Although the reasons for poor glucose control amongst diabetics is complex, one concerning issue remains the reluctance of physicians and patients to begin insulin therapy. This has been widely documented, despite awareness amongst both caregivers and Type 2 diabetics of the increased health risks caused by inadequate glucose control.
Diabetes, and the complications caused by poor management of the disease, are rapidly becoming a health concern of epidemic proportion in Europe and the United States. According to Celafu (2004), normal glucose levels are seldom maintained over time in Type 2 diabetics. “Even with early intervention and education, many patients with type 2 diabetes are unable to achieve treatment goals through lifestyle changes alone” (Anon 2005, 4). Oral antidiabetic drugs, the initial treatment for Type 2, “eventually fail to provide adequate glycemic control” (Anon 2005, 4). Targets are missed both due to the progressive nature of the disease and to a reluctance to initiate insulin therapy (Davies 2004).
Davies (2004, S15), citing an unpublished study by the British Diabetic Association, reports that “in the UK a large dataset of over 600, 000 from across the country in the year 2000 reported a mean HbA1c of 8.6 in type I patients and 7.8 in type II patients.” This is significantly above the 6.5 recommended (Davies 2004). Funnell and Kruger (2004) similarly report that over half the Type 2 diabetics in the United States regularly exceed recommended glycemic goals, such as an A1C of less than 7%. However, they cite three large independent trials which all show significant A1C improvement with the introduction of insulin therapy (Funnell and Kruger 2004).
Results from the 1998 UK Prospective Diabetes Study suggests that even a 1% Hb reduction can lead to a 21% reduction in diabetes-related death (Stratton et al 2000). Similar reductions also result in a 14% reduction in myocardial infarction, and up to a 37% reduction in microvascular complications (Stratton et al 2000). Reductions in peripheral vascular disease by over 40% are also cited (Stratton et al 2000). According to Davies (2004, S14), a number of studies show “unequivocally that reducing hyperglycemia reduces both the incident risk and progression of diabetic complications, with no threshold level of HbA1c beneath which further prognostic advantage cannot be achieved.”
“Given the scope of the problem, clinicians need to identify type 2 diabetes early and initiate aggressive intervention to positively influence patients at risk for the disease and help prevent disease progression and associated complications” (Anon 2005, 3). “In order to achieve the suggested targets for glycemic control necessary to reduce the incidence of diabetic complications, it has been established that a more intensive insulin regimen” and earlier use of insulin is often called for (Cefalu 2004, 1149). Unfortunately, such early insulin use is uncommon (Cefalu 2004).
Literature reviewed cites a number of barriers responsible for the slow introduction of insulin regimens to Type 2 diabetic treatment. Barriers on the part of patients typically include fear of injections, feelings of failure, misconceptions regarding the effects of insulin, and concern that the disease is worsening. Cefalu (2004) found that fear of pain and inconvenience of having to inject insulin greatly increases patient anxiety regarding initiating insulin. He concludes “a major limitation for advancing to intensive insulin therapy is that the only viable way to administer insulin is through injection” (Cefalu 2004, 1149). Davies (2004, S18) similarly found that in Type 2 diabetics, “needle phobia presents as a common additional barrier to good control.”
Patients may also view moving to an insulin regimen as a indicator they have failed at other therapies, such as lifestyle management (Cefalu 2004). This can produce guilt over even minor incompliance in previous treatment, and cause the patient to want to “try harder” on their existing treatment plan rather than move to insulin (Cefalu 2004). In a recent survey, nearly forty percent of patients agreed that ‘Starting insulin would mean that I have not followed my treatment recommendations properly’ (Davies 2004, S16). Kuritzky and Nelson (2004, S11) additionally found that “well-intended practitioners may have inadvertently set the stage for patient nonreceptivity by portraying insulin as appropriate therapy for patients who have “failed” with oral agents.”
Davies (2004) goes further, offering anecdotal evidence of practitioners who attempt to coerce non-compliant Type 2 diabetics into lifestyle and oral medication compliance by the threat of beginning insulin therapy. This can result in strong patient resistance to insulin when it is eventually called for (Davies 2004). This can even lead to belief that insulin indicates inevitable complications or death to the patient. “The perception is that use of insulin signifies progression to a more serious phase of their disease; some patients view insulin use as a ‘prelude to death’ (Cefalu 2004, 1152). Some patients also “mistakenly believe that insulin intensifies insulin resistance” (Kuritzky and Nelson 2004, S11). Others claim considerations of weight gain outweigh their desire for tight glucose control (Anon 2005).
Physicians and caregivers more often cite hypoglycemia, obesity, and patients lack of coping skills as reasons to delay insulin initiation. Davies (2004, S16) found “concerns about causing hypoglycemic episodes or increasing patients’ obesity means that physicians may permit poor control to continue unduly by delaying the initiation or intensification of insulin therapy” and “regard insulin as treatment of last resort.” Instead, Kuritzky and Nelson (2004, S11) recommend “patients should be taught that insulin therapy is appropriate at any time during the course of diabetes to achieve glycemic goals.”
Finally, those diabetics on insulin therapy are often on less than optimal dosages. Mayfield and White (2004, 489) conclude from their study of Type 2 diabetics that “statistics suggest that suboptimal insulin therapy is too common.” Nearly thirty percent of Type 2 diabetics use insulin therapy, “but less than one half achieve the recommended A1C level of 7 percent or less” because even physicians who are willing to intiate insulin therapy are hesitant to aggressively use insulin (Mayfield and White 2004, 489).
Anon 2005. The Role of Basal Insulin in Type 2 Diabetes Management. Supplement to The Journal of Family Practice, October 2005, 2-8.
Cefalu, W. 2004. Evolving Strategies for Insulin Delivery and Therapy. Drugs 2004, 64(11): 1149-1161.
Davies, M. 2004. The reality of glycaemic control in insulin treated diabetes: defining the clinical challenges. International Journal of Obesity, 28(Suppl 2): S14–S22.
Funnell, M. and Kruger, D. 2004. Type 2 Diabetes: Treat to Target. The Nurse Practitioner , January 2004, 29(1):11-23.
Kuritzky, L. and Nelson, S. 2004. Insulin therapy in primary care: Practical issues for clinicians. Supplement to The Journal of Family Practice, June 2005, S10-S11.
Mayfield, J. and White, R. 2004. Insulin Therapy for Type 2 Diabetes: Rescue, Augmentation, and Replacement of Beta-Cell Function. American Family Physician, August 1, 2004, 70(3): 489-500.
Rizvi, A. 2004. Type 2 Diabetes: Epidemiologic Trends,Evolving Pathogenic Concepts, and Recent Changes in Therapeutic Approach. Southern Medical Journal, November 2004, 97(11): 1079-1087.
Stratton et al 2000. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes. British Medical Journal, 321: 405–412.
UKPDS 1998. UK Prospective Diabetes Study (UKPDS) Group: Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes. Lancet 1998, 352: 837-853.