https://orcid.org/0000-0001-5928-4034
ABSTRACT
Objective
To understand physicians’ reasons for prescribing Insulin Lispro 200 units/ml (IL200) and their experience with IL200 treatment in Germany.
Methods
The survey consisted of 28 questions on physician’s profile, average IL200 patients’ characteristics and rationales for prescribing IL200. Questions were rated on a scale of 0 (‘not at all important’/‘strongly disagree’) to 4 (‘absolutely important’/‘strongly agree’).
Results
The surveyed physicians had a mean (SD) experience of 18.1 (7.0) years managing diabetes, consulted an average of 226.8 patients with diabetes/month and prescribed IL200 to 56.1% of their patients on mealtime insulin (MTI). About 80.0% of IL200 patients had type 2 diabetes mellitus, were overweight/obese, and received >20 units/day of MTI. More than 70.0% of physicians rated patient’s insulin dose, pattern of self-measured glucose levels, hemoglobin A1c (HbA1c) (clinical); adherence, hypoglycemia knowledge, motivation to improve lifestyle, desire to reduce injection volume and emotional struggle with controlling HbA1c (behavioral) as ‘very important’/‘absolutely important’ factors when prescribing IL200.
Conclusion
Physicians considered IL200 a promising treatment option that reduces the injection burden for patients on MTI. Physicians adopted a patient-centered perspective by aligning IL200 prescribing decisions with each patient’s medical needs and non-clinical preferences, with an aim to encourage treatment adherence through resorting to IL200’s advantageous attributes.
1. Introduction
Diabetes mellitus (DM) accounts for a huge burden on healthcare systems, estimated at USD 825 billion globally in the year 2015 [Citation1,Citation2]. According to the International Diabetes Federation’s estimates for 2019, the prevalence of DM in Europe among the population aged 20–79 years is 59.3 million (Germany has the highest prevalence among European countries; 9.5 million), with USD 161.4 billion total healthcare expenditure [Citation3].
Insulin therapy is the primary treatment for persons with type 1 DM (T1DM) [Citation4] and is used in combination with other hypoglycemic agents for persons with type 2 DM (T2DM) uncontrolled (hemoglobin A1c, HbA1c≥7.5% [58 mmol/mol]) with diet, exercise, and other hypoglycemic agents alone. However, for persons with diabetes, an increase in body weight and/or worsening insulin resistance inevitably results in the required insulin dose to increase over time [Citation5–7]. With the ever-growing prevalence of obesity around the world, more patients than ever face challenges with increasing insulin doses in order to achieve glycemic goals. The challenges include increased numbers of insulin injections, larger injection volume, and more frequent insulin pen changes [Citation8–10]. Furthermore, large subcutaneous insulin depot causes injection site discomfort and pain [Citation11]. As a result, adherence to insulin therapy could become more difficult for patients facing these treatment complexities and inconveniences, leading to poor glycemic control [Citation12,Citation13].
In recent years, multiple concentrated insulins with different concentration levels have become available. Potential benefit of using concentrated insulin via pens includes decreased injection volume, decreased number of injections, decreased pain at injection site, less frequent pen changes, and easier delivery of larger doses [Citation14]. With these benefits, concentrated insulins offer greater opportunities to provide tailored therapy for patients needing insulin therapy. For obese and severe insulin-resistant patients who require relatively larger doses of insulin, concentrated insulins are obvious good choices [Citation15].
