Barriers toward insulin therapy in T2DM

Poor glycaemic control is a risk factor for the development of diabetes-specific complications in diabetic patients. Many T2DM require insulin therapy after several years of disease duration in order to maintain good glycemic control and prevent complications.

But many T2DM do not receive insulin therapy in a timely manner because of a negative appraisal of this treatment option.

Kulzer B. Diabetes. 2004: 53: A438-A439.

Patients’ negative attitudes towards starting insulin

therapy are based on their beliefs that the need for

insulin therapy indicates a greater severity of the

disease and proves their failure to self-manage

the diabetes adequately.

Snoek FJ. Health Qual Life Outcomes. 2007: 5:69.

This phenomenon is called psychological insulin

resistance .

Polonsky WH.Diabetes Care 2005, 28:2543-2545.

Data from the UK have shown that patients may

typically delay the initiation of insulin by around

8 years despite poor glycemic control .

Calvert MJ, et.al. Br J Gen Pract 2007, 57:455-460.

There were also substantial reductions in cumulative

incidence and time to onset of all diabetes-related

complications with immediate versus delayed insulin

initiation.

Gordon Goodall , et al . BMC Endocrine Disorders 2009, 9:19.

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Skyler JS. Endocrinol Metab Clin. 1996;25:243–254.

Unfortunately, many patients are reluctant to begin

insulin and may delay starting insulin therapy for

significant periods of time.

Okazaki K, et.al. Diabetes 48 (Suppl.1):A319, 1999.

To achieve tight glycemic control in T2DM, it may

be advantageous to introduce insulin therapy much

earlier in the disease course.

Delayed initiation of subcutaneous insulin therapy after failure of oral glucose-lowering agents (OGLAs) in T2DM patients in the UK

Insulin-naïve patients failing on OGLAs, which

collects records from general practices throughout

the UK.

Retrospective cohort study

Estimate the time to insulin initiation in patients with T2DM inadequately controlled on oral glucose- lowering.

25% of patients had insulin initiation delayed for at

least 1.8 years

Diabet Med. 2007 Dec;24(12):1412-8.

50% of patients delayed starting insulin for 5 years

after failure of OGLA poly therapy, even in the

presence of diabetes-related complications.

Cross-sectional interviewer-administered survey ,

265 patients .

prevalence of insulin refusal amongst Singaporean patients with Type 2 diabetes

mellitus

Diabet. Med. 28, 206–211 (2011).

A tertiary level of education was associated with

willingness to use insulin .

Refuse to use insulin (70.6%).

Prevalence and reasons for insulin refusal in Bangladeshi patients with poorly controlled

T2 DM

212 Bangladeshi with poor glycemic control on maximum OHA

57.5% commenced insulin immediately, 22.1% started insulin within 6 months and 20.3% refused to commence insulin despite repeated counselling.

Diabet Med. 2008 Sep;25(9):1108-11.

Most subjects reported several reasons for avoiding

insulin, rather than just one.

Polonsky WH.Clinical Diabetes 2004:22,147-150.

Patients may associate insulin therapy with a sense

of personal failure due to common physician

practice, where the possibility of insulin therapy

may be used to motivate better glycemic control .

To overcome these psychological barriers to

insulin treatment, first it is necessary to identify

these barriers in specific patients in order to

decide which interventions are appropriate.

Thus, a well-validated diagnostic tool may be helpful

to identify specific obstacles against the initiation of

insulin treatment.

Barriers to Insulin Treatment Questionnaire( BIT)

Scale 1 :Fear of injections and self-testing

Scale 2 :Expectations regarding negative insulin-related

outcomes Insulin works worse than pills. People who get pills feel better. Insulin can cause long-term complications.

Scale 3 :Expected hardship from insulin therapy

Scale 4 :Stigmatization by insulin injections

Scale 5 : Fear of hypoglycemia and permanent damage to my health FRANK PETRAK . Diabetes Care .2007:30:2199–2204,

Scale 4 “Stigmatization by insulin injections

When people inject insulin, it makes them feel like drug addicts.

Injections in public are embarrassing to me. Pills

are more discreet.

