Challenges and unmet needs in basal insulin therapy: lessons from the Asian experience

Figures & data

Table 1 Number of adults with diabetes, endocrinologists, and estimated rates of insulin usage by territory

Territory	Adultsa with diabetes in thousands (uncertainty range)^Citation73	Number of endocrinologists	Estimated rate of insulin usage (insulin and insulin analogs)
Hong Kong	582.5 (515.8–686.5)	104	21.8%^Citation74
Indonesia	10,021.4 (8,736.6–10,882.8)	101	Not reported
Philippines	3,506.5 (2,702.3–4,584.6)	202	42.0%^Citation75
Singapore	541.6 (466.4–613.3)	105	Not reported
Taiwan	1,781.1 (1,386.6–2,293.8)	~600	27.3%^Citation76
Thailand	4,025.1 (2,965.6–4,633.2)	~250	25.3%^Citation77
Vietnam	3,509.1 (2,582.5–5,501.2)	~300	Not reported

Note:

a 20–79 years old.

Table 2 Diabetes-related resources by territory

Territory	Clinical practice guidelines on insulin titration	Diabetes support teams and education programs	Availability of insulins for basal insulin therapy	Subsidy status of consumables and insulins for basal insulin therapy
Hong Kong	The Hong Kong Reference Framework for Diabetes Care for Adults in Primary Care Settings 2013 recommends an initial insulin dose of 10 units/day (0.1–0.2 units/kg per day), followed by titration every 1–2 weeks according to Hemastix monitoring.^Citation4 However, in clinical practice, there is no standardized way of titration, and it is often up to the discretion of individual physicians and diabetes nurses.	There are no formal diabetes education programs. However, certified diabetes educators are available in the public sector to educate patients on insulin administration and to support subsequent titration.	NPH insulin, Gla-100, and insulin detemir are available in all hospitals.	Fully subsidized: NPH insulin is fully subsidized. Gla-100 and insulin detemir are fully subsidized only if patients meet certain criteria (eg, frequent admission for hypoglycemic episodes and the presence of cardiovascular disease) Partially subsidized: none Partially subsidized for a selected group of patients who require financial assistance: none Nonsubsidized: needles, syringes, and glucometers
Indonesia	The Consensus Management and Prevention of Type 2 Diabetes Mellitus in Indonesia 2011 recommends the addition of 2–4 units of basal insulin every 3–4 days until glycemic target is achieved.^Citation8	The availability of certified diabetes educators differs between cities, and they are concentrated mostly in larger cities. Where certified diabetes educators are available, they provide patient education on insulin administration and support subsequent titration.	NPH insulin, Gla-100, and insulin detemir are available in all public and private hospitals and in medical community outlets in rural areas.	Fully subsidized: NPH insulin, Gla-100, and insulin detemir are fully subsidized for both type 1 and type 2 diabetes Partially subsidized: none Partially subsidized for a selected group of patients who require financial assistance: none Nonsubsidized: Needles, syringes, glucometers, and glucose test strips
Philippines	The Philippine Practice Guidelines on the Diagnosis and Management of Diabetes Mellitus 2014 does not specify a standardized algorithm for titration as response depends on the individual patient’s metabolism and the type of insulin taken.^Citation5	Certified diabetes educators are available during outpatient visits and prior to hospital discharge to provide patient education on insulin administration and titration. However, most patients still depend on their doctors for subsequent titration of insulin doses.	NPH insulin, Gla-100, and insulin detemir are available in most private hospitals. In government hospitals under the Department of Health, NPH insulin is available, but Gla-100 and insulin detemir are not available. NPH insulin, Gla-100, and insulin detemir can be purchased from drug stores in major cities. However, access to insulin tends to be difficult in geographically isolated and disadvantaged areas of the Philippines.	Fully subsidized: NPH insulin is fully subsidized by the Philippine Health Insurance Corporation for inpatient care Partially subsidized: none Partially subsidized for a selected group of patients who require financial assistance: NPH insulin (assisted by a PSEDM program). NPH insulin, Gla-100, and insulin detemir for indigent patients (depending on availability, subsidized by the Philippine Charity Sweepstakes Office) Nonsubsidized: NPH insulin for outpatient care. Gla-100 and insulin detemir for both inpatient and outpatient care. Needles, syringes, glucometers, and glucose test strips
