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 Table of Contents  
ORIGINAL ARTICLES
Year : 2022  |  Volume : 13  |  Issue : 2  |  Page : 177-183

Patient reported attitude, practice, satisfaction, and quality of life on insulin degludec/insulin aspart: A single-center survey from India in adult with diabetes


Dr. Kovil’s Diabetes Care Centre, Mumbai, Maharashtra, India

Date of Submission30-Mar-2022
Date of Decision22-Apr-2022
Date of Acceptance25-Apr-2022
Date of Web Publication21-Jul-2022

Correspondence Address:
Dr. Rajiv Kovil
Dr. Kovil’s Diabetes Care Centre, Andheri West, Mumbai 400058, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jod.jod_27_22

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  Abstract 

Objective: The study aimed to assess the knowledge, attitude, practice, satisfaction, and quality of life (QoL) of adult patients with type 2 diabetes (T2D) on insulin degludec/insulin aspart (IDegAsp). Materials and Methods: Data were collected through an online survey from patients with T2D being treated with IDegAsp at a single center in India. Results: Survey was completed by 247 participants. On the Likert scale, 1 to 5 (1: most difficult and 5: most easy), 41.6% and 26.6% scored 5 and 4, respectively, for ease of increasing or decreasing the dose. Most participants (n = 190) consulted a physician to adjust the dose; 53.3% and 28.8% scored 5 and 4, respectively, for a good experience while injecting IDegAsp; 89.8% of participants felt their QoL improved with a reduction in the number of pricks; 86.7% participants found it comfortable to inject IDegAsp in different social situations; 94.2% reported they could manage their day to day activities better after initiating IDegAsp. After initiating IDegAsp, the oral antidiabetic (OAD) pill burden reduced from three to one or two pills in 70% of patients. Conclusions: Our survey-based study shows the majority of participants found it easy to administer IDegAsp, inject IDegAsp in different social situations, they were able to increase and decrease the dose with ease, and benefited from reduced injection pricks and reduced OAD pill burden. The survey points towards a positive attitude towards achieving glycemic control with IDegAsp.

Keywords: Attitude, glycemic control, IDegAsp, knowledge, satisfaction, self-management


How to cite this article:
Kovil R. Patient reported attitude, practice, satisfaction, and quality of life on insulin degludec/insulin aspart: A single-center survey from India in adult with diabetes. J Diabetol 2022;13:177-83

How to cite this URL:
Kovil R. Patient reported attitude, practice, satisfaction, and quality of life on insulin degludec/insulin aspart: A single-center survey from India in adult with diabetes. J Diabetol [serial online] 2022 [cited 2022 Aug 11];13:177-83. Available from: https://www.journalofdiabetology.org/text.asp?2022/13/2/177/351756




  Introduction Top


Diabetes is growing at an epidemic pace in many regions of South Asia, including India.[1],[2],[3],[4] One in five adults have diabetes in some urban Indian communities.[5] The International Diabetes Federation has projected that India will have approximately 101 and 134 million adults with diabetes by 2030 and 2045, respectively.[6]

Of the adults with diabetes, approximately 90%–95% of them have type 2 diabetes (T2D).[7] Insulin is the mandatory treatment requirement for type 1 diabetes and plays a key role in T2D management as the disease progresses and oral anti-diabetic drugs (OADs) fail to lower the blood glucose (BG) levels to the desired levels.[3],[8]

Diabetes-related knowledge and health literacy at patient and community level is an important prerequisite for its prevention and control.[4],[8] Patients on insulin should have the adequate knowledge, attitude, and practices (KAP) regarding insulin use, dose adjustment, and management of hypoglycemia to be comfortable enough to incorporate it into their daily practices.[4] Previous diabetes KAP studies have found that there is a felt need to improve diabetes awareness in the general population.[4]

Additionally, evidence shows that educated patients are able achieve better and durable glycemic control than those not having adequate knowledge.[9],[10]

Inadequate knowledge and misconceptions influence the acceptance and adherence to insulin, especially since it is an injectable therapy.[3] Also, insulin knowledge and attitude scores are more affected than practice scores and are inadequate to allow desired integration of insulin into daily life.[11],[12],[13],[14],[15]

There are many Indian KAP studies assessing the knowledge, attitude and practice of insulin use and its adverse effects in adult diabetic population.[3],[11],[13],[14],[16],[17],[18] However, to the best of our knowledge, there is no study assessing KAP, satisfaction and quality of life (QoL) with insulin degludec/insulin aspart (IDegAsp) use in Indian patients. IDegAsp KAP studies in general are lacking.

