This Physician’s Weekly feature covering insulin initiation and strategies to overcome hurdles was completed in cooperation with the experts at the American Diabetes Association.

According to current recommendations for the management of type 2 diabetes, timely initiation of both oral medications alone or in combination with insulin therapy is paramount to ensuring a desired level of glycemic control and improved patient outcomes. Although most providers agree that insulin is an effective approach to treating diabetes, many still consider it a last resort. “Patients are hesitant to take insulin for a variety of reasons,” says Mary T. Korytkowski, MD. “It is important that providers understand some of the barriers that exist among patients for insulin initiation as a way of reducing some of the negative attitudes many express to this form of therapy as a way of ensuring good outcomes.”

Before initiating insulin, it can be helpful to obtain an understanding of a patient’s view of insulin therapy. “When patients express apprehension, efforts to identify the reasons underlying this apprehension or refusal to take insulin can provide clinicians with the information they need to improve acceptance,” Dr. Korytkowski says. “Insulin therapy means different things to different people. When barriers exist, it is important to determine the level of concern among patients and ask open-ended questions [Figure 1]. Responses to such questions allow for the ability to follow up with additional inquiries that can help guide physicians to better understand and support their patients’ concerns.”

Assessing Patient Barriers

Several common patient related barriers to insulin initiation have been identified. These include:

Beliefs that insulin is a personal failure.
Beliefs that insulin causes complications or death.
Beliefs that insulin injections are painful.
Fears of hypoglycemia, loss of independence, weight gain, and cost.

Fortunately, there are strategies providers can use to address each of these barriers. “Providers previously used insulin as a threat to promote meal planning and exercise behaviors, but we’ve learned that this approach ultimately backfires when insulin is needed,” says Dr. Korytkowski. “To diminish beliefs that insulin results from personal failure, inform patients that non-insulin treatment options are no longer effective and describe insulin therapy as the next step in the continuum of treatment. Informing patients that they may eventually require insulin early in the disease can prepare patients well in advance of a need for insulin initiation.”

Regarding efficacy, it is important to inform patients that insulin is a hormone normally made by their own pancreas. “Tell patients that they can continue to have flexibility in their lives—sometimes with more energy—for activities they enjoy with the initiation of insulin,” says Dr. Korytkowski. Some patients with diabetes have had experiences with the disease through relatives or friends. The belief that insulin causes complications or death may stem from these experiences. “Facts alone may do little to allay patients’ fears,” adds Dr. Korytkowski. “Instead, acknowledge fears and then provide information about your own experiences as a clinician managing patients with diabetes. To address fears about painful injections, tell patients that insulin needles are smaller and thinner than ever before, and that most patients find it less painful than testing their blood glucose levels.”

Clinicians can acknowledge fears of hypoglycemia by discussing strategies for minimizing this risk and by providing education regarding early warning symptoms and treatment. Patients should be reassured that they will be taught strategies to prevent, recognize, and treat hypoglycemia while avoiding severe events. If weight gain is a concern, offer to arrange a meeting with a dietitian before initiating insulin to identify strategies to prevent weight gain. When costs are a concern, it may behoove physicians to inform patients that insulin can sometimes be less expensive than using multiple oral medications while also improving glycemic outcomes; this may ultimately reduce costs.

Consider Provider Barriers Too

While patient-identified barriers are the most common reasons cited for delays in initiating insulin therapy, many providers are also hesitant to initiate the drug. Some of these barriers are identified in Figure 2. “Strategies exist to help physicians overcome barriers to insulin initiation,” says Dr. Korytkowski. “For example, patients can be referred to certified diabetes educators for diabetes self-management education and medical nutrition therapy. Diabetes educators can have a significant impact on helping patients both initiate and titrate insulin therapy. Patients require initial education about insulin as well as continued follow-up and support to sustain gains in diabetes self-care behaviors. Office staff can help in supporting and reinforcing self-management efforts related to insulin therapy, particularly in early phases.”

The key to overcoming insulin initiation issues, Dr. Korytkowksi says, is to create proactive, collaborative relationships with patients. “It’s essential to ask patients about their thoughts or feelings on insulin. Clinicians cannot forget the emotional toll that diabetes may take on patients, especially when insulin is necessary. By taking time to educate patients and address potential concerns early and throughout the course of treatment, physicians can help ensure that their messages about insulin are supportive, tailored for each individual, and effective.”

References

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

Funnell MM. Overcoming barriers to the initiation of insulin therapy. Clin Diabetes. 2007;25:36-38. Available at: http://clinical.diabetesjournals.org/content/25/1/36.full.

American Diabetes Association. Standards of Medical Care—2010. Diabetes Care. 2010;33(Suppl 1):S11-S61. Available at: http://care.diabetesjournals.org/content/33/Supplement_1/S11.full.

Kabadi UM. Starting insulin in type 2 diabetes: overcoming barriers to insulin therapy. Int J Diabetes Dev Ctries. 2008;28:65-68.

Nathan DM, Buse JB, Davidson MB, et al. Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2009;32:193-203.