Improving Insulin Adherence
Although insulin was discovered more than 75 years ago, this medical breakthrough is still vastly underutilized. A panel of diabetes experts addressed barriers to insulin therapy and offered strategies for improving adherence during a symposium at the American Diabetes Association’s 75th Scientific Sessions held in Boston this past June.
Perception and Behavior
M. Sue Kirkman, MD, professor of medicine, University of North Carolina, discussed insulin perception and patient and provider behavior. Studies have identified perceived barriers to insulin initiation and intensification among patients and heathcare providers. Patient barriers include impact on social life, weight gain, hypoglycemia, confidence