#532 - Levemir No More, Race in Research, Improv, Post Traumatic Growth

Two Brief Questions From Colleagues

1a)  Insulin Detemir (Levemir) Discontinuation

Question:  “I’m getting many questions from patients that they’ve been told they will no longer be able to get insulin detemir (Levemir).  What’s going on?”  

Answer:  According to Novo Nordisk, Levemir FlexPen, the injection pen version of insulin detemir, will likely face supply disruption starting in mid-January 2024, lasting up until the FlexPen’s discontinuation on April 1 of 2024. Levemir in vials will no longer be available after Dec. 31, 2024.  According to the company, this is due to global manufacturing constraints, formulary losses impacting patient access, and the availability of alternative options.

Levemir, which was originally approved in 2005, has been a staple as a long-acting insulin option along with insulin glargine U-100 (Lantus, Basalglar, Semglee), which was approved in 2000.  Levemir is also currently the only long-acting insulin approved for pregnancy in the US.

In 2015, a new longer-acting basal insulin manufactured by Novo Nordisk, Tresiba (insulin degludec), received regulatory approval as a once-daily option, as did Toujeo (insulin glargine U 300– Sanofi). 

For your patients presently on insulin detemir (Lantus), refill with a chosen alternative that the patient knows is covered or have the pharmacy notify of preferred alternatives if not covered by their insurance.  Conversions include:

•  For insulin detemir (Levemir) once daily doses can be converted 1:1 with insulin glargine U-100 (Lantus, Basaglar, Semglee), insulin degludec (Tresiba), and insulin glargine U-300 (Tresiba) 
• For insulin detemir (Levemir) twice daily doses, consideration should be given to a 10-20% decrease in total once-daily dose to avoid the potential for hypoglycemia  
• To switch from insulin detemir (Levemir) to long-acting NPH insulin, use the same daily dose but divide the total dose into twice-daily

Mark’s Comments:

Levemir represents a sizable portion of the basal insulin market (it generated $649 million in revenue in 2022 alone). As a commonly used basal insulin that people with diabetes rely on to manage their blood sugar, its discontinuation – particularly near the onset of a significant price cut – is likely to affect consumers, reducing access to medications for many.  We don’t usually include the pharmaceutical manufacturers in Take 3, but this dynamic is relevant in this setting.  There is some speculation that this change was also necessary in order to increase manufacturing capacity for semaglutide (Ozembic) due to demand/anticipated demand (ie: this was a business decision). 

For Carilion clinicians, our PharmD colleagues have ask that we NOT forward these patients to them to determine coverage.  Doing so will quickly overwhelm present resources and will result in a delay of care for your patient.

Reference:

Prescriber Insights (fka Prescriber’s Letter-by subscription only): January 2024.

2b)  Race and National Origin in Research Studies and Guidelines

Question:  “You recently did a Pointer in which parameters for BMI implications were different for those who were ‘Asian’ than other populations.  In this context, what groups does this distinction include?”

Answer:  When the term "Asian" is used in medical practice guidelines, it generally refers to individuals who are from or have ancestry linked to the continent of Asia.   According to the National Institutes of Health (NIH), the terms “Asian” and “Asian American” refer to any persons whose origins are in any of the original populations of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, Bangladesh, India, Japan, Korea, Malaysia, Pakistan, the Philippines, Thailand, and Vietnam.  The word “Oriental” is no longer used in this context.   The NIH encourages us of specific terms whenever possible and to not hyphenate Asian American or other dual-heritage terms.

AAPI, which stands for Asian Americans and Pacific Islanders, is an acronym widely used by people within these communities but may not be familiar to readers outside of them and the NIH does not recommend this acronym be used.

Mark’s Comments:

Remember that risk differentiation is an epidemiological construct which is thought to be based on genetic predisposition and not culture/subculture.  It's worth noting that the broad categorization of "Asian" in medical guidelines has been critiqued for potentially oversimplifying the diversity within Asian populations. There is a growing movement towards more nuanced and detailed classifications that better reflect the genetic, environmental, and social heterogeneity of these groups.

When specific guidelines refer to "Asian" populations, they should ideally clarify the context and the specific populations or subgroups they are referencing in order to avoid these generalizations and ensure the guidance is as relevant and useful as possible.  Remember this is a rapidly evolving area of understanding on a population scale with much personalization required in the context of individual patient care. 

Reference:

NIH Style Guide – Race and National Origin:  Link

From Academic Medicine

2)  Using Improvisation Principles in Clinical Teaching

Usually, teaching medical students or residents in the clinic affords many novel lessons for learners: common bread-and-butter diseases, rare diseases, atypical presentations of common disease, physical examination findings, etc. But sometimes, our students may actually see a patient with well-controlled hypertension who is up to date on everything…what to do then? We have our list of more formal teaching techniques – the One-Minute-Preceptor, mini-lectures, well-rehearsed teaching scripts, etc., but sometimes we haven’t thought well-enough ahead to have prepared even these, and we need to come up with something new...quick.