Insulin Lispro 200 units/ml (IL200) is a concentrated insulin commercially known in Germany as Humalog® 200 units/ml KwikPen™ and Liprolog® 200 units/ml KwikPen™. It is a short acting analog insulin that is given prandially in T1DM and T2DM. Being bioequivalent to Insulin Lispro 100 units/ml, IL200 is expected to have similar clinical efficacy and safety [Citation16]. While the IL200 pen is similar in size and shape to the Humalog 100 units/ml pen, it contains twice as many units of insulin per unit volume and delivers the same insulin dose in half the volume. It is designed to be dosed in 1 unit increments, so the patient experience of dialing a dose requires no dose calculations or adjustments when moving from 100 units/ml insulin pen to IL200. In addition, the IL200 pen exhibited significantly lower glide force and glide force variability compared to the 100 units/ml insulin pen [Citation6], indicating that patients may exert less effort to self-inject and that insulin delivery will be smoother, which may have a positive impact on the ease of administration. This is supported by a simulated injection (non-injecting) study among caregivers and persons with diabetes, which indicated the IL200 pen to be a preferred option over the 100 units/ml insulin pen [Citation17]. In this study, the primary drivers of the patient preference for the IL200 pen included reduced glide force, reduced injection volume and the ability to have 600 units of insulin in the pen compared to 300 units in the 100 units/ml insulin pen [Citation17].
As part of patient-centered care, physicians are oriented to the patient’s values, preferences, and needs when making treatment decision [Citation18,Citation19]. In order to effectively manage diabetes, treatment decisions will also need to take into consideration the perceived advantageous attributes of a treatment and the perceived benefit to a patient. However, the preferences of physicians and patients regarding treatment options can differ substantially. While the aforementioned studies [Citation6,Citation17,Citation20] provided information on patient preference toward IL200, little is known about how physicians prescribed IL200. This physicians’ survey-based study aimed to describe the characteristics of average IL200 patients and the importance of patients’ clinical factors and behavioral aspects when prescribing IL200. This study also reported the physicians’ perception about IL200 and their reasons for prescribing IL200 to persons with diabetes.
2. Material and methods
2.1. Cross-sectional survey
The study was a cross-sectional survey, designed to assess physicians’ experience with IL200 in Germany. The study was conducted in the year 2018. Physicians from an IQVIA primary market research German panel were contacted and invited to participate in the survey that contains both a screener and a main survey (Supplementary material 1).
Screening of participating physicians
The screener comprised of six questions around specialty and the number of patients prescribed IL200 under the physician’s management. These screener questions allowed for the identification of a convenience sample of high prescribers of IL200 to complete the main survey. Endocrinologists, diabetologists, and internal medicine physicians who were actively treating persons with diabetes and were attending a minimum of 20 IL200 patients/month (definition of high prescribers used for this survey) were eligible for the main survey.
Survey design
The design of the main survey was based on the hypothesis that prescribing decisions are likely to be driven by objective patient factors, physician-specific factors, and/or non-clinical issues and incorporated the considerations for insulin therapies and the characteristics of IL200. The survey consisted of 28 questions in four distinct sections:
1. Physicians’ profile and experience in treating persons with diabetes: Physicians’ gender, age, years of practice, years of treating diabetes, and healthcare settings in which the patients are seen.
2. Description of the IL200 patient profile treated by survey physicians: The proportion of patients in the categories of gender, age, body mass index (BMI), HbA1c level, diabetes type, years since diagnosis, units, and number of injections of basal insulin and mealtime insulin (MTI) per day and months since receiving IL200.
3. Rationale for prescribing IL200: Level of importance of the following aspects while prescribing IL200:
Clinical characteristics–patients’ age, BMI, HbA1c level, insulin dose, pattern of self-measured glucose levels, blood pressure, and comorbidities.
Subjective behavioral factors–patients’ adherence behavior, knowledge about hypoglycemia, request to try IL200, decreased number of doctor appointments/pharmacy visits due to a fewer number of pens needed, desire to reduce insulin injection volume, motivation to improve lifestyle, emotional struggle with keeping HbA1c level under control, and fewer pens to store and carry when traveling.
Clinical practice and setting practice management policy, expert guideline/hospital algorithms, and medication cost.
Any additional factors and barriers for prescribing IL200.
4. Experience (physicians’ personal perceptions and preferences) with prescribing IL200: Level of agreement that patients find IL200 convenient to use, easy to dose, and administer when switched from 100 units/ml insulin, use IL200 as prescribed, adherent to MTI treatment algorithm when taking IL200 and fewer split doses required on IL200 than other MTI therapies.