Feelings of dependence.

• The literatures showed that resistance to initiate insulin

may be impacted by patients’ beliefs and knowledge

about diabetes and insulin.

Qual Life Res (2009) 18:23–32.

• Lack of knowledge about diabetes and insulin

therapy or erroneous beliefs and misconceptions

about the disease and treatment contribute to PIR.

Funnell, M. M. Clinical Diabetes. 2007: 25, 36–38.

• Some patients believe that insulin, rather than diabetes,

causes serious health problems and severe or chronic

complications, such as amputation, heart attack, or

possibly blindness and even death .

• Patients may also perceive that insulin is for more

severe disease and/or that insulin initiation means

that they are becoming ‘‘more ill,’’ their disease

has dramatically progressed and become more

serious, or that they are at the ‘‘end of the road’’.

Polonsky, W. H, et.al. Clinical Diabetes. 2004: 22, 147–150.

Feelings of guilt

Negative self-perceptions and attitudinal barriers

Insulin is a threat, resulting in anger ,

because patients may feel unfairly punished for

poor self-care.

Unable to control the disease in the future

It was shown that women are also more likely to

perceive insulin as punishment, whereas men view

insulin more as a form of treatment that may help

them .

Women have been found to be more unwilling

than men (P < 0.001) to initiate insulin therapy .

• Technical concernsTechnical concerns

Fear of injections’’ consists of multiple components

• Needle phobiaNeedle phobia

• General anxietyGeneral anxiety

• Fear of self-injectingFear of self-injecting

• Fear of inflicting self-harmFear of inflicting self-harm

• Fear that injections will be painfulFear that injections will be painful

Lifestyle adaptations and restrictions

• Patients may have concerns that insulin adds to the burden

and stress that they already experience from managing

diabetes on a daily basis ,and do not feel confident that

they can handle the day-to-day demands of insulin therapy.

Funnell, M. MClinical Diabetes . 2007: 25, 36–38.

• It cause a loss of personal freedom that will severely

restrict their lives and be too inconvenient, time-

consuming, and complex to manage may also facilitate

PIR. It adversely affecting independence and lifestyle .

Fear of side effects/complications

• Patients may experience PIR as the result of

misconceptions regarding their disease, so that they

attribute complications of diabetes to insulin use rather

than insufficient glycemic control .

Polonsky, W. H. Diabetes Care1994:17, 1178–1185.

• patients also worry about potential side effects and

complications, such as weight gain, hypoglycemia,

which may be due to insulin use.

• Hypoglycemia and weight gain are the most common

side effects leading to PIR.

• For those who are already overweight the prospect of

further weight gain can, therefore, be a major barrier

to both the initiation and the intensification of insulin

for both patients and health care providers.

• Insulin omission was found in 1/3 women of all ages

with T1DM, with approximately half of the them

reporting omitting insulin for weight-management

purposes .

Polonsky, W. H. Diabetes Care1994:17, 1178–1185.

• Increased weight in T2DM is associated with

increased insulin resistance, so may compromise the

efficacy of treatment ,thus reinforcing the belief that

insulin is not good for one’s health.

In the attempt to avoid episodes, people with diabetes

may modify their maintenance of glycemic levels

especially during work or school hours .

Fear of hypoglycemia can also be a major barrier to

achieving optimal glycemic control.

Hypoglycemia can give rise to high insecurity; the

thought of future episodes can cause fearful and

disturbed feelings.

Social stigma

It is not surprising that social stigma plays a key

role in PIR because vials and syringes carry a

strong negative connotation and are usually

identified with either IV drug addicts or severe

illness . It cause social embarrassment and social

rejection.

• Thus, the fear of social stigma when injecting in public may impact adherence to treatment, as the absence of a private area in which to inject may result in either injecting too early or, in some cases, the omission of an injection.

• Persons with DM often hide their injections to avoid disturbing other people.

• Fears that use of syringes would damage their relationships with others or that taking insulin will result in family members and friends treating them differently .

• This may lead to a lack of motivation due to the

inconvenience and embarrassment related to

injections, patients selecting suboptimal locations

to inject themselves while away from home, such

as in public toilets, and may also cause some patients

to delay injections and avoid social activities .

