TABLE 3
General strategies for initiating insulin therapy
| Invite the patient to take an active role in treatment decisions. |
| Remind the patient that type 2 diabetes is primarily self-managed. |
| Discuss the progressive nature of β-cell dysfunction in type 2 diabetes. |
| Emphasize the physiologic role of insulin to maintain glucose homeostasis. |
| Discuss that insulin will help to achieve glycemic control and minimize the risk for long-term complications. |
| Discuss that treatment will be modified as needed to maintain glycemic control and to best meet their needs, capabilities, and interest. |
| Utilize insulin pen devices whenever possible. |
| Emphasize the importance of lifestyle management. |
| Ask if hearing other patients talk of their experiences with insulin therapy would be helpful; consider a group office visit. |
| Discuss and provide the patient with an individualized, written action plan that includes insulin dosing, self-monitoring of blood glucose, and signs/symptoms of hypoglycemia and other adverse events with appropriate action(s) to take. |
| Simplify diabetes (and comorbidities) treatment whenever possible. |
The remainder of this article uses case studies to further explore various patient barriers to insulin therapy and strategies for addressing them with the patient. While other therapies may be appropriate in the case studies below as recommended by current guidelines, these case studies will focus on insulin. In addition, dosing strategies for initiating and intensifying insulin therapy are discussed. Changes to the treatment plan to adjust for comorbidities, such as hypertension and dyslipidemia, or for smoking cessation or aspirin therapy, are not addressed in these cases, but are crucial components of comprehensive management.
CASE STUDY 1
RF is a 49-year-old female insurance analyst diagnosed with T2DM 6 years ago. Initial therapy with lifestyle modifications and metformin has since been intensified. Glimepiride was added, then pioglitazone was added 1.5 years ago when the A1C had risen to 7.5%. There is no evidence of cardiovascular disease. She reports bothersome lower extremity edema and an 8-pound weight increase since starting pioglitazone treatment. RF states that she takes her medications every day, although she acknowledges that she sometimes forgets on Sundays.
Clinical Impression
After taking her history, performing a physical examination, and reviewing her laboratory and self-monitored blood glucose (SMBG) data, her physician concludes that her treatment plan needs to be changed (TABLE 4, TABLE 5).
TABLE 4
Case study 1: Chart notes
| Physical examination | Laboratory tests | Lifestyle habits | Current therapy | |
|---|---|---|---|---|
| Glucose-lowering | Other | |||
| BP: 126/80 mm Hg Weight: 176 lb (79.2 kg) BMI: 27 kg/m2 Eyes: no retinopathy Neurology: intact Skin: intact | SCr: 1.4 mg/dL Albuminuria: negative A1C: 8.2% Cholesterol: Total: 204 mg/dL LDL: 134 mg/dL HDL: 36 mg/dL | Exercise: Walks 2 miles 3-4 d/wk Nutrition: eats 3-4 meals/d | Metformin 1000 mg BID Glimepiride 8 mg QD Pioglitazone 45 mg QD | Lisinopril 30 mg QD Simvastatin 40 mg QD ASA 80 mg QD |
| ASA, acetylsalicylic acid; BMI, body mass index; BP, blood pressure; HDL, high-density lipoprotein; LDL, low-density lipoprotein; SCr, serum creatinine. | ||||
TABLE 5
Case study 1: Self-monitored blood glucose (mg/dL) over the previous 2 weeks
| Day | Fasting | 2 h Post-breakfast | 2 h Post-lunch | 2 h Post-dinner |
|---|---|---|---|---|
| Wednesday | 205 | |||
| Thursday | 158 | |||
| Friday | 179 | |||
| Saturday | 201 | 162 | ||
| Sunday | ||||
| Monday | 166 | |||
| Tuesday | 189 | |||
| Wednesday | ||||
| Thursday | 153 | 221 | ||
| Friday | 150 | |||
| Saturday | 199 | 186 | 213 | |
| Sunday | ||||
| Monday | 181 | |||
| Tuesday | 167 |
Treatment Plan
- Initiate basal insulin once daily in the evening.
- Continue glimepiride, but reduce pioglitazone to 15 mg once daily (or discontinue if cost is a concern).
- Ask RF to monitor fasting blood glucose and self-adjust insulin doses as appropriate.
Barriers
While discussing the need to change the treatment plan and the physician’s suggestion that RF begin basal insulin, RF asks her physician for another few months on her current regimen stating that she will try harder to take her medications on Sundays. She also voices concern that insulin treatment requires injections and that she is concerned about what her coworkers and friends might think. The physician confirms that these concerns are understandable; he also confirms that RF is fearful of needles. The following are possible responses that RF’s physician could use to address these concerns.
Patient’s concern: Perceived failure/low self-efficacy
Physician responses:
- We all forget to do things from time to time, but overall I think you have done a great job taking your medications.
- As we have talked about before, with T2DM there is a progressive loss of insulin production over time regardless of what you do. That is why we added glimepiride and then pioglita-zone and that is why we need to make a change now and put you back in control of your diabetes. It is likely that further changes will be needed and we can discuss and agree on them together.
Patient’s concern: Social stigmatization
Physician responses:
- We can begin by having you administer insulin once daily in the evening in the privacy of your home.
- The insulin can be administered with a device that looks like a pen. It is small and can be carried in your purse; it does not need to be refrigerated once opened. If the time comes that you will need to administer a dose of insulin during the day, you can easily administer the insulin discretely in a public restroom or your work area.
- The use of insulin is more common than it was even a few years ago. In fact, about 5 million people in the United States use insulin to replace what is missing, control blood sugars, and decrease the risk for diabetes complications.34