Physicians scored the above-mentioned aspects of prescribing IL200 and their personal perceptions on its use on a scale of 0–4, where 0 indicated ‘not at all important’/‘strongly disagree,’ 1 indicated ‘of little importance’/‘disagree,’ 2 indicated ‘neither unimportant nor important’/‘neither disagree nor agree,’ 3 indicated ‘very important’/‘agree,’ and 4 indicated ‘absolutely important’/‘strongly agree.’
The survey took approximately 20–30 minutes to complete. Physicians were remunerated for their participation in the study. The study duration was approximately 6 months, from setting up, through screening and up to the final results.
2.2. Statistical analysis
Survey responses were presented using descriptive statistics. The factors evaluated in each of the following categories, patient clinical characteristics, subjective patient behavioral factors, clinical practice/setting, and physician experiences, were categorized by the proportion of respondents assigning the importance/agreement for each variable. There were no missing responses to any of the questions in the survey. Responses for the overall sample are reported. Confidentiality of data was maintained through the study.
2.3. Compliance with ethics guidelines
The protocol and survey questionnaire were submitted to the Western Institutional Review Board (WIRB) for review and approval. The WIRB registration number is IRB00000533. Due to the type of research in Germany, relevant guidelines from the European Pharmaceutical Market Research Association (EphMRA) were followed. Physician participation was voluntary.
3. Results
Of the 5,656 German physicians approached, 254 answered the screening questions, of which 98 met the inclusion criteria (screened-in) and completed the survey ().
Figure 1. Schematic diagram of survey respondents
3.1. Physician characteristics
Among the 98 physicians who completed the survey, 60 were diabetologists, 33 were internal medicine physicians and five were endocrinologists. Three-fourths (75.5%) of the surveyed physicians were males and 87.8% were aged between 36 and 60 years. The mean duration of practice was 20.3 (SD: 7.9) years, with the majority of experience (mean: 18.1 [SD: 7.0] years) in treating persons with diabetes. In a month, the surveyed physicians saw a mean number of 226.8 (SD: 152.1) patients with diabetes, and a mean number of 128.1 (SD: 109.9) patients with diabetes were treated using insulin. About 82% of the insulin-treated patients were on MTI. On average, physicians prescribed IL200 to 56.1% (SD: 24.1%) of their MTI-treated diabetes patients ().
Table 1. Physician characteristics, by specialty, and at overall level
3.2. Physician-reported average IL200 prescribed patient characteristics
As reported by the surveyed physicians, there was an equal distribution of males and females among the patients receiving IL200. On average, 51.9% (SD: 17.4%) of patients were in the age range of 21–64 years and 78.6% (SD: 18.1%) had T2DM. Approximately, half of the patients (mean: 50.7% [SD: 27.1%]) have been diagnosed with diabetes for more than 5 years while an average of 12.8% (SD: 11.8%) of the patients were reported to be newly diagnosed. Among the patients prescribed with IL200, on average, 45.1% (SD: 23.8%) of them were obese (BMI≥30.0 kg/m2) and 42.7% (SD: 19.9%) were overweight (25.0≤ BMI<30.0 kg/m2). Physicians further reported that, among patients receiving IL200, the mean proportions of patients with HbA1c 6.5–7.5% (48–58 mmol/mol) and 7.6–9.0% (60–75 mmol/mol) were 40.2% (SD: 19.6%) and 34.5% (SD: 17.5%), respectively, while 13.8% (SD: 13.9%) of the patients had HbA1c>9.0% (75 mmol/mol).
In terms of the basal insulin usage pattern, on average, around one-third of patients were on less than 40 units/day of basal insulin, one-third on between 40 and 60 units/day, and another third on more than 80 units/day. The mean proportion of patients reported to be taking one basal injection/day was 64.7% (SD: 27.4%), while 28.5% (SD: 20.7%) were taking two injections/day. A significant portion of the patients (mean: 40.1% [SD: 23.3%]) were prescribed concentrated basal insulin (200 units/ml or 300 units/ml).