Singapore	The Singapore Clinical Practice Guidelines for Diabetes Mellitus 2014 does not specify a standardized algorithm for titration.^Citation7 In clinical practice, titration is often up to the discretion of individual physicians and diabetes nurses.	Public sector institutions have multidisciplinary diabetes centers with access to certified diabetes educators (nurse only) and dietitians. The diabetes centers provide initial patient education on insulin administration face-to-face and provide ongoing support via phone, e-mail, fax, and face-to-face consultations.	NPH, Gla-100, and insulin detemir are available in all public sector hospitals and polyclinics. In private sector primary and specialist centers, availability of the different types of basal insulins varies and is dependent on the preferences of individual centers.	Fully subsidized: none Partially subsidized: NPH insulin (if purchased through government-linked primary healthcare clinics, known as polyclinics) Partially subsidized for a select group of patients who require financial assistance (scheme: Medication Assistance Fund): Gla-100 and insulin detemir Nonsubsidized: Gla-100, insulin detemir, syringes, needles, pen needles, glucometers, and glucose test strips
Taiwan	The DAROC Clinical Practice Guidelines for Diabetes Care 2015 recommends a starting basal insulin dose of 0.1–0.2 U/kg.^Citation6 The choice of the titration scheme is based on physician’s clinical judgment on individual patients’ condition.	Over 5,000 certified diabetes educators are available in Taiwan. Certified diabetes educators provide patient education on insulin administration and support subsequent titration.	NPH insulin, Gla-100, and insulin detemir are available in all hospitals.	Fully subsidized (Scheme: National Health Insurance): NPH insulin, Gla-100, insulin detemir, syringes, needles and insulin pens for all diabetes patients. Glucose test strips only for patients with type 1 diabetes Partially subsidized: none Partially subsidized for a selected group of patients who require financial assistance: none Nonsubsidized: Glucometers and glucose test strips (except for type 1 diabetes)
Thailand	The Thailand Diabetes Clinical Practice Guidelines recommend a starting basal insulin dose of 0.1–0.15 unit/kg/day, followed by a titration of 2–4 units every 3–7 days.^Citation2	The Association of Diabetes Educators offers a curriculum for training diabetes educators. However, there is still a lack of qualified diabetes educators. Certified diabetes educators are available in some hospitals (eg, teaching hospitals or large hospitals) to educate patients on insulin administration.	NPH insulin is available in all hospitals. Gla-100 and insulin detemir are available in university hospitals and regional center hospitals but are usually not available in community hospitals situated in rural regions.	Fully subsidized: NPH insulin, glucose test strips (type 1 diabetes only, subsidized only in some teaching hospitals, up to 3 strips/day), Gla-100 (type 1 diabetes only) Partially subsidized: none Partially subsidized for a selected group of patients who require financial assistance: none Nonsubsidized: Insulin detemir (for both type 1 and 2 diabetes), Gla-100 (type 2 diabetes), syringes, needles, pen needles, glucometers, and glucose test strips (type 2 diabetes)
Vietnam	The Vietnamese Association of Diabetes and Endocrinology guidelines do not specify a standardized algorithm for titration. In clinical practice, most physicians refer to the ADA/EASD or AACE guidelines for insulin dose titration.	Individual hospitals and institutes have their own diabetes education programs to provide patient education on insulin administration and support subsequent titration. There is no formal certification program for diabetes educators.	NPH insulin is available in all hospitals. Gla-100 and insulin detemir are available in the hospitals of major cities, but unavailable in local and provincial hospitals situated in rural regions.	Fully subsidized: none Partially subsidized (up to US$70/prescription): NPH insulin, Gla-100, and insulin detemir Partially subsidized for a selected group of patients who require financial assistance: none Nonsubsidized: syringes, needles, pen needles, glucometers, and glucose test strips

Abbreviations: AACE, American Association of Clinical Endocrinologists; ADA/EASD, American Diabetes Association/European Association for the Study of Diabetes; DAROC, Diabetes Association of the Republic of China; Gla-100, glargine 100 units/mL; NPH, Neutral Protamine Hagedorn; PSDEM, Philippine Society Endocrinology, Diabetes and Metabolism.

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