Removing barriers to insulin use

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Applied Evidence

Removing barriers to insulin use

J Fam Pract. 2011 October;60(10):577-580

By

Molly G. Minze, PharmD

Kavita Dalal, PharmD

Brian K. Irons, PharmD, BCPS, BC-A

Patients with type 2 diabetes and their physicians are often reluctant to begin insulin therapy—despite evidence of its efficacy. Here’s help in overcoming this other form of “insulin resistance.”

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References

1. United Kingdom Prospective Diabetes Study 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). Lancet. 1998;352:837-853.

2. Holman R, Paul S, Bethel M, et al. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med. 2008;359:1577-1589.

3. Brown J, Nichols G, Perry A. The burden of treatment failure in type 2 diabetes. Diabetes Care. 2004;27:1535-1540.

4. Nathan D, Buse J, Davidson M, et al. Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy. Diabetes Care. 2009;32:193-203.

5. Rodbard H, Jellinger P, Davidson J, et al. Statement by an American Association of Clinical Endocrinologists/American College of Endocrinology consensus panel on type 2 diabetes mellitus: an algorithm for glycemic control. Endocr Pract. 2009;15:540-559.

6. DeFronzo R, Stonehouse A, Han J, et al. Relationship of baseline HbA1c and efficacy of current glucose-lowering therapies: a meta-analysis of randomized clinical trials. Diabet Med. 2010;27:309-317.

7. Gerstein H, Yale J, Harris S, et al. A randomized trial of adding insulin glargine vs. avoidance of insulin in people with type 2 diabetes on either no oral glucose-lowering agents or submaximal doses of metformin and/or sulphonylureas. The Canadian INSIGHT (Implementing New Strategies with Insulin Glargine for Hyperglycaemia Treatment) Study. Diabet Med. 2006;23:736-742.

8. Skovlund SE, Peyrot M, et al. The Diabetes Attitudes, Wishes, and Needs (DAWN) program: a new approach to improving outcomes of diabetes care. Diabetes Spectrum. 2005;18:136-142.

9. Funnell MM. Overcoming barriers to the initiation of insulin therapy. Clin Diabetes. 2007;25:36-38.

10. Polonsky WH, Jackson RA. What’s so tough about taking Insulin? Addressing the problem of psychological insulin resistance in type 2 diabetes. Clin Diabetes. 2004;22:147-150.

11. Zambanini A, Newson RB, Maisey M, et al. Injection related anxiety in insulin-treated diabetes. Diabetes Res Clin Pract. 1999;46:239-246.

12. Brunton SA, Renda SM, Davis SN. Overcoming psychological barriers to insulin use in type 2 diabetes. Clin Cornerstone. 2006;8(suppl 2):S19-S26.

13. Peragallo-Dittko V. Removing barriers to insulin therapy. Diabetes Educ. 2007;33(suppl 3):60S-65S.

14. Korytkowski M. When oral agents fail: practical barriers to starting insulin. Int J Obes Relat Metab Disord. 2002;26(suppl 3):S18-S24.

15. Parchman ML, Pugh JA, Romero RL, et al. Competing demands or clinical inertia: the case of elevated glycosylated hemoglobin. Ann Fam Med. 2007;5:196-201.

16. Riddle MC, Rosenstock J, Gerich J. Insulin Glargine 4002 Study Investigators. The Treat-to-Target Trial: randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients. Diabetes Care. 2003;26:3080-3086

PRACTICE RECOMMENDATIONS

• Reassure patients who fear stigmatization that the small needles and devices available today make it easy to discreetly incorporate insulin therapy into everyday life. C

• Consider making a referral to a diabetes support group or a mental health counselor when a patient is reluctant to pursue insulin therapy, despite the benefits to his or her health. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

PATIENT HANDOUT
Is it time for insulin? (PDF)

For patients with type 2 diabetes, control of hyperglycemia through diet, exercise, and pharmacologic therapy reduces the risk of microvascular complications and may have long-term cardiovascular benefits.^1,2 But when the disease progresses and oral medication and lifestyle changes are no longer sufficient, many patients experience long periods of elevated glucose concentrations before insulin is added to (or replaces) a failing oral regimen.³

Both the American Diabetes Association and the American Association of Clinical Endocrinologists recommend early initiation of insulin therapy^4,5 for patients with significantly elevated HbA1c, and a stepwise treatment approach, beginning with oral medications, for more modest elevations. Overall, insulin therapy offers the greatest potential for improved glycemic control.^4,6,7 Yet patients, as well as their physicians, are often reluctant to initiate it. In the review that follows, we identify common barriers to insulin therapy and provide practical tips on how best to overcome them.

Why patients are “insulin resistant”

Patient barriers to insulin therapy can be divided into 3 general categories (TABLE 1)—psychological resistance, harmful effects (whether real or perceived), and financial barriers. Understanding what’s behind their hesitancy (as well as your own) makes it easier to overcome these barriers and properly integrate insulin into their health care regimen.

TABLE 1
Patient barriers to insulin^8-11

Psychological
Belief that insulin represents failure of self-care Lack of perceived benefit Pain/fear of injections Belief that insulin use is complicated Loss of independence/change in lifestyle Stigma related to needle use
Harmful effects
Hypoglycemia Weight gain Perceived adverse effects
Financial
Cost of insulin and supplies

Most barriers are psychological
Because insulin therapy is typically introduced some time after diagnosis (and conservative management), patients often view the need for insulin as an indication that they have failed to manage their type 2 disease effectively. What’s more, many patients are convinced that insulin will provide few, if any, benefits.⁸

The Diabetes Attitudes, Wishes, and Needs (DAWN) study, a large international trial, found that only 27% of noninsulin-dependent patients believed that insulin could help manage their disease.⁸ Patients’ lack of belief in insulin’s efficacy can be attributed to negative experiences with insulin therapy, which may have been related by family or friends or simply reflect societal views. The complex nature of insulin therapy is another problem, as patients often feel overwhelmed by the prospect of having to adhere to what they consider to be a stringent daily regimen.

FAST TRACK

Patients often view the initiation of insulin therapy as an indication that they have failed to appropriately manage their disease.

And for many, resistance to insulin therapy is triggered by fear of:

needles and subcutaneous injections^9-11
loss of independence and lifestyle changes (eg, having to sacrifice pleasurable activities, such as eating out and traveling)⁹
adverse effects, most notably hypoglycemia and weight gain.^9-11

Other psychological barriers can be attributed to perceived societal norms, including the stigma associated with the use of needles and illicit drug use and the potential embarrassment of self-injection.⁹

FAST TRACK

In one study, only 27% of patients with type 2 diabetes who were not insulin dependent believed that insulin could help manage their disease.

Harmful effects. Concern about insulin’s negative effects may be exacerbated by the fact that symptoms or complications of diabetes itself, which often develop as the disease progresses, are often mistakenly attributed to insulin therapy.

Financial concerns, too, are often associated with resistance to insulin therapy, relating to the costs of newer insulin analogs and insulin administration devices.

Replace misconceptions with facts

Patients respond in different ways to a discussion of insulin initiation, and it is important to identify barriers and help resolve them. Yet there are few validated measurement tools designed for this purpose. We’ve created a patient handout, “Is it time for insulin?”, which addresses a number of common concerns. The tips that follow here should also help.

“It won’t help me”
If a patient tells you that insulin therapy will be of little or no benefit, explain that type 2 diabetes is largely due to a lack of insulin activity and that the newer insulin analogs mimic the normal physiologic response. Make it clear that insulin use is not a punishment or evidence of personal failure, but a therapeutic option that most patients need as their diabetes progresses.^9,10,12