On average, 43.6% (SD: 20.0%) of patients of these surveyed physicians were reported to be taking IL200 dose of 20–50 units/day, 26.1% (SD: 17.9%) were taking 51–100 units/day, and 22.1% (SD: 17.2%) were taking less than 20 units/day of IL200. The mean proportion of patients taking more than 100 units/day of IL200 was 8.2% (SD: 9.7%). The mean proportion of patients needing three-four daily injections was 65.3% (SD: 27.0%) while one-two IL200 injections daily was needed by 27.4% (SD: 24.1%) of patients. A small proportion of patients (7.3% [SD: 10.7%]) treated by the surveyed physicians took at least five injections of IL200 per day.
Physicians reported the proportion of their IL200 patients with the following length of time on IL200: an average of 12.0% (SD: 14.5%) of patients had taken IL200 for more than 2 years, and 31.1% (SD: 18.6%) of patients for 1-2 years 35.6% (SD: 17.8%) of patients for 6 months to 1 year, and 21.4% (SD: 14.1%) of patients had been on IL200 for less than 6 months ().
Table 2. Insulin Lispro 200 units/ml patient profile reported by the surveyed physicians, by specialty and at overall level
3.3. Rationale for prescribing Insulin Lispro 200 units/ml
Among the different clinical aspects considered in the survey, the insulin dose was considered a ‘very important’ (56.1% of respondents) or absolutely important’ (32.7% of respondents) clinical factor by 88.8% of the surveyed physicians when prescribing IL200. The next two most important clinical factors were pattern of self-measured glucose levels and HbA1c level, both were rated ‘very important’ or ‘absolutely important’ by 80.6% of the surveyed physicians. The proportion of surveyed physicians who considered BMI and comorbidities to be ‘very important’ or ‘absolutely important’ clinical factors was similar: 68.4% and 67.4%, respectively. However, more physicians rated comorbidities (21.5%) as ‘absolutely important’ than BMI (8.2%). A little more than 40.0% of physicians considered blood pressure and age as ‘very important’ or ‘absolutely important’ ().
Figure 2. Importance of patient’s clinical/behavioral aspects for prescribing Insulin Lispro 200 units/ml as considered by surveyed physicians
Figure 3. Physicians’ level of agreement on Insulin Lispro 200 units/ml prescribing experience
Out of the nine perceived patient behavioral factors listed in the survey, patient’s adherence behavior and knowledge about hypoglycemia topped the list with 88.8% of physicians rating each of these two factors to be ‘very important’ or ‘absolutely important’ when prescribing IL200. However, 44.9% of physicians thought patient knowledge of hypoglycemia to be ‘absolutely important,’ compared to 28.6% who considered adherence behavior as ‘absolutely important.’ Motivation to improve lifestyle was rated an important factor for prescribing IL200 by 80.6% of physicians, ranking the third among the list of factors surveyed. Patient’s desire to reduce insulin injection volume as well as patient’s struggle with keeping HbA1c level under control were regarded as ‘very important’ or ‘absolutely important’ by more than 70.0% of the surveyed physicians. About 55.0% of physicians took a patient’s request to try IL200 into consideration. When prescribing IL200, having to store and carry fewer pens when traveling was regarded as important by 55.1% of surveyed physicians. In addition, 45.0% and 39.8% of physicians, respectively, thought decreased number of doctor appointments and pharmacy visits due to fewer number of pens needed would be important factors for prescribing IL200 ().
Physicians were asked to assess the importance of clinical practice and setting aspects in their decision to treat specific patients with IL200. The clinical practice management policy and expert guideline/hospital algorithms were indicated to be ‘very important’ or ‘absolutely important’ factors by 59.2% and 55.1% of physicians surveyed, respectively. The remaining aspect, medication cost, was rated ‘very important’ or ‘absolutely important’ by 58.2% of the surveyed physicians ().
Figure 4. Importance of clinical practice and healthcare setting aspects for prescribing Insulin Lispro 200 as considered by surveyed physicians
Four open-ended questions were included in the survey to understand the additional factors and barriers deemed to be of importance to physicians when prescribing IL200. However, there was no other discernible pattern.
