and when it happens.
Sure it seems like these patients have the easiest path but this ignores how diabetes management works in the real world. So many view diabetes management in a silo that diabetes management is the only thing these patients worry about. On the surface this is logical as how hard can be it to take pills. However these patients aren’t just taking pills for their diabetes but also pills for high blood pressure, cholesterol, etc. Look into the medicine cabinet of a typical Type 2 patient who is on oral medication alone and you’ll likely find a cornucopia of other medications they must also take.
As much as we believe these patients would benefit from using CGM the fact is it will take some time before CGM is embraced by this patient population. The same goes for all those way cool whiz bang apps which come with way cool whiz bang coaching. And while a move is underway in the algorithm community to expand their reach into non-insulin patients it will take years for this work to reach these patients.
So what’s the best hope for these patients? A group which we should remind everyone vastly outnumbers the insulin using community. This is by far the largest patient segment although one would never know it given the disproportionate attention given to the insulin using community. We have long known there is a major bias towards insulin using patients and that this bias is harming patients who do not use insulin. All the attention, all the money is disproportionately tilted towards the insulin side of the ledger.
That being said we continue to see GLP-1 therapy as the current best hope for these patients. Once-weekly products are replacing once daily, new delivery systems like the Intarcia micropump are on the way as is an oral version. (This assumes of course that Novo Nordisk stops studying the damn drug and actually submits for approval.) GLP-1 therapy requires no glucose monitoring, does an excellent job controlling glucose and for many has the additional plus of helping patients lose weight. Even better GLP-1 is moving beyond the endocrinologist office and into the Primary Care Physicians office.
Still there are millions of patients who for a wide variety of reasons will not move to GLP-1 or insulin therapy. They will remain on pills. Is there any hope for these people, is there anything on the horizon that will make their lives easier? The simple answer is no. While many have tried no one has yet come up with a workable method that ensures these people take their pills when they are supposed to.
Therapy adherence, compliance or whatever you want to call it is a problem that has perplexed diabetes. A problem for which there is no whiz bang way cool technological solution. As Momma Kliff used to say; “All the advanced technology in the world won’t change one indisputable fact, when it comes to the patient it’s easy to provide the how to but difficult to provide the want to.”
It goes without saying that education is the most reliable and proven method for helping with the want to. Yet it is also true these patients for one reason or another aren’t getting or are not interested in education. Therefore the solution must come from an unconventional approach which when we think about it isn’t unconventional at all. In fact it makes so much sense we are surprised no one has given it a chance. Then again something so simple and elegant is often ignored in our wacky world which seems to believe in complexity rather than simplicity.
Will someone please explain why everyone is so afraid of incentivizing the patient. Why not make better outcomes worth all the heavy lifting. Well we’ll tell you why as these people just can’t get out of their silos. They have no clue how these patients think or feel. They have no idea what it is like to live with diabetes even when the patient is just taking pills, which to these uniformed individuals seems so damn easy. They’d rather spend millions on useless toys when those same millions could be put to much better use incentivizing the patient.
And will give you one more reason to do this; NOTHING ELSE HAS WORKED. While we are thrilled that life is getting much better for insulin using patients and that GLP-1 therapy offers hope for those not on insulin, the largest fastest growing patient segment is being ignored because why? Because everyone is enamored with way cool whiz bang, the toys in the toy chest.
Are these patients not worthy? Is there not money to be made by helping this patient segment? Isn’t it time we end the hypocrisy?