Paradigms in Insulin Use for Type 2 Diabetes - Episode 4

Fixed-Ratio Combinations for Type 2 Diabetes

Dr Jennifer Brigitte Green considers the patient selection for fixed-ratio combinations of basal insulin and GLP-1 receptor agonists among patients with type 2 diabetes and provides insight around Medicare patient access to insulin and injectable medications.

Jennifer Brigitte Green, MD: I always do look for opportunities to use combination therapies in patients with type 2 diabetes, and we have many such medications available now. We’ve had combinations of different kinds of oral agents from different classes for many years. And now, of course, we have combinations of both basal insulin and GLP-1 [glucagon-like peptide-1] receptor agonists available for prescription. If we think about the patients for whom that kind of combination therapy might be appropriate, I have to say that those could be considered appropriate interventions for just about anyone with type 2 diabetes.

If we look into that in a little greater detail or think a bit more carefully about that, naturally you would think of the person who is on basal insulin therapy, or for that matter a GLP-1 receptor agonist, who clearly needs additional intensification as the ideal candidate to switch to the injected combination of basal insulin plus a GLP-1 receptor agonist. Because that can be a very effective further intensification of their care, probably with the same number of injections per day and ideally no added injection or medication burden.

Thus, there are many different people who would be good candidates for that combination therapy. If we think about why those kinds of combinations are effective and good to think about in the treatment of type 2 diabetes, the rationale for using those medications together would be of course that the basal insulin works to control blood sugars overnight in the fasting state and in between meals. Then, the GLP-1 receptor agonist’s main role in glycemic control is to blunt the rise of blood sugar after meals. So they have a very complementary mechanism of action, and in general, those are combinations of very effective agents.

When we think about the Part D Senior Savings Model, which is known as the $35 insulin plan, first I have to say that any interventions or changes that can improve access to insulin, a drug many people need for survival, is a terrific step forward. This will hopefully result in fewer people rationing insulin in the future, which is unfortunately a practice that can be incredibly dangerous to the individual. Thus, I’m very happy to see this movement forward, and I think it will be of great benefit to many people with type 1 and type 2 diabetes.

However, I would love to see some consideration or expansion of access to other injectable therapies for people with type 2 diabetes moving forward. One of the reasons that this could be considered is shown in the most recent ADA [American Diabetes Association] standards of care for the management of type 2 diabetes, in which those guidelines or suggestions recommend that the first injectable agent used in someone with type 2 diabetes who requires intensification actually be a GLP-1 receptor agonist. And if we have improved access to care, that will be more likely accessible to the many people with type 2 diabetes in this country and can be implemented effectively.

Transcript Edited for Clarity