Medical Crossfire®: The Role of Concentrated Insulins in Overcoming Insulin Resistance and Improving Adherence: A Patient-Centered, Multidisciplinary Approach


Release Date: December 29, 2017
Expiration Date: December 29, 2018
Media: Internet - based

Activity Overview

During this Medical Crossfire, expert faculty will engage in a multidisciplinary roundtable discussion that includes an endocrinologist, a certified diabetes educator, an endocrinology NP and a patient to discuss how to best optimize and individualize insulin therapy. In patients with insulin-resistant diabetes who have requirements of more than 200 units/day or 100 units/injection, novel concentrated insulins provide the same or better glucose control compared to older insulins, with fewer daily injections and reduced injection volume. However, safe use requires an experienced physician, a motivated and cooperative patient, and a dynamic diabetes management team. This program will provide practical strategies that can be implemented to improve quality of care with a focus on how an interdisciplinary team can help support the patient.

Acknowledgement of Commercial Support

This activity is supported by independent educational grants from Novo Nordisk, Inc and Sanofi US. This activity is jointly provided by Global Education Group and Physicians’ Education Resource®, LLC.

Instructions for This Activity and Receiving Credit

  • You will need to login to participate in the activity.
  • Each presentation may contain an interactive question(s). You may move forward through the presentation; however, you may not go back to change answers or review videos/content until you finish the presentation.
  • At the end of the activity, “educational content/video files” will be available for your reference.
  • In order to receive a CME/CE certificate, participants must complete the activity.
  • Complete the posttest and pass with a score of 70% or higher, complete the evaluation and then click on request for credit. Participants may immediately download a CME/CE certificate upon completion of these steps.

Target Audience

This educational series is designed for endocrinologists, certified diabetes educators, nurse practitioners, physician assistants and other health care professionals with an interest insulin therapy.

Learning Objectives

At the completion of this activity the participant will be able to:

  • IDENTIFY patients with T2DM who may benefit from the addition of insulin to their management strategy.
  • LIST patient/practitioner barriers toward insulin that impact patient adherence.
  • ARTICULATE the role of diabetes team members in implementing DMSE/S algorithm of care.
  • EVALUATE the pharmacologic features of concentrated insulin formulations.
  • PROPOSE an individualized treatment strategy utilizing a collaborative team-based approach to patient care that safely appropriately and effectively transition patients to concentrated insulin.

Faculty, Staff, and Planners' Disclosures

Mark E. Molitch, MD
Martha Leland Sherwin Professor of Endocrinology,
Division of Endocrinology, Metabolism and Molecular Medicine
Northwestern University Feinberg School of Medicine
Chicago, Illinois

Disclosure: Grants/Research Support – Bayer, Calibria, Chiasma, Novartis, Novo Nordisk
Consultant - Chiasma, Novartis, Janssen
Davida F. Kruger, MSN, APN-BC, BC-ADM
Certified Nurse Practitioner
Supervisor Nurse Practitioner
Henry Ford Health System
Division of Endocrinology, Diabetes and Bone Disorders
Detroit, Michigan

Disclosure: Advisory Board – Abbott, Dexicom, Eli Lily, Intarcia, Janssen, Novo Nordisk, Sanofi US
Grants/Research Support - Astra Zeneca, Dexcom,  Eli Lilly, Hemsley Foundation, Lexicon
Speaker’s Bureau – Abbott, Astra Zeneca, Boehringer Ingelheim, Dexcom, Janssen, Eli Lilly, Novo Nordisk, Valeritas
Stock – Dexcom
Lucia M. Novak, MSN, ANP-BC, BC-ADM, CDTC
Director, Riverside Diabetes Center
Riverside Medical Associates
Riverdale, Maryland
Adjunct Assistant Professor, Graduate School of Nursing
Uniformed Services University of the Health Sciences
Bethesda, Maryland

Disclosure: Advisory Board – Sanofi US
Consultant – CeQur, Intarcia
Speaker’s Bureau - Astra Zeneca, Janssen, Novo Nordisk
Russell Davis, Patient

Nothing to disclose

The staff of PER® have no relevant financial relationships with commercial interests to disclose.

Physician Accreditation Statement

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Global Education Group (Global) and Physician’s Education Resources.  Global is accredited by the ACCME to provide continuing medical education for physicians.

Physician Credit Designation

Global Education Group designates this enduring material for a maximum of 2.0 AMA PRA Category 1 Credits™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity

Nurse Practitioner Continuing Education

AANP Provider Logo - Updated 01-22-2013This activity has been planned and implemented in accordance with the accreditation Standards of the American Association of Nurse Practitioners (AANP) through joint providership of Global Education Group and Physicians’ Education Resource®, LLC.  Global Education Group is accredited by the American Association of Nurse Practitioners as an approved provider of nurse practitioner continuing education.  Provider number: 1561024. This activity is approved for 2.0 contact hour(s) which includes 0 hour(s) of pharmacology.

