Delivering on the promise of insulin
The discovery of insulin was one of the most remarkable breakthroughs in the history of medicine – and subsequent innovations have radically improved its use and flexibility, says Professor Kamlesh Khunti in the latest in our series ‘Insulin@100’. But its full potential is being stymied by therapeutic inertia.
Professor Khunti is in no doubt as to the great strides made to improve insulin and its associated delivery devices. “From that old era when one used to have painful needles and syringes, we’ve come on to vials, now self-dial vials, and injectable pens with pain-free needles. We have innovations in terms of how fast the insulins are working – the ultra-fast and the longer-acting second generation insulins as well.”
The problem as he sees it isn’t what insulin is capable of. It’s a question of timing. “Despite all these innovations, we haven’t had transformation of the research evidence into clinical practice as much as we would like. There’s still a major barrier to use of insulins, particularly in primary care. So we’re delaying use of insulins longer and longer – what we term therapeutic inertia.”
The consequence is that improvements we should be seeing from these innovations are stalling. “If you look at the mean HbA1cs over 10 years, they’ve remained the same – despite insulin being the most effective glucose-lowering therapy that we currently have.”
In his compelling and wide-ranging presentation, Kamlesh explores the causes for this impasse. He also outlines some strategies for tackling it – such as better use of the wider multidisciplinary team (nurses and pharmacists) to support insulin initiation and education, use of group education – even taking a leaf out of the COVID-19 book with more virtual consultations.
Further innovations will play their part too – and Kamlesh sees several exciting new options coming down the track. “We now have the additional option of adding a GLP-1 receptor agonist, of course. Trials are already underway for weekly insulins. And we might even have oral insulin before long – which would be a complete game changer.”
In the meantime, though, a key objective must be to tackle therapeutic inertia, ensuring insulin therapy is initiated in a timely manner to help people with high HbA1cs. “It’s important to do everything possible to get appropriate people on to insulin - and to keep them on insulin; adherence and persistence are problems as well.”