A review article in Academic Medicine recently discussed this dilemma and drew some principles from improvisational theater to spark creativity in teaching; what the authors call pseudo-improvised teaching. These techniques are content neutral and can be applied to follow up earlier educational points or to broach new themes in the discussion afterward. The authors define five categories of improvisational theory applied to clinical teaching with some examples:

1.    “Watch This!” Assigned Observation and Discussion – have the learner listen for specific elements of your interaction with the patient (empathy cues, jargon, etc.), or have the learner observe the patient walking into the room, or through a window, and gather all they can about their medical condition.

2.    “Everything is a Gift” Humanity rounds – These were clearly developed for a small team rather than 1:1 preceptor: student teaching but can still be applicable. Everyone on the team is encouraged to share:

1. gratitude - for something in their lives (patients can participate in this one.
2. vulnerability – each person shares something they don’t know well.
3. wellness – an interest or hobby from life outside medicine.
4. culture – music, art, food, etc. from each team member’s culture that they have recently enjoyed.

3.    “Make Your Scene Partner Look Good” Using Multidisciplinary Team Members as Teachers – Ask nurses, other clinical staff, or patients to share teaching pearls about the clinical topic with the learners. Or go around the room and have everyone share knowledge about the topic (without worrying about correctness until the summarizing at the end).

4.    “Mini chalk talks” When drawing a blank…draw a blank – Draw a stick figure and have learners label with symptoms and signs for a random (or recently seen) disease. Or completely deconstruct a lab test by writing all the components, and having learners present what they know about each.

5.    "What’s the Theme?": Longitudinal Themes –

1. Equity rounds – how would social and structural determinants have affected this patient’s diagnosis and treatment?
2. Brevity – distill patient information into a Haiku, tweet, or pager phrase.
3. Pager party – give a hypothetical on-call problem to a learner to solve to practice cross-covering.
4. Spaced learning – spread a mini-lecture into multiple chunks to be given between each patient.

John’s Comments:

While the authors refer to some literature, this is not a study, so reader beware. Techniques like this can be engaging for learners, certainly, but they also might mix it up in a healthy way for preceptors – working against burnout by injecting a little creativity and humor. In addition, some of these techniques can leverage the learners’ powers of observation in new contexts that might allow us new insight into our patients’ complaints.

Reference:

·         Jarrett ES, Allen KA, Marmet J, Klein M, Moerdler S, Pitt MB. “What’s My Line?”: Pseudo-Improvised Teaching When the Clinical Teaching Script Is Blank. Acad Med. 2023;98(12):1360-1365. Link

From PeerRxMed ( www.PeerRxMed.org )

3) Bouncing Back … and Then Some ….

"In the depth of winter, I finally learned that within me there lay an invincible summer." - Albert Camus, French Novelist and Nobel Prize Winner

We’ve all cared for them – patients who seemingly defy all odds to not only overcome their medical challenges but emerge “better” somehow amid them, or even because of them.  This, as we know, is not the norm.  Many others are left with physical and/or emotional wounds from which they never recover or at best find a “new normal” that is far less than before.   Yet there is a growing number for whom such events seem to propel them forward to a life more deeply meaningful and generative than they could have previously imagined.  This last group is experiencing what has come to be called post-traumatic growth (PTG). 

How about we clinicians?  Many of us experience traumatic clinical circumstances often, and personal ones as well.  PTG holds that people who endure psychological struggle following adversity can often experience a greater appreciation for life, improved personal relationships, increased personal strength, recognition of new possibilities, and a deeper spiritual sense of meaning and purpose.  How might we allow ourselves to process these events in a way that we could emerge from them not only healed, but perhaps under the right circumstances, even “better”? 

I think often of one such transformational time for me when a woman I cared for during her pregnancy developed disseminated intravascular coagulation (DIC) during her delivery and died despite all we did to help her.  Though I was emotionally devastated, I initially mistook my “cognitive resilience” (“We did all we could under the circumstances”) as emotional healing and dismissed any emotions that did not fit that narrative.  It wasn’t until more than a year later that I finally conceded how poorly I was really doing emotionally and sought the help of a therapist.  Growth came about for me by processing the many emotions, including these, that had been suppressed along my medical journey and developing new tools to understand and navigate the entirety of my emotional life.  As I integrated these lessons, I emerged healthier and more whole.   

While the concept of growing from adversity is inspiring and certainly appealing, it is essential to recognize the nuanced pathways and numerous challenges on the path of  recovery and not be seduced into believing that all adversity can be magically converted into a positively transformed life.  That’s what I initially tried to do after my patient’s death.  In reality, my growth required overcoming much emotional scripting and professional programming, and ultimately only happened because of the many people who provided support, encouragement, and expertise to me. 

Certainly, the possibility of post-traumatic growth is something that can be inspiring for us all, offering a hopeful perspective on recovery.   As healthcare professionals, let's strive to foster environments that support both the acknowledgment of pain and the possibility of growth; with our patients, with each other, and with ourselves.  In doing so, let’s approach post-traumatic growth as a “team sport” rather than an individual undertaking or accomplishment.  While we can’t “rush” our healing, with the help of others we can recognize that within the depths of any trauma, there lies the potential for an "invincible summer."  Remember, no one should try to heal alone, including you ….

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org