Hypoglycemia episodes are common among patients with diabetes and can vary in severity. The spectrum of these episodes may include: not experiencing any symptoms at all, experiencing sweating, weakness, dizziness to fatal coma, seizures and death. Hypoglycemia is often under-reported and under-diagnosed, despite the fact that it can be disabling and potentially fatal. A study done to determine the rate of hypoglycemia among 27000 patients showed an incidence of 83% in type I diabetes and 46% in type II diabetes1. Hypoglycemia incidence is higher among patients on insulin. A study in the UK showed that the incidence of hypoglycemia tripled from year 2 to year 5 of insulin initiation2. The most common causes for hypoglycemia include incorrect dosing of insulin, increased gap between meals, increased time gap between taking insulin and having the meal and incorrect carbohydrate proportions in the meal. There are patient-side as well as provider-side factors that are responsible for under-detection of hypoglycemia. For example, some providers believe that in patients with uncontrolled T2DM, hypoglycemia is not common. However the UK study shows that hypoglycemia occurs in all patients of diabetes and is not correlated with their HBA1c levels2.
Patients on insulin have a lot of issues to pay attention to including correct storage, administration and use of insulin. An integral component of education to patients includes the right timings and the correct dose and regimen of insulin. Choosing the right regimen and dose for a patient requires time and patience. Providers have to choose from basal, basal-bolus, pre-mixed regimens of insulin. Once insulin is initiated, it has to be optimized and intensified based on glucose monitoring in the patients3. The vital requirement for this optimal titration of insulin is that there are fasting and meal-time blood glucose levels available to the provider. Timely availability of this data will enable the health care provider to make the right decisions.
So, what are some of the solutions? For patients who have access to a smart phone and the internet, digital therapeutics is a great option to explore. By digitally logging meal contents, times and insulin doses the health care provider (HCP) can titrate insulin efficiently. Let’s look at an example.
“Mr.Madhu, a 45 year old banker in the city of Mumbai, has had T2DM for the past five years now. His fast paced life is wrecking with his diet, sleep and exercise patterns. His HBA1c has been consistently above 10 since over a year. The HCP and Mr.Madhu agree to initiate Insulin considering the long term benefits of preventing disabling complications by achieving target control in T2DM. Mr.Madhu is started on a pre-mixed twice daily regimen as he doesn’t want to take Insulin at work. He leaves home at 7 am to avoid rush hour and is back by 10 PM. Unfortunately he experienced multiple sweating episodes during the day at work disrupting his work. Mr.Madhu’s HCP prescribed a Digital therapeutic (DTx) for Mr.Madhu. He used DTx to log his meals, learn more about how to adjust meal times and insulin injections. On his HCP’s advice, he started doing self-monitoring of blood glucose and logging them in his digital diary on DTx. His HCP was able to see this information real-time and advise him on titration of insulin. To Mr.Madhu’s relief, his sweating episodes went down and he was able to carry on with his work with ease.”
This scenario demonstrates how DTx can be leveraged to successfully titrate insulin and reduce hypoglycemia among patients with T2DM. By effectively capturing patient longitudinal data and using insights from the data, a doctor can be more accurate in insulin titration. Even among patients who are not naïve to insulin, titration is required. Insulin titration is a continuous long-term process that needs to be done to achieve glycemic targets and reduce hypoglycemia. The inertia to dose-titrate that is commonly seen in India4 needs to be fought off with innovative tools like DTx.
A study done by Wellthy CARE TM, a pioneer DTx company in India shows that 282 patients with diabetes who used their DTx product had 1.95% lower instances of hypoglycemia over a period of 6 months with increase in glycemic control. The app allows the user to log their blood glucose values in the digital diary and gives Artificial intelligence (AI) powered real-time feedback and self-management. This also helped patients to have lesser variability in their blood glucose levels from 32.83% to 19.69% over six months of use.
Hence, DTx is a driver of desirable outcomes in patients with diabetes as it helps patients and HCPs manage insulin dose-titration and reduce hypoglycemia episodes. This feat has far reaching consequences on the quality of life of patients and in reducing costs and productivity losses.
References:
- Rates and predictors of hypoglycaemia in 27 585 people from 24 countries with insulin-treated type 1 and type 2 diabetes: the global HAT study – PubMed [Internet]. [cited 2021 Jun 3]. Available from: https://pubmed.ncbi.nlm.nih.gov/27161418/
- UK Hypoglycaemia Study Group. Risk of hypoglycaemia in types 1 and 2 diabetes: effects of treatment modalities and their duration. Diabetologia. 2007 Jun;50(6):1140–7.
- Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M, et al. Management of Hyperglycemia in Type 2 Diabetes, 2015: A Patient-Centered Approach: Update to a Position Statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2015 Jan;38(1):140–9.
- Madhu SV, Neelaveni K, Pitale S, Somani S, Pandey AK, Kalra P, et al. Basal Insulin Titration: Moving Towards a More Patient-Centric Approach with Gla-100 in India. J Assoc Physicians India. 2020 Dec;68(12[Special]):38–42.