PIR and diabetes management

• For any treatment to be optimally efficacious, it must

be initiated, be properly dose-adjusted over time,

and treatment compliance must be achieved. PIR

may be one of the major etiologies explaining both

the reluctance of patients to initiate and to intensify

treatment .

• All components of PIR can interfere not only with

the initiation of insulin treatment, but also with

attempts to intensify and increase compliance with

insulin therapy in individuals who are already

using insulin .

Physicians have also been shown to experience PIR for their patients.

Doubts about a patient’s compliance with treatment,

Fears of hypoglycemia

Weight status,

Impressions based on previous physician experience with insulin,

Concerns about the patient’s age,

Perception that the disease is so severe that even insulin would not help the patient

Nakar, S., et.al. Journal of Diabetes and its Complications.2007: 21(4), 220–226.

Overcoming Barriers to the Initiation

of Insulin Therapy

Patient concerned with pain from injection

o Use of insulin pens

o Minimal with thinner, smaller needles

Patient worried that starting insulin signifies worsening diabetes

Taking insulin will control blood glucose and

help prevent complications

Taking insulin may slow down the rate of beta

cell failure

Diabetes is a progressive disease

Patient believes that need for insulin signifies

patient failure to follow treatment regimen

beta cell activity declines over time Not related to

patient compliance

Diabetes is a progressive disease

Patient fears low blood sugar reactions

Use of insulin pens

Explain that severe hypoglycemia is rare in type 2

diabetes

Self-monitoring glucose levels

Explain how to avoid and how to treat hypoglycemia

Patient concerned that taking insulin will upset daily routine

Address specific concerns

Taking insulin may be less intrusive than complicated

drug regimens

Patient believes that insulin will decrease his/her quality of life

Benefits from glucose control: more energy,

better sleep, overall well-being

Patient thinks insulin will lead to diabetic complications

• Discuss role of insulin in reducing risk of diabetic

complications

Patient concerned that he/she will be treated differently by friends and family

• Educate friends and family

Patient has heard insulin causes weight gain

• Role of diet and exercise

Patient wants a more natural alternative therapy

• Insulin is the most natural therapy for diabetes. It

is replacing the hormone that the patient does

not make enough of.

Brunton, S.J Fam Pract 2005; 54:445.

Implications of new insulin TX for PIR

The use of a new pen system may help patients to

overcome the embarrassment issues that are commonly

associated with using a vial and syringe in public.

Korytkowski, M.2005:p27(Suppl B), S89–S100.

There are new modern insulin analogs and more discreet delivery systems (pen, inhaled, pump) available which have the potential to decrease PIR and improve treatment outcomes.

These treatment advances may help to eliminate or reduce many of the key factors that contribute to PIR, namely, social stigma, and fear of side effects.

• These pen overcome issues of needle anxiety and the

social embarrassment associated with self-injection .

Lee, W. C., et.al.Clinical Therapeutics, 2006, 28(10), 1712–1725. 1710–1711.

• Following the switch, the patients demonstrated improved medication adherence, fewer hypoglycemic events, reduced emergency department and physician visits, and lower annual treatment costs .

• Overcome problems with insulin dosing errors and low adherence. This was recently demonstrated in a study of patients with type 2 diabetes treated in a managed care setting who switched from the administration of insulin by vial/syringe to a prefilled insulin pen device .

• Incidence of hypoglycemia is reduced using modern

long-acting insulin analogs (detemir and insulin

glargine) compared with human intermediate-acting

insulin (NPH insulin).

Hermansen, K., et.al. Diabetes Care. 2006 :29(6).1269-1274.

• Modern insulin analogs and pen systems offer the

promise of novel insulin treatment with improved

technological features.

Polonsky, W. H., Diabetes Care, 28(10), 2543–2545

Limited reimbursement for pharmacy costs or

difficulty with access to health care may negatively

impact patients’ ability to care for themselves and

their diabetes appropriately .

• Appreciating and understanding the multifaceted and

complex nature of PIR and discussing the etiology of a

given patient’s PIR is an important first step.