Activity ID # 2523E
This activity was planned in accordance with AANP CE Standards and Policies.
The Diabetes Educator Certification is pending board approval

Global Contact Information

For information about the accreditation of this program, please contact Global at 303-395-1782 or

Instructions to Receive Credit

To receive credit, participants must complete the online pretest, view the activity in its entirety, and complete the online post-test and activity evaluation form. After completing the online assessment tests, and completing the activity evaluation form, participants may request credit. All participants must request credit by December 29, 2018, CE credit will not be issued after this date.

Disclosure of Conflicts of Interest

Global Education Group (Global) requires instructors, planners, managers and other individuals and their spouse/life partner who are in a position to control the content of this activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly vetted by Global for fair balance, scientific objectivity of studies mentioned in the materials or used as the basis for content, and appropriateness of patient care recommendations.

PER Pulse Recap™

PER Pulse Recap (1 of 3)

Timely Insulin Therapy

Medical Crossfire®: The Role of Concentrated Insulins in Overcoming Insulin Resistance and Improving Adherence: A Patient-Centered, Multidisciplinary Approach, provides clinicians involved in the management of patients with diabetes with an engaging discussion on how to best optimize and individualize insulin therapy.

Expert faculty engage in a multidisciplinary roundtable discussion that includes an endocrinologist, a nurse practitioner, a certified diabetes educator, and a patient to discuss how to best address patient barriers related to initiation of insulin and the different treatment options for high-dose insulin products. The 3 PER Pulse™ Recaps from this program focus on how to appropriately identify patients where initiation of the concentrated insulin products may be appropriate, barriers and challenges that may impact their adherence to therapy, and the role of the multidisciplinary team in the care of patients with diabetes. Key takeaways from this first panel discussion of the Medical Crossfire® include:

Clinical evidence from the United Kingdom Prospective Diabetes Study (UKPDS) reveals a loss of β-cell function as plasma glucose levels rise, resulting in deterioration of hemoglobin A1C (A1C) over time in all treatment groups, albeit the levels were significantly lower in the intensive treatment group compared with the conventional group. This progressive deterioration of diabetes control has shown that after 3 years, only 50% of patients could attain this goal with monotherapy, and by 9 years this declined to approximately 25%. Evidence also shows that metabolic control achieved early in the course of diabetes substantially reduces development and progression of diabetes, and associated microvascular and macrovascular complications. This “legacy” effect or some “metabolic memory” will be maintained for many years after the initial metabolic control.  
To achieve glycemic targets, an analysis from UKPDS revealed an increasing number of patients required insulin to be added to their treatment as the study period progressed. But despite guideline recommendations and beneficial outcomes from clinical studies, insulin is too often regarded as a last resort for use on top of initial oral drug regimens. While there are some newer insulin formulations on the market that have been shown to reduce the incidence of hypoglycemia, clinicians have reasons for hesitating to use insulin earlier in a management strategy to achieve a glycemic target. There are many benefits to initiating insulin earlier, but there are barriers that need to be addressed from both the clinician and patient perspectives.
Despite the available data, the guidelines differ as to when to initiate insulin and refer to the A1C level.  The American Association of Clinical Endocrinologists states to initiate insulin if A1C is greater than 7.5% after 3 months of monotherapy (metformin) or combination therapy with 2 or more drugs, or if the first A1C is greater than 9.0% and the patient is symptomatic. The American Diabetes Association recommends starting insulin if entry A1C is greater than 10.0% and the patient is symptomatic or part of dual therapy, or if the A1C is greater than 9.0% or part of dual/triple therapy if A1C not at target after 3 months of monotherapy (metformin) or combination therapy with 2 or more drugs. 


  1. American Diabetes Association (ADA). Glycemic targets. Sec. 6. In Standards of Medical Care in Diabetes—2017. Diabetes Care. 2017;40(suppl 1):S48-S56. doi: 10.2337/dc17-S009.
  2. Garber AJ, Abrahamson MJ, Barzilay JI, et al. Consensus statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm—2017 executive summary. Endocr Pract. 2017;23(2):207-238.
  3. LeRoith D, Fonseca V, Vinik A. Metabolic memory in diabetes—focus on insulin. Diabetes Metab Res Rev. 2005;21(2):85-90. doi: 10.1002/dmrr.530.
  4. Turner RC, Cull CA, Frighi V, Holman RR. Glycemic control with diet, sulfonylurea, metformin, or insulin in patients with type 2 diabetes mellitus: progressive requirement for multiple therapies (UKPDS 49). UK Prospective Diabetes Study (UKPDS) Group. JAMA. 1999;281(21):2005-2012.
  5. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33) [Erratum in Lancet. 1999;354(9178):602]. Lancet. 1998;352(9131):837-853.
  6. Wright A, Burden AC, Paisey RB, Cull CA, Holman RR; U.K. Prospective Diabetes Study Group. Sulfonylurea inadequacy: efficacy of addition of insulin over 6 years in patients with type 2 diabetes in the U.K. Prospective Diabetes Study (UKPDS 57). Diabetes Care. 2002;25(2):330-336.

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