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——加拿大西安大略大学Stewart B. Harris教授访

作者:S.B.Harris 2015/6/17 10:43:00    加入收藏
内容概要:在ADA 2015年会上,来自加拿大西安大略大学的Stewart B. Harris教授以“Deceptively Simple Insulin Titration—Strategies to Demystify Insulin Therapy(令人迷惑的简单胰岛素滴定——阐明胰岛素治疗的策略)”为题进行了报告。报告结束后,Harris教授接受《国际糖尿病》记者采访,详细阐述了其简单胰岛素注射的理念,并表达了未来胰岛素发展的个人观点。

  <International Diabetes>: So which factors will influence the effectiveness of insulin therapy?

  Dr. Harris: Right. So one of the big challenges we have in the acceptance of insulin therapy in practice both by practitioners who might not be as familiar with insulin therapy, but especially by patients, is the complexity of the regimes. So what I really try to focus on in my presentation today was that: keep it simple. So start at a very simple low dose of basal insulin, slowly up titrate until you’re maxed out on your basal and then use the same process to introduce your prandial insulins in a stepwise approach. I think we’re long – we’re moving away from the era where we automatically put patients on complex insulin regimes, NDI regime therapy. It’s not to say we don’t think that will work. But it’s the way we get there. So start on your basal. Introduce a single meal prandial insulin. When you need to add it to a second meal, use the same process. Start on a low dose of insulin. Two units of a prandial insulin, a Gilliananalogue prandial insulin to reduce risk of hypoglycemia and then introduce it to a second meal and then introduce it to a third meal. In fact many of the studies that I talked about today show that you don’t even need to go to three meal prandial insulins a day, that the majority of your patients will get to target either on basal insulin or basal plus one or basal plus two. At least two thirds can get to basal – can get to optimal glycemic targets with addition of one or two prandial insulins a day.



  <International Diabetes>:Thank you. So in Canada or in the U.S., which?conditions?causedelayed-treatment for patients who need insulin treatment? How to achieve optimized insulin treatment by simple insulin titration?

  Dr. Harris: Right. So studies around the world now – and we’ve done it in Canada, there’s studies in the U.S., recent studies in the U.K show that in general there is tremendous delay in the introduction of insulin into the regime, and on average you could say, if you were to summarize the literature, the mean anyone sees is about 9.5% when patients are finally getting put on insulin. So quite a bit of delay – the clinical inertia around delay – and they already have established complications. So I think one of the challenges in introducing insulin therapy is that clinicians think it’s complicated. Endocrinologists are very comfortable using insulin therapy but often it’s late until the patients are seeing the endocrinologists so we need simpler protocols such as the protocols I reviewed today. That will broaden the healthcare provider that’s comfortable in using insulin. So both endocrinologists and primary care physicians and internists could use simpler protocols that may allow for us to introduce insulin at an earlier stage of the disease and the hope is with simpler titration protocols reducing the complexity, empowering patients to self-titrate, that these will help make an impact in the clinical inertia around the delay of insulin therapy.


  <International Diabetes>:Great, thank you so much. So the last question would be: in your opinion, which is the future of insulin preparation? Will human insulin be completely replaced by insulin analogs in future?And also what is the prospect of inhaled insulin?

  Dr. Harris: Right. So we’re at a very interesting time in our insulin therapeutic options. We’ve certainly seen that over the last decade the evolution of analogue insulins have made insulin a safer therapy. At the end of the day, it’s all about keeping our patients safe and so if we have an insulin therapy that reduces their risk of hypoglycemia as we get closer to target that is always going to be the preferred insulin. So I see the day where insulin analogues will preferentially be used around the world over regular insulin – regular human insulin and intermediate insulin, again PHB, because it’s a safer medication. There’s reduced risk for hypoglycemia. And what we’re seeing in the evolution of insulins is we now have the introduction of the second generation of basal analogue insulins that have an even safer profile compared to the first generation like glargine or Levemir, by reducing nocturnal hypoglycemia by another 25% against the so-called gold standard: glargine insulin. So we see that with toshiyo, we see that with degludec, it’s similar kind of findings coming out of the bill data, the new Lilly PEGylated basal lispro insulin, and we’re now soon – trials are underway now testing the second generation of fast-acting analogue insulins that again – their major benefit is reduced risk for hypoglycemia. So I would hope that in the future we will see only analogue insulins being used because of their safety profile. If they’re safer we can be more aggressive, hence we can get more patients to get to the recommend target safely. In terms of inhaled insulin, it’s early days to know where and how inhaled insulin is going to fit into the whole insulin paradigm. Certainly anything you can do to reduce the number of injections patients require is going to be a potentially benefit. I can see in my own practice using inhaled insulin for patients who are very reluctant to go onto a second or third needle, injectable therapy, but would be willing to take more insulin if they could get it in the inhaled version. So that’s where I think its niche will be, at least initially as we gain experience in using it.


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