Initiating insulin: How to help people with type 2 diabetes start and continue insulin successfully

Abstract

Initiating insulin successfully With the growing incidence of type 2 diabetes worldwide, healthcare professionals (HCPs) find an increasing proportion of their time devoted to the management of diabetes. Because this condition is chronic and characterised by progressive decreases in insulin secretion and sensitivity, insulin therapy becomes necessary for a large number of persons with type 2 diabetes.1 However, despite the efficacy of insulin treatment, patients and their HCPs continue to be challenged with reaching glycaemic goals and maintaining long-term insulin therapy. As many as 30%-50% of patients may remain above their glucose target 6 months after starting basal insulin.2, 3 One key contributor is problematic patient adherence. In this paper, we consider what factors may be critical to encouraging successful insulin initiation and promoting long-term treatment maintenance, and we provide practical tips to help with this important transition, particularly in the current environment of limited time and resources. The lack of success with real-world insulin therapy is attributable to several factors including interruption and/or discontinuation of therapy. Recent estimates from claims databases in the USA, Japan and Germany found that 18%-26% of insulin naïve people with type 2 diabetes who started insulin discontinued therapy in the first year, and an additional 15%-62% had at least one interruption in that year.4-6 Many patients may be lost to follow-up or are reluctant to admit to poor adherence or discontinuation, thus the true extent of problematic insulin persistence is likely to be underestimated. Although there is substantial literature on how to help patients overcome barriers to initiating insulin, there is less information on how to ensure that patients get off to a good start, maintain treatment and successfully reach their glycaemic targets. To provide HCPs with some practical advice on this problem, we summarise the best practices recommended by an international panel of clinicians who specialise in the care of persons with diabetes. The panel consisted of primary care physicians, diabetologists, clinical psychologists and diabetes nurse educators. Acknowledging that a large number of patients do not persist with their insulin treatment, the panel was asked to draw from their clinical experience and (1) identify the main reasons behind insulin treatment interruption or discontinuation, and (2) share a list of strategies they employ to ensure their patients get off to a “good start” and prevent lapses or discontinuation of treatment. The panel identified multiple reasons for insulin interruption or discontinuation and allocated them in four general categories: perceived harm, inconvenience, no perceived benefit and difficult patient-HCP interactions. Patients may view the need for insulin, along with the requisite dose titration, as a sign that their condition has worsened. Patients may also feel stigmatised and personally at fault when insulin is finally added to their regimen. They may attribute the severe complications of diabetes, such as amputations, visual impairment and even death, to the use of insulin. Thus, many patients may worry that insulin will do more harm than good. Some patients may be worried that insulin treatment will adversely affect their current employment or future job opportunities. They may experience job discrimination related to keeping regularly scheduled treatment appointments or when needing to check their blood glucose (BG) at work. In some countries, employment restrictions may exist in such fields as the Armed Services, fire and police departments, as well as public transportation vehicles operated on land, in the air or by sea. The belief that insulin may cause more harm than good is also closely linked to perceived adverse consequences, such as hypoglycaemia and weight gain. Interestingly, patients may discontinue insulin not only if they experience adverse consequences but also because they fear the occurrence of these outcomes, especially hypoglycaemia. Family members and friends may also influence a person's decision to discontinue insulin based on their personal beliefs and experiences. Finally, some patients may experience significant financial hardship because of the cost of insulin as well as glucose testing supplies. Some patients may find that the lifestyle changes required by insulin therapy to be too inconvenient or burdensome. Work schedules that are either inflexible or rotating (shift work) can pose challenges such as changes in sleep patterns, meal times and injection times that patients and prescribers must accommodate. It is easy for patients to feel overwhelmed by all the tasks that come with the use of insulin. Others may feel self-conscious about injecting insulin in the presence of others, and also feel embarrassed when they have to leave to find a private place to inject. Some may find it too difficult to successfully inject insulin and follow titration algorithms because of low literacy and/or low numeracy issues. Travel away from home requires special planning for safe carriage and storage of supplies, including the need to anticipate additional supplies that will be