Diabetes is a progressive disease, and its natural history is such that the majority of individuals will eventually require insulin in order to achieve or maintain acceptable glucose control. Insulin should be initiated whenever A1C levels are above target (less than 7%) for two readings over 3 months. Patients will usually be on maximum effective doses of at least one and usually two glucose-lowering agents. It should also be initiated immediately if patients are symptomatic and their blood glucose is repeatedly 300 mg/dL or higher. If patients are clinically stable but drink too many sugar-sweetened beverages (36 oz or more per day), they should be told to eliminate consumption of these beverages and then be reevaluated for their need for insulin within a week or 2.

A Two-Step Process

Insulin therapy is essentially a two-step process. First, the therapy must be initiated, and patients should be educated on all aspects of using it. Clinicians should talk to their patients about their eating habits, level of physical activity, and daily schedules. Nutrition guidelines should be provided to further enhance their education. Choices for insulin plans and diabetes education options should be discussed. Patients should also be referred to diabetes educators so that they can learn how to take insulin, review food plans, and review glucose self-testing. At that point, initial regimens and starting doses should be selected. The second step is to make adjustments. Patients will need to have their glucose levels monitored regularly, and therapy will need to be advanced once or twice a week until they reach target A1C goals. Insulin should then be titrated for high and low glucose levels using fasting or pre-meal glucose levels as the initial guide and later including post-meal glucose readings as needed. For instance, if fasting and pre-meal glucose readings are at target levels and A1C is still elevated, then the problem is post-meal hyperglycemia; this should be verified by patient self-monitoring.

Address Common Concerns

Patients with type 2 diabetes often express concerns about starting insulin. They’re sometimes under the impression that insulin is the consequence for something they did wrong. Patients should be informed that diabetes changes over time, and their need for insulin most likely isn’t due to their actions. Others may be concerned about injecting themselves with insulin and that it’ll hurt. Most people with diabetes, however, report that insulin needles hurt less than when they prick their fingers for blood glucose tests. Patients should also be told that their provider or a diabetes educator will guide them on using insulin.

Some patients may claim that insulin plans are too complicated for them. Fortunately, a variety of different insulin regimens are available, and there are simple ways to start each regimen. To address concerns about the hassles of using insulin and how it will change patients’ lives, tell them that they can find an insulin regimen to match their lifestyles and needs. They can still eat their favorite foods (in reasonable portions), travel, play sports, and do all the things they like to do. Insulin supplies are easy to carry and use, with many patients preferring to use an insulin pen device to deliver the drug simply, accurately, and in a relatively discreet manner.

It’s also important to address fears about insulin causing health problems. Patients should be told that effective use of insulin is one way to keep health problems from worsening and may enable them to live longer. If patients are worried about hypoglycemia or insulin reactions, it’s important to take time to teach patients how to quickly treat low blood glucose levels and how they can balance insulin with food and activity plans so that such problems can be avoided. As clinicians, we must be positive and emphasize that insulin therapy is not a punishment; it’s a normal part of treatment progression. We must also show support by asking about and addressing any and all concerns.

Richard M. Bergenstal, MD, has indicated to Physician’s Weekly that he has conducted clinical research or served on a scientific advisory board or as a consultant to Eli Lilly, Sanofi-Aventis, and Novo Nordisk. He receives no personal compensation from any of these activities; all contracts are with the non-profit Park Nicollet Institute for Research and Education.

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