3.4. Experience with prescribing IL200
The study assessed physician experience through their level of agreement with different statements. Overall, 92.9% of physicians believed that their patients find IL200 convenient to use. More than 85.0% of physicians perceived IL200 to be easy for patients to dose/administer once instructed to switch from 100 units/ml insulin to IL200. Majority of physicians (80.6%) were confident that their patients use IL200 as prescribed with 74.5% of physicians confident that patients adhere to MTI treatment algorithm when taking IL200. The statement ‘fewer split doses are required on IL200 than other MTI therapie’ was agreed upon by 75.5% of surveyed physicians. ().
3.5. Differences among physician specialties
Surveyed diabetologists had anon average of 22.5 (SD: 7.4) years of practice while internal medicine physicians had 15.9 (SD: 7.1) years. Diabetologists practiced mostly in an office setting (81.7%) while internal medicine physicians were equally divided between hospital setting and office/outpatient clinic setting. Diabetologists saw at least twice as many diabetes patients, insulin-requiring patients, and MTI patients on average than internal medicine physicians. The proportion of MTI patients treated with IL200 was 50.6% (SD: 23.5%) SD: for diabetologists and 67.5% (20.3%) for internal medicine physicians. Almost all internal medicine physicians (97.0%) considered HbA1c level to be a very important/absolutely important clinical factor, while only 73.3% of diabetologists were of the same opinion. More internal medicine physicians (87.9%) and diabetologists (60.0%) considered comorbidities and BMI important for prescribing IL200. It also appeared that internal medicine physicians were more sensitive to patient requests to try IL200, their motivation to improve lifestyle, and their emotional struggle with keeping HbA1c under control. Eighty-eight most internal medicine physicians considered clinical practice management policy (75.2%) and expert guideline/hospital algorithms (81.4%) to be very important/absolutely important factors. Among diabetologists, only 50.1% and 38.3%, respectively, considered these factors important. Medication costs were absolutely important to 18.2% of internal medicine physicians, but were absolutely important to only 8.3% of diabetologists. At least 80.0% of diabetologists were confident that patients used IL200 as prescribed and adhered to MTI treatment algorithm when on IL200, compared to less than 70% of the internal medicine physicians. The statement ‘fewer split doses are required on IL200 than other MTI therapies’ was agreed to by 81.8% of internal medicine physicians but only 71.7% diabetologists.
4. Discussion
This survey study was conducted among a group of German physicians experienced in treating diabetes and prescribing insulin therapies. The selected experienced physicians were prescribing IL200 to more than half of their MTI patients with roughly 40.0% of their patients on IL200 for more than a year. Majority of the surveyed physicians believed that IL200 is convenient to use and easy to dose/administer after switching from 100 units/ml pen. They were confident that their patients would be adherent to MTI treatment regimen when on IL200.
Consistent with an overall assessment with concentrated insulins, this survey showed that IL200 was prescribed to patients with a wide range of insulin requirements [Citation21,Citation22]. The majority of patients taking IL200 were obese or overweight with T2DM and were likely to be severely insulin resistant. Most patients were on a significant amount of insulin and faced significant injection burden from both basal and bolus therapies. Of note, physicians reported prescribing concentrated basal insulin to 40.0% of their IL200 patients. This practice would take full advantage of reduced injection volume, fewer injections, and fewer split doses.
With respect to specific clinical factors impacting the prescribing decisions, previously published literature reported that physicians, in general, placed more importance on the treatment outcomes and effectiveness/efficacy than other factors [Citation23,Citation24]. Our survey also showed that this is indeed the case with the importance of patient-measured blood glucose pattern and HbA1c level ranked the second and third among the seven patients’ clinical factors surveyed. Nevertheless, the clinical factor ranked first was patient’s insulin dose. This is in line with physicians trying to personalize patient care by aligning the treatment attributes with their patients’ needs, as the reduced injection volume and ease of injection with IL200 would be particularly beneficial to patients with high insulin requirements. Additionally, three-quarters of physicians recognized that IL200 has the potential to reduce the number of split doses. Unless the last injection dose delivered by the pen matches the prescribed dose, insulin wastage, double injection, or under-dosing would occur [Citation25]. Consistent with the dose consideration, BMI was another important IL200 prescribing factor. While comorbidities are known major consideration for physicians considering initiating insulin therapy, their importance for prescribing IL200 was only ranked above blood pressure and age, but similar to that of BMI. The order of importance of the clinical factors considered for prescribing IL200 suggested that the prescribing behavior may be driven by the perceived advantages of the IL200 as well as physician sensitivity to the injection needs and preferences of their patients [Citation23].
