I recently visited the Golden Triangle of Central Europe (the cities of Vienna, Budapest and Prague) with seven friends. In the golden city of Prague I had the immense pleasure of meeting much of the staff at the Institute for Clinical and Experimental Medicine’s Diabetes Clinic, the Klinika Diabetologie. Everyone I met in Prague exuded such hospitality and such a optimistic outlook for these changing times in this historical city. The staff at the Klinika was no exception.
I was surprised and impressed with what I saw at the Klinika. In fact, in terms of choices for people with diabetes with regard to insulins and injection devices, the Czech Republic is ahead of the United States.
One of my hosts for the visit, Alexandra Jirkovska, MD, PhD, (or Sasha as she is called) noted that the standards for care were based on the DCCT and the Ohkubo Study, a large study on type 2 diabetes care from Japan.
There are 501,945 people with diabetes in the Czech Republic – nearly five percent of the population. According to Frantisek Saudek, MD, PhD, head of the Department of Diabetes at the Institute, approximately 80 percent of the patients on insulin seen at the Klinika practice intensive insulin therapy, but some are still on one to two injections per day.
Treatment regimens appeared to be very similar to those practiced in the United States, but it seemed to me that patients are moved along through the different stages of therapies more rapidly. I was, however, observing care at the largest and most sophisticated diabetes care facility in the country.
The Land of Insulin Plenty
Of the differences between Czech and American diabetes care, the two most striking to me were the huge number of choices in insulins that are available in the Czech Republic and the frequency of pen use.
The available options in premixed insulins are far greater than in the United States. Besides the 70/30 mixes we are accustomed to, 25/75, 50/50, 60/40, 75/25, 80/20, 85/15, 90/10 and nearly every other mix imaginable are available in the Czech Republic, in addition to pure NPH and pure Regular. All European insulin is marketed with bright color-coded labels and caps. This is a much safer and innovative system that patients and educators envy in the United States.
Travelers should be warned, however, that the proportions are listed in the opposite order in the Czech Republic, with the Regular portion listed first and the NPH portion second.
A Preference for Pens
It’s not just the insulin that is different in the Czech Republic, the injection devices also differ. Sasha told me that in her estimation, pens account for approximately 80 to 90 percent of all insulin delivery. As it is with insulin in the Czech Republic, so it is with pens – choice reigns supreme.
Because of the frequency of pen use, more insulin choices are available in both 1.5 and 3.0 ml pen cartridge sizes than are available in vials in the United States.
Greater pen use has also led to more sophisticated pen designs. Hoechst, the makers of Amaryl, market the OptiPen (for 1.5 ml cartridges) and the OptiPen II (for three ml cartridges). This is an effective system that is easier to read than the traditional systems because it makes use of a LCD screen, like the ones used in BG meters, that let users know how many units they are delivering. These pens are designed to work for three years on the original battery, at which time they are returned to the manufacturer and replaced with new ones. (Hoechst also produces and markets insulin in the Czech Republic that is not yet available in the United States.)
Seeing how common pens are in the Czech Republic reminds me of a study I conducted with my patients, regarding the use of Lispro in pens. After the conclusion of the study, 98 percent of these patients said that they would prefer to continue using pens.
What About Pumps?
Sasha, who wrote the 1997 instruction manual for pump therapy used in the Czech Republic, has approximately 25 patients on pump therapy. The pumps are covered by insurance and government sponsored health coverage, but their use must be recommended by a specialist. Both MiniMed and Disetronic pumps are used.
You Gotta’ Have Glucagon
Glucagon is a naturally secreted hormone that works to balance glucose, energy and insulin. It is used to counter the action of insulin and combat hypoglycemic attacks for people with diabetes. It works by pulling out stored glycogen from the liver and muscle tissue to make glucose available.
Glucagon emergency kits are marketed by Lilly in the United States, but they are grossly under prescribed and under utilized. In my opinion, every person with type 1 diabetes should have friends and family members learn how to use these kits should the need arise. Unfortunately, in the States, there is a bit of a stumbling block. While no prescription is needed for insulin, one is needed for a glucagon emergency kit.
In the Czech Republic, kits contain 1 mg of glucagon, like the ones in the United States, however they are more readily available and a step ahead in terms of design.
The most striking difference is the kit’s design. First off, it is packaged in a bright orange container that can be especially helpful in emergency situations. In addition, the lid of the kit has instructions for use consisting of four, color drawings explaining how to use the kit in a very clear, language-neutral fashion. The design the kit’s use make it much easier for the untrained user, and because the instructions are part of the kit itself, they can’t be lost.
What They Need
While the Czechs might have a greater opportunity to choose their preferred type of insulin and injection device, they suffer from a lack of patient education funding. The professionals whom I spoke with believe that this is the biggest problem with diabetes care in the Czech Republic, with a lack of test strip coverage running a close second.
To make up for this, there is a magazine in the Czech Republic that is very much like DIABETES HEALTH called Dia Zivot. It is a patient-oriented magazine for which Sasha is an advisory board member.
The services of diabetes educators and registered dietitians are not covered by insurance. As a result, my friends at the Klinika feel that patients lack an appreciation of the importance of lifestyle factors such as exercise and nutrition in the management of diabetes. Many of them also expressed concern that patients do not fully appreciate the importance of proper foot care. In addition, I noticed that smoking, a big factor in complications, is rampant in the Czech Republic.
My trip was a wonderful opportunity to meet new friends and to learn more about diabetes care around the world. I would like to thank the staff at the Klinika that made my visit so enjoyable and informational. Special thanks to: Frantisek Saudek, MD, PhD; Alexandra Jirkovska, MD, PhD; Terezie Pelikanova, MD; Peter Boucek, MD and Veronika Woskova, MD.