required while away. Travel to different time zones may require patients to adjust the timing of their insulin administration. Patients may not anticipate the benefits from insulin therapy or understand how insulin could play a role in helping them to feel better and achieve specific life goals and objectives. Many patients have not felt well for some time and do not believe that taking insulin and improving their glucose control will make a difference. Consequently, patients may reject insulin as a necessary treatment and adopt the view that its use is optional or best suited for others, or that no harm will be done if they miss a few doses. These feelings may also result in refill delays when their medication supplies run out. Such beliefs are likely to be reinforced if patients remain on suboptimal doses of insulin and/or do not see improvements in their glucose readings. Patients may also doubt the effectiveness of insulin therapy if they miss a dose early in their titration phase and fail to see a significant worsening of their BG. Patients may not understand that diabetes is a chronic condition and that daily insulin treatment is needed to maintain glucose control. Sadly, some patients reach their glucose target and then stop their daily insulin assuming it is no longer needed. Lastly, patients may become discouraged and stop their insulin if they have not been given specific instructions, individualised to their lifestyle and life circumstances, to assess their progress. Mutually agreed upon glucose targets can serve as concrete guideposts to reinforce positive behaviour changes. Because of demanding office schedules and time constraints, an effective and meaningful insulin initiation conversation between the patient and HCP may never occur. This may lead patients to feel that their concerns are not being sufficiently considered and that they have been given no voice in the decision to start insulin. Patients left with multiple unanswered questions or unresolved fears will find their insulin “journey” is on a shaky foundation. All patients new to insulin will require frequent contact and support, and it is important that they understand who they should contact for questions or concerns, when they should make contact, and the best way to communicate with the office (by phone, email or fax). Without specific contact instructions, patients may feel alone or abandoned in the midst of their insulin journey. These issues are compounded if the HCP lacks the practical experience to confidently introduce and initiate insulin therapy in a sensitive way, collaborating with the patient in ways that make insulin initiation fit the patient's lifestyle and wishes. The HCP's lack of confidence and/or insensitivity to their patients’ needs will be apparent to the patient and may contribute to delaying basal insulin initiation, titration and maintenance of therapy. The panel discussed ways to introduce insulin to patients that might not only enhance uptake but also minimise future interruptions or discontinuations. There was a strong consensus that helping patients get off to a good start with insulin is critical, and that this must be complemented by timely clinical support and follow-up over the first few months. Below we describe specific insulin initiation strategies that can be easily implemented by the healthcare team. We group our solutions into four categories: effective insulin conversation, education including setting expectations, titration and follow-up support (see Section 5). Insulin initiation should be viewed as a normal part of the diabetes care continuum. In addition, it is recommended that HCPs start the initial insulin conversation and set appropriate patient expectations at, or shortly after, diagnosis. This allows the opportunity to frame insulin treatment in a positive way, which may prevent patients from feeling a sense of guilt or personal failure at the actual time of insulin initiation. The first insulin conversation should focus on the patients’ lifestyle and daily routine, any concerns about insulin, and their short- and long-term goals living with diabetes. The HCP can ask open-ended questions to explore and address patient fears or needs. Having the right insulin conversation at the right time enables the HCP to obtain patient buy-in, a key component for achieving successful insulin initiation. In Table 1, we give steps, goals and examples of how to have a positive insulin conversation, while in Table 2 we list some common patient objections or concerns around insulin therapy, and suggested HCP responses. Timely self-management education can assist patients in setting realistic expectations and feeling more in control of their disease and the methods of treatment. The more patients know and understand about their condition and insulin treatment, the greater their chance for success. It is important to assess how much the patient understands and provide access to education when needed. This may include an appointment with a diabetes educator or nutritionist when available. Alternatively, training may be done in the office by the HCP or other trained medical staff, such as medical assistants, who can use a structured diabetes education programme. It is strongly recommended that each HCP office assign a designated team member responsible