We hope this survey study will provide insights on real-world IDegAsp literacy of IDegAsp in Indian patients, the extent to which IDegAsp users follow accepted practice and whether this co-formulation insulin is improving QoL of patients.


  Materials and Methods Top


All male or female patients, 18 years and older with T2D being managed on IDegAsp at our center were asked to fill an online KAP survey between January 2017 and December 2020. The initial questionnaire had several questions designed by the authors and was too lengthy and cumbersome to fill. Then the questionnaire was paired down to 26 questions based on the authors’ collective experience and agreement on collecting information from their patients that was considered mandatory to collect information regarding the participants’ demographic details; KAP details and self-reported QoL on IDegAsp.

There were three questions to collect demographic information on age/gender and duration of diabetes; two questions on duration of insulin (duration since insulin start, duration since IDegAsp was started); two questions to capture diabetes status on initiation of insulin (HbA1c at insulin start, number of OAD pills when insulin started); eight questions on current diabetes and IDegAsp use status (IDegAsp dosing [OD vs. BD], number of daily IDegAsp units injected, current HbA1c level on IDegAsp, number of OAD pills currently on, how IDegAsp dose is increased or decreased [self or in consultation with physician], experienced low blood sugar with IDegAsp, frequency of low blood sugar episodes in last 3 months, timing of low blood sugar episodes [day 6 AM to bedtime or night: bed time to 6 AM]); five questions on ease of use and QoL (how easy/difficult it is to increase/decrease IDegAsp dose, experience of injecting IDegAsp, Have the reduction in number of pricks benefitted you?, Do you feel comfortable while injecting IDegAsp in different social situation [e.g. at work and social gathering]?, Do you feel that you can perform your day-to-day activities better after initiation of IDegAsp?); three questions on missed insulin dose (frequency of missing dose, reason for missing insulin dose [forgot, was busy, because of hypoglycemia, other reasons], how missed dose was handled [took when remembered, increased next dose, consulted physicians, no action]); two questions on weight gain since insulin start (was there weight gain on insulin, if yes how much: < 1 kg, 1–2 kg, 2–3 kg, >3 kg); and one question on frequency of blood sugar monitoring (daily, 2- times a week, weekly). A Likert scale was used to rate experience [scale 1 to 5; 1 very difficult and 5 very easy or 1 very rare to 5 very often].

The results of the survey were expressed as percentage of patients choosing a particular response to a question. Demographic details were present both as percentage and as mean ± standard deviation (SD). Several sub-group analysis according to baseline HbA1c levels were carried out to assess the efficacy of IDegAsp. The implication of efficacy in improving the QoL was then derived.


  Results Top


Baseline characteristics

The survey was completed by 247 participants with T2D being managed on IDegAsp at our center. Two patients did not answer majority of the questions and hence were excluded from the analysis; 245 patients (129 males and 116 females) were finally included in the analysis. The majority of the participants were >60 years of age (n = 117), had diabetes for >15 years at the start of IDegAsp (n = 96), and their baseline HbA1c before the start of IDegAsp was mostly in 9–11% range (n = 90); 27.9% of patients had been taking insulin for >5 years, and 23.5% for 3–5 years; on the other hand majority of patients (47.4%) had been taking IDegAsp for <1 year, and 22.7% of them had been taking IDegAsp for 1–2 year. Of the patients on IDegAsp, 68.8% were on OD dose and 32.4% were receiving 10–15units, whereas 30% were receiving 10-20units. Demographic and baseline details are outlined in [Table 1].
Table 1: Baseline characteristics of the participants

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Survey outcomes

Ease of adjusting IDegAsp dose/Experience while injecting IDegAsp

On the Likert scale 1 to 5 (1 being most difficult and 5 being most easy), 41.6% found it very easy (score 5) to increase or decrease the dose; 26.6% gave a score of 4 for dose adjustment; 18.7% rated the ease as 3; 4.7% gave a score of 2; and 8.4% gave a score of 1 for dose adjustment [Figure 1]. Most patients (n = 190) consulted a physician to adjust the dose, whereas 56 patients adjusted the dose themselves.
Figure 1: Ease of use with IDegAsp

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On the Likert scale 1 to 5 (1 being most difficult and 5 being most easy), 53.3% reported good experience while injecting IDegAsp (score 5); 28.8% rated the experience as 4, 8.8% as 3, 4.6% as 2, and 4.6% rated the experience as 1 [Figure 1].

