Individualizing Insulin Therapy

DPP-4, dipeptidyl peptidase-4; DPP-4-i, DPP-4 inhibitor; Fx’s, bone fractures; GI, gastrointestinal; GLP-1, glucagon-like peptide 1; GLP-1-RA, GLP-1 receptor agonist; HbA_1c, hemoglobin A1c; HF, heart failure; NPH, neutral protamine Hagedorn; SU, sulfonylurea; TZD, thiazolidinedione.

^aConsider beginning at this stage in patients with very high HbA_1c (eg, ≥ 9%); ^bConsider rapid-acting, non-SU secretagogues (meglitinides) in patients with irregular meal schedules or who develop late postprandial hypoglycemia on SUs; ^cUsually a basal insulin (NPH, glargine, detemir) in combination with noninsulin agents; ^dCertain noninsulin agents may be continued with insulin. Consider beginning at this stage if patient presents with severe hyperglycemia (≥ 16.7–19.4 mmol/L [≥ 300–350 mg/dL]; HbA_1c≥ 10.0–12.0%) with or without catabolic features (weight loss, ketosis, etc).

Diabetes Care by American Diabetes Association. Copyright 2012. Reproduced with permission of AMERICAN DIABETES ASSOCIATION in the format Journal via Copyright Clearance Center.

Individualizing Therapy

The importance of individualizing therapy in a way that allows patients with T2DM to effectively self-manage their disease cannot be overstated. A study involving 1381 patients with T2DM cared for by 42 primary care physicians was conducted to estimate the magnitude of effect that physicians have on glycemic control.¹⁸ Hierarchical linear modeling showed that physician-related factors were associated with a statistically significant but modest variability in A1C change (2%) for the entire patient group. On the face of it, this finding might be discouraging. Further analysis showed, however, that for patients whose A1C did improve, physician-related factors accounted for 5% of the overall change in A1C (P = .005). On the other hand, physician-related factors had no impact on patients whose A1C did not improve or worsened. These results support the role that physicians play in affecting patient outcomes. The results also make it clear that without a physician’s influence, a patient’s glycemic outcomes may be difficult to change. The question is: How best can a physician influence patient outcomes?

A 2011 survey of patients with DM, general practitioners, and DM specialists reported that clinicians tended to underestimate patients’ perceived seriousness of the disease, while overestimating patients’ level of distress. In addition, physicians had difficulty identifying which DM-related complications concerned patients most and the information and support patients needed to feel more at ease with DM. Patients placed greater importance on having easy access to their physicians rather than more time with them. But most importantly, the survey investigators concluded that patients generally wished for greater involvement in decision making and being provided more information.¹⁹ These findings suggest that patients understand that T2DM is a largely self-managed, chronic disease, and want a collaborative relationship with their physician.

Patient Barriers to Insulin Therapy

Numerous factors have been identified as impeding patients’ willingness to initiate insulin therapy (TABLE 1).^20-24 Barriers often vary from patient to patient and, in fact, may change over time in an individual patient. It is crucial, therefore, to identify the root reasons for a patient’s apprehension with insulin when talking about options for intensifying treatment. Once insulin has been initiated, the patient should be asked about continuing or new concerns regarding insulin therapy (and DM management in general), including adherence.

TABLE 1

Barriers to insulin therapy identified by patients^20-24

A recent, international survey of 1400 patients with insulin-naïve T2DM reported that 3 negative beliefs about insulin were prominent: (1) feeling that the disease was worsening; (2) fear of injection; and (3) a feeling of personal failure.²⁰ Certain patient comorbidities, such as poor eyesight, arthritis, and forgetfulness, might also serve as barriers to self-management of DM with insulin. Additional comorbidities may contribute as indirect barriers, such as the need for polypharmacy, which may make the initiation of additional treatments such as insulin logistically or financially difficult.

It is possible that the discussion about initiating insulin may uncover patient concerns about T2DM in general. The Diabetes Attitudes, Wishes, and Needs (DAWN) study reported that psychosocial issues were the major source of difficulty in patient self-management (TABLE 2).²⁵ In fact, 85% of people who reported a high level of distress at the time of diagnosis of T2DM continued to experience psychological distress at a mean follow-up of 15 years.

TABLE 2

Patients experiencing various aspects of diabetes-related distress²⁵