for education on insulin use. Office protocols can be made to ensure that the key educational messages are covered. It is important that the HCP and office staff instill confidence in the patient regarding insulin use. Furthermore, the HCP can provide information to patients about community resources or hospitals that may be offering group classes. Once insulin is started, the office can provide information on meal planning, exercise, self-monitoring of blood glucose (SMBG), BG targets, hypoglycaemia signs and treatment, sick day plans, proper injection technique and site rotation.7 We cover some of these topics in more detail below, and provide a stepwise approach to insulin-specific diabetes education in Table 3. Individualised patient education should be kept simple and focus on one topic at a time (during the appointment) for better retention. It is crucial for patients to be active partners in the insulin initiation process. Therefore, the HCP and healthcare team can help the patient to problem-solve independently when they have been adequately prepared with the skills and knowledge needed for successful self-management. A discussion with patients on the risks of hypoglycaemia is essential to prepare them to recognise the signs and symptoms as well as appropriate treatment. It is important to proactively inform patients about the possibility of severe hypoglycaemic events (ie, events that need assistance by someone else), although the actual risk may be quite low. For example, a retrospective study of adults in the USA with well-controlled type 2 diabetes (n=31 542) found an overall unadjusted 2-year incidence of severe hypoglycaemia of 1.4%.8 Still, fear of hypoglycaemia is one of the most common reasons that patients refuse to start, or subsequently stop, insulin therapy.9, 10 Ideally, the care team would address specific patient fears about low blood sugar during both initial and ongoing insulin conversations. The risk for hypoglycaemic events may be higher and potentially more harmful in special populations like the frail, elderly, persons with end-stage renal disease, cardiovascular disease, autonomic neuropathy, dementia, hypoglycaemic unawareness and persons with comorbidities.11 Elderly patients using sulfonylureas combined with insulin are especially vulnerable to developing hypoglycaemia if they miss meals or have an interrupted meal schedule such as during an acute illness or hospitalisation. For those with an elevated risk of hypoglycaemia, the HCP team in close collaboration with the patient, should frequently review glycaemic values (set appropriate BG targets for treating hypoglycaemia), consider reducing or eliminating sulfonylureas, and adjust insulin dose and timing if needed. *Hypoglycaemia treatment recommendations for adults can be reviewed at the following links: http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/hypoglycemia-low-blood.html, http://spectrum.diabetesjournals.org/content/diaspect/27/1/58.full.pdf, http://care.diabetesjournals.org/content/suppl/2015/12/21/39.Supplement_1.DC2/2016-Standards-of-Care.pdf Patients are often apprehensive about gaining weight once they start insulin. When such concerns are raised, they should be addressed early in the conversation. HCPs should acknowledge their patients’ beliefs and fears and demonstrate their understanding by offering clear and concise explanations with possible solutions to mitigate concerns. Patients need to understand that insulin therapy is often associated with some weight gain as the body loses less glucose in the urine and begins to utilise and store glucose as an energy source. Patients should be reminded that what and how much they eat will also have an impact on the extent of weight gain. When available, a dietitian along with an exercise specialist or other trained personnel from the medical care team can help patients understand how to minimise weight gain by teaching and reinforcing healthy nutritional habits, portion control and the incorporation of increased amounts of physical activity in their daily lives. Healthcare professionals should ensure that patients receive training on SMBG, and work with their patients to develop realistic plans regarding frequency and timing of testing, target glucose goals, timing of injections and instructions on use of a simple insulin titration algorithm. Glycaemic targets should be set according to national or international guidelines (figure 1 in reference12). Furthermore, glycaemic targets may be individualised because of the following clinical considerations: patient ability, insulin sensitivity, comorbidities and the perceived risk of hypoglycaemia. During the titration period, patients should be encouraged to keep a glucose log and regularly check fasting glucose values and an occasional postprandial and bedtime glucose. Managing BG levels is a balancing act and patients should strive for progress rather than perfection. Glucose values are affected by many factors and patients must be informed that these variations are not the result of wrongdoing. If patients report that their BG tends to be low after certain activities or high after certain meals, it gives their care team an opportunity to discuss these effects and make treatment adjustments accordingly. SMBG values combined with an effective insulin