QoL on IDegAsp

89.8% of patients felt their QoL improved because there was a reduction in number of pricks; 86.7% patients found it comfortable to inject IDegAsp in different social situations; 94.2% reported they could manage their day to day activities better after initiating IDegAsp [Figure 2].
Figure 2: Quality of life with IDegAsp

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Missed insulin injections per month/reasons for missing/action taken

83.9% missed one injection/month; 5% missed two injections; 6.5% missed three injections; 2% missed four injections; and 2.5% missed five injections per month. Reasons cited for missing injections were “forgot to take” (52.9%), were busy at the dose time (29.7%), were out/traveling (9.4%), had hypoglycemia episode (4.3%), had a gastric issue (1.4%), and other reasons not specified (2.2%). Majority of participants (n = 90) did nothing after missing the injection, 35 consulted their physician, 27 took the missed dose when they remembered and six patients increased their next dose.

Frequency of blood sugar monitoring

52.1% monitored it weekly, 32.9% two-three times per week and 15% monitored it daily.

Effect of IDegAsp on HbA1c, number of OAD pills and daily IDegAsp dose

In patients with baseline HbA1c >11% (n = 48): 58.3% achieved a HbA1c of 7–9% and 16.7% achieved a HbA1c of <7% after the start of IDegAsp; 78.6% of the patients who were able to reduce their HbA1c were on IDegAsp OD dose; 70% of patients on three OAD pills could be shifted to one or two OAD pills, whereas 50% on two pills a day were shifted to one pill a day. On the other hand, 75% of patients on one OAD pill a day had to be shifted to two pills a day.

In patients with baseline HbA1c 9–11% (n = 90): 56.7% attained HbA1c of 7–9% and 17.8% had HbA1c of <7%; 66.7% of the patients who were able to reduce their HbA1c were on IDegAsp OD dose; 17% of patients on four OAD pills, 47% on three OAD pills, 13% on two OAD pills could be shifted to a lower pill number, whereas 75% of patients on one OAD pill continued on that.

Of the patients with baseline HbA1c of 7–9% (n = 86), 33.7% attained HbA1c of <7%, whereas 59.3% remained in the 7–9% range; 64.3% of the patients who were able to reduce their HbA1c were on IDegAsp OD dose.

Of the patients with baseline HbA1c of <7% (n = 17), 82.4% remained at <7% but 17.6% had HbA1c of 7–9% range.

Weight gain after initiating insulin:

34.4% reported weight gain. Of the patients who reported weight gain, 31.8% reported 1–2 kg weight gain, 29.4% reported >3Kg weight gain, 20% reported 2–3 Kg weight gain and 18.8% reported <1Kg weight gain.

Hypoglycemia events (HEs) with IDegAsp:

36.4% of patients reported HEs; 41.7% reported one HE in last three months, 23.8 had two HEs, 13.1% had three HEs and 21.4% had more than three HEs in last three months. Of the patients who experience HE, 69.4% experienced it during the day, whereas 30.6% had a nocturnal episode.


  Discussion Top


The survey showed that majority of participants did not practice adequate diabetes self-care as their HbA1c levels were above the American Diabetes Association (ADA) recommended target of <7%.[19] Only 6.9% of participants (n = 17) had HbA1c levels <7%. Diabetes knowledge, management and self-care are usually adequate in patients who have diabetes for >5 years.[20] However, in this study, 86.1% of participants had diabetes for ≥5 years. Inadequate diabetes knowledge, poor diabetes self-care, poor attitude towards diabetes, and inadequate knowledge and use of insulin may have been responsible for poor glycemic control in this patient population.[4],[15],[20]

Poor self-care was evident as most patients (52.1%) monitored BG weekly or two-three times per week (32.9%). The survey showed that majority of participants did not practice self-monitoring of blood glucose (SMBG) at the ADA recommended frequency (according to insulin regimen: fasting, prior to meals/snacks, exercise, at hypoglycemia episode and until normoglycemia is achieved and before performing critical tasks like driving).[21]

Another common practice with insulin is missing the dose.[22] Majority of surveyed participants (83.9%) missed one insulin dose per month. Though hypoglycemia is a known cause of missing the insulin dose, only 4.3% of participants missed dose due to hypoglycemia. “Forgot to take” (52.9%) or “were busy at the dose time” (29.7%) were cited as the most common reasons for missing doses.[22]