The present survey explored the importance of various patient’s behavior factors perceived by their physicians when prescribing IL200. It is well known that adherence is a major problem with insulin therapies and has a great impact on the outcomes [Citation13,Citation26–28]. The five most common reasons for insulin omission/non-adherence identified by both patients and physicians were: too busy; traveling; skipped meals; stress/emotional problems; and public embarrassment [Citation29]. Adherence is also negatively impacted by the number of injections prescribed [Citation30]. Lutfey et al (2008) further commented that, with diabetes, a condition requiring extensive self-management, physicians consistently made efforts to evaluate patients’ capacities for understanding and taking care of their health outside of a medical context [Citation31]. Grant et al (2007) found that physicians used patients’ demographic characteristics only as a starting point, and made detailed assessments about cognitive ability, motivation, social support, and other factors for predicting the adherence [Citation23]. In our assessment, patients’ safety was of the utmost importance for the physicians, so they ranked patients’ cognitive ability in understanding hypoglycemia above all other patient behavioral factors.
The rest of the factor assessment centered on the ability of each of the factors to be impacted by IL200 to make insulin treatment a little easier for patients to adherence. Patients’ adherence behavior was rated important by nearly all of the surveyed physicians and more than three-quarters were confident that IL200 would help patients adhere to MTI treatment algorithm. It is likely that if a patient had not been adherent to a large insulin dose requirement with multiple basal and bolus injections of insulin with standard concentration, the physician would consider this patient a good candidate for IL200. This helped explain that the survey physicians reported 40.0% of their IL200 patients were also prescribed with concentrated basal insulin.
Furthermore, in a study conducted in the United States (US), the patient medication cost is the main factor considered during the T2DM medication intensification and decision-making process [Citation32]. However, in our survey, only a little more than half of the physicians gave an important consideration to medication cost. This difference is probably due to the health system differences between Germany and the USA, as in Germany the cost of the medication is covered by the national health insurance while in the USA, the cost must be paid through a private insurance or by the patient.
Lutfey et al (2008) found that physicians relied heavily on perceived social, cognitive, and psychological characteristics of patients for their clinical decision-making, including intellectual ability, motivation, social support, lifestyle, anxiety levels, and style of interaction [Citation31]. The results from our survey were in line with published literature. The majority of these experienced physicians gave important considerations to patients’ motivation to improve lifestyle, desire to reduce insulin injection, and patients’ struggle with keeping HbA1c under control. Furthermore, a good portion of the surveyed physicians recognized the convenience aspects of IL200 as important for patients, such as fewer pens to store and carry when traveling, decreased pharmacy/physician visits, and fewer split doses, all due to fewer numbers of IL200 pens needed than with 100 units/ml pens [Citation25]. In a fast-paced modern society with most people having a mobile and time-pressed lifestyle, all these additional efforts by the physicians could potentially encourage treatment adherence of their patients struggling with insulin therapy while trying to keep an active lifestyle.
We observed some general trends in prescribing patterns and considerations among the surveyed internal medicine physicians who were truly high IL200 prescribers. While they appeared to place more emphasis on clinical characteristics such as HbA1c and BMI as the rationale for prescribing IL200, they were also more responsive to non-clinical characteristics such as the patient’s request to try IL200, lifestyle motivation, emotions and struggle with glucose control, and medication costs. In a patient-centered era in medicine, these tendencies among internal medicine physicians could offer crucial advantages for managing a notoriously difficult disease. These physicians also reported major reliance on expert guidelines and hospital algorithms when prescribing IL200. Given that currently there are few international practice guidelines for IL200 available, this suggests the importance of further study of IL200 in a real-world setting.