Clinicians can help patients overcome their PIR

by working together to increase patients’ sense of

control over their lives .

Clinicians should emphasize the simplicity of the

treatment in order to decrease their patients’ fear

of dependency .

• Tailoring modalities, such as the use of modern insulin

analogs and insulin pen devices, may greatly reduce

PIR.

Insulin as a personal failure

• Explaining type 2 diabetes as a progressive disease of insulin resistance and b-cell failure from the onset will help to diminish or even prevent this erroneous belief.

• Point out to patients that they have not failed but that the other treatment options have failed them.

• Instead, describe insulin as a logical step in the continuum of treatment.

Insulin is not effective

• This barrier could stem from personal experiences in which friends were prescribed insulin in doses insufficient to lower blood glucose levels, but still resulting in side effects such as weight gain or hypoglycemia.

• Although most patients think of diabetes as a “sugar” problem, pointing out to them that diabetes is actually an insulin problem and that the insulins used in therapy today are very similar to the insulin that the body naturally makes may be helpful.

Insulin causes complications or death

• It stems from friends experiences.

• Insulin might have delayed or prevented these complications.

• It is generally more helpful to respond by acknowledging the patient’s fears and then providing information about the provider’s experiences.

• For example, “I have cared for many patients with T2DM, and I have never known anyone who became impotent as a result of insulin therapy?”

Insulin injections are painful

• Many patients equate insulin injections with inoculations or injections of antibiotics that they have experienced in the past. Insulin needles are smaller and thinner and that most patients find it less painful than testing their blood glucose levels.

• Educators ask patients to give a dry injection to themselves at the time of the initial education. Insulin pens can also be helpful. True needle phobias. For those who do, psychological counseling is often needed and effective.

Fear of hypoglycemia

• The fear of hypoglycemia often stems from observing people with diabetes who take insulin.

• Point out that with the use of newer rapid-acting andlong-acting insulins, hypoglycemia is less likely to occur and that very few patients with type 2 diabetes actually have severe hypoglycemia.

• Reassure patients that you can teach them strategies so that they can prevent, recognize, and treat hypoglycemia and thus avoid severe events.

Change in lifestyle

• A concern among older adults or patients who live alone is that once they begin insulin therapy, it will adversely affect their independence, either because of hypoglycemia or because they fear they will not be able to draw up or administer their own injections.

• Providing information about insulin pens or other devices to increase accuracy and ease of administration may help to diminish these barriers.

• Teaching patients to correctly identify symptoms of hypoglycemia and strategies to facilitate insulin use is also often helpful.

• Other lifestyle concerns are related to timing, difficulty in traveling, and loss of flexibility.

• Provide information about insulin regimens that offer maximum flexibility, strategies for traveling with insulin, or other identified lifestyle barriers.

• Some of these barriers result from concerns about injecting insulin away from home, for example in public places or at work.

• Some patients worry that if they inject in public places they will be perceived as injecting illegal drugs. Insulin pens can be very helpful for overcoming this barrier by increasing patients’ ability to inject discretely.

• Using only morning and/or bedtime insulin regimens can also eliminate this barrier for some patients.

• Some patients have concerns about the loss of their jobs if they need to begin insulin therapy. Regimen may be adjusted to allow for insulin injections to be given while patients are at home instead of at work.

Insulin causes weight gain

• It is true that many patients who begin insulin therapy gain weight with improved glycemia and greater meal plan flexibility.

• If this is a barrier, offer to arrange a meeting with a dietitian before the initiation of insulin to identify strategies to prevent weight gain.

Insulin is too expensive

• There is no question that diabetes is expensive, particularly for patients who have limited drug coverage or no insurance at all.

• Generally, however, insulin is less expensive than using multiple oral medications to produce the same glycemic outcomes. The regimen may also be adjusted to decrease this barrier by using premixed insulins if co-pays are a concern or less expensive insulins for patients with no or limited drug coverage.

• Other strategies to reduce this barrier include teaching patients to reuse insulin syringes, providing information about the least expensive sources for insulin and other supplies in your area, prescribing less expensive insulins.

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