titration algorithm can help patients assess their progress and provide them with positive reinforcement. SMBG analysis informs the HCP and the patient whether the insulin dose is adequate or needs to be further optimised. Lastly, structured SMBG allows patients to experience a “cause and effect” relationship between their glucose values, food intake, different levels of activity and insulin dosages.13 Diabetes management is a continuous process of learning and education and will empower patients with the knowledge they need to allow for confident self-management of their insulin therapy. Furthermore, it is imperative for patients to learn the benefits of organising their diabetes care in balance with the demands of daily life, which may include the consideration of the day's activities, meal timings, insulin storage, glucose monitoring and refilling prescriptions. Insulin titration can be done either by the patient or their healthcare team, depending on the patient's ability, willingness and motivation.14 Insulin titration is a necessary step in helping patients to reach their glycaemic goals, and patients have demonstrated in multiple studies that they can do this task as effectively as HCPs.15, 16 Titration algorithms that are simple, safe and effective, and can be customised and individualised by the HCP based on clinical considerations, are highly recommended.12 An example of an easy-to-use patient self-titration algorithm comes from the INSIGHT study17 where the dose of basal insulin is increased by 1 unit/day until the patient reaches target glucose values. When discussing the titration algorithm, it is helpful to involve and educate family members as well. Clear written instructions should be given to the patient and/or caregiver, and the patient or caregiver should be asked to repeat back to confirm understanding. In addition, we that the diabetes care team provide of BG values in the office that the patient can their insulin If the patient is to the appropriate the is to consider algorithms and if If the patient is or to use a self-titration algorithm, then they must be given a simple insulin to follow with instructions on when to the office for dose HCP access and is never more than during the early insulin initiation and titration Timely follow-up is a critical success and can be by the HCP or other members of the healthcare team. These may but should frequently in the initial of insulin can help patients make the between their BG levels and how they are feeling frequent If patients fail to make these the benefit of daily insulin potentially an sense of be lost on those new to insulin therapy. after insulin is started may from as as 1 day to 2 at The specific of should be based on the patient's or contact is important patients receive and appropriate it is not helpful for office staff to for patients to make a contact office 3 months once patients are on insulin treatment. glucose targets should be by the HCP and patients need to know when to and report their glucose values. If patients are with how their glucose levels are they should be encouraged to The office should identify the that will help to patient questions if the HCP is not available. Patients need timely to insulin questions and the that their care team will be there for them when they or as the first after starting insulin, HCPs can the of the insulin dose as well as the patient's to follow their treatment This also an opportunity to assess the patient's insulin technique and address any follow-up questions or concerns. The HCP can use the following for a patient's the for this the patient understand how and what they are the patient on the right the insulin need to be they in as and the they it time to A care team may include the diabetes and any family member or when This group should focus on the patient's needs and concerns and provide the necessary and The solutions including the insulin conversation, titration and can be one or more members of a medical team. The office staff can play an active role in patient management by appointment glucose into the medical insulin changes to patients and family members to be part of the care team. Office staff should schedule longer appointments for patients starting on insulin or their first follow-up such as a medical or community may be to patients how to use an insulin how to inject how to of and BG An office staff will feel more and if they as part of the care team, while some of the HCP's When a team approach for insulin initiation is not with community resources such as diabetes and diabetes can be a good Patients may or discontinue their insulin therapy more frequently than In this we the of effective insulin initiation, that patients can get off to a good start and will be more likely to on their treatment. It is that patients will achieve better glycaemic long-term complications and healthcare if we both the insulin conversation and the initiation process. As an example, may affect patients’ initiation experience and insulin Because lack of medication adherence is common to many chronic we that the practical tips in this may be helpful in a clinical related to the are at and also on the site The and of and for helpful and and of and for This study was by and and and the study and the to the and the and to the and the All the to be