Majority of participants did not follow the correct practice of missed insulin dose; 36.7% (n = 90) of participants did nothing after missing the injection or took the injection when they remembered (11.0%, n = 27) or increased the next dose (2.4%, n = 6). Only 14.3% (n = 35) of participants followed the correct practice and consulted a physician after missing the dose. For long-acting insulin-like IDegAsp, the participants should check the BG level and contact the physician to assess what part of the missed dose should be taken. The physician guide the dose to be taken based on time elapsed since the missed dose and the BG level. Alternatively, an expert panel formulating the best practices for missed IDegAsp dose recommended that the usual IDegAsp dose can be taken with the next main meal rich in carbohydrates.[23]

Majority of participants (69.3%) were on OD IDegAsp dose. Real-world evidence and several clinical trials support the efficacy of OD IDegAsp dose.[24],[25],[26],[27],[28] In our study too IDegAsp was efficacious in reducing HbA1c from >11% and 9–11% to 7–9% (58.3% and 56.7% of participants, respectively) and <7% (16.7% and 17.8% of participants, respectively). The HbA1c lowering effect was seen across all HbA1c levels above the American Diabetes Association (ADA) recommended target of <7%.[19] Initiating dose of IDegAsp (10–15 units) was able to provide good glycemic control in 32.8% of participants.

Majority of patients (64.8%) reported no weight gain on IDegAsp. Of the patients who reported weight gain, only 29.4% reported >3Kg weight gain. The survey showed that 36.4% of patients had a HE. HEs with IDegAsp occurred mainly during the day (69.4% of participants), whereas 30.6% reported a nocturnal episode. These findings are in line with previous evidence on IDegAsp.[24],[25],[26],[27],[28] SMBG is statistically significantly(P < 0.05) associated with HEs.[29] Poor SMBG practice may have resulted in some of the HEs in this patient population.

The survey also showed that IDegAsp use was associated with reduced OAD pill burden. It has been seen that reduced pill burden improves QoL and adherence to treatment in patients with diabetes.[30]

The survey highlighted that 41.6% of the participants found it very easy to increase or decrease the dose and most patients (n = 190) consulted a physician to adjust the dose. Also, majority reported good experience while injecting IDegAsp. Other than this, majority of participants felt their QoL improved due to reduction in number of injection pricks, comfort in injecting IDegAsp in different social situations and because they could manage their day to day activities better after initiating IDegAsp. Evidence shows that flexibility of dosing IDegAsp according to patient schedule, the ability to dose it once daily, and achieving good glycemic control has a positive impact on QoL.[24],[31],[32],[33] A small percentage of patients did report that they found it difficult to cope with IDegAsp. However, evidence shows that patients who do not find it easy to mentally cope with insulin injections improve with counseling support.[34] These patients can be encouraged to resume their professional and social life as before to maintain their QoL.[34]

Limitation of the study

This study was conducted in a single institution and therefore the results cannot be generalized. Besides, the KAP information was assessed solely on patients’ responses without actual observation and confirmation, and therefore the results may vary from those of their physicians and caregivers, which were not assessed in this survey. Additionally, the survey was more focused on IDEgAsp related QoL and therefore the practice followed during and after an HE was not captured. Also, the survey population consisted of patients with enough education and awareness of online surveys. The results may not be the same in uneducated and if other methods on survey were used.


  Way Forward Top


IDegAsp KAP studies are very limited. This KAP gap can be overcome by conducting more surveys, gathering real-world evidence and gathering more information. IDegAsp awareness programs by health care providers can sensitize people about the benefits, proper use and side effects of IDegAsp.[16] The survey showed gaps in IDegAsp practice and this can be overcome by integrating practice counseling in routine patient care.[3],[16],[35]


  Conclusions Top


Our survey based study shows majority of participants found it easy to administer IDegAsp, inject IDegAsp in different social situations, were able to increase and decrease the dose with ease and benefited from reduced injection pricks and reduced OAD pill burden. The survey points towards a positive attitude towards achieving glycemic control with IDegAsp. However, the survey also shows that self-care practices such as frequency of SMBG, and care after missing IDegAsp dose were not adequate for diabetes management. Further real-world studies are required to identify practice gaps and assess the attitude of patients towards IDegAsp. This will help build practical IDegAsp practice and self-care guidelines for the patients and increase their knowledge about managing diabetes with IDegAsp.

Acknowledgement

All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this manuscript, take responsibility for the integrity of the work, and have given final approval for the version to be published. The authors thank Dr. Kokil Mathur and Dr. Punit Srivastava of Mediception Science Pvt Ltd (www.mediception.com) for providing medical writing support in the preparation of this manuscript.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.

Ethics compliance

The study was approved by Dr. Kovil’s Diabetes Care Centre.



 
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