4.1 Limitations
The current study is the only physician survey of IL200 prescribing practices and focuses on understanding the experience and opinion of a specific subset of physicians in Germany. As this study is descriptive in nature, it may not be completely generalizable. In addition, the low response rate (4.5%), which is often seen in this type of research, may also have impacted generalizability of the results. Reasons for low response rates among physicians are variable, and may include time constraints, perceived value of the research/confidentiality issues, and design of the survey [Citation33]. However, it is worth noticing that although the initial response rate was low, the screening of those physicians willing to participate yielded higher results (38.6% screened-in). Of those physicians eventually included in the study, 100% completed the survey. The physicians included were from the specialties that regularly see persons with diabetes and have experience in prescribing concentrated insulins. The unique characteristics of the German health system may affect how certain factors, especially non-clinical factors, were considered by physicians prescribing IL200. To make the survey feasible, the questionnaire did not explore in depth how certain factors were evaluated by physicians. For example, the questionnaire did not explore the specific comorbidities that physicians considered to be important for introducing IL200. In addition, the survey questionnaire developed for this study may not have covered all the relevant factors. This limitation was addressed to some degree by collecting additional free text comments from the surveyed physicians. However, no additional meaningful factor beyond those evaluated in the survey was noteworthy. Another limitation of the study is that the ability to explore the prescribing differences by physician specialty is constrained by the fact that only a few endocrinologists participated in the study. One useful future study would be to understand the treatment pattern differences between patients with type 1 diabetes and type 2 diabetes on IL200.
5. Conclusion
IL200, a concentrated insulin, offers another treatment option for persons with diabetes, yet currently there is very little international practice guideline available. The experienced clinicians in prescribing IL200 in Germany who were surveyed in this study offered valuable practice information to help to understand the current clinical decision-making. Not surprisingly most of the patients prescribed with IL200 were obese or overweight with T2DM although one-fifth of the patients had T1DM. A significant injection burden was the main challenge identified for IL200 candidates. Taking into consideration the known treatment attributes of IL200 such as reduced injection volume and injection burden, fewer split doses, and fewer pens needed, the surveyed physicians consider IL200 as a relevant treatment option. Physicians followed a patient-centered perspective through the alignment of IL200 prescribing medical decisions with patient’s medical needs and non-clinical preferences. They tried to encourage patients to improve adherence to insulin therapy by taking the advantages of the IL200 attributes. In this survey, the most frequently selected clinical considerations for prescribing IL200 were the total daily insulin dose, pattern of self-measured glucose levels, and HbA1c level. Furthermore, adherence, knowledge about hypoglycemia, motivation to improve lifestyle, desire to reduce insulin injection volume and emotional struggle to keep HbA1c under control were identified as key patient behavioral aspects for IL200 prescription from the surveyed physicians’ point of view.
Author contribution
MPN, CPO, BO, NS, NL, and LGA made substantial contributions to the concept and design of the study. JC, ES, and MR analyzed the data. JC, ES, BO, JLP, NS, and MR provided interpretation of the data. JC, NS, and NL drafted the manuscript. All authors critically revised the manuscript for important intellectual content and approved the manuscript for publication.
Declaration of interest
JC, MPN, CPO, BO, and JLP are employees of Eli Lilly and Company. JC, MPN, and JLP are minor stockholders of Eli Lilly and Company. NS is an employee of Lilly Deutschland GmbH. ES received personal fees from Eli Lilly and Company. LGA, NL, and MR are employees of IQVIA, a vendor supporting Eli Lilly and Company for the study.
Supplemental Material
Download MS Word (56 KB)Acknowledgments
The authors would like to thank Dirk Lennartz for his diligent management and contribution on conducting this research and Paranjoy Saharia and Sanowar Sayeed from IQVIA for their writing and editing support.
Supplemental data
Supplemental data for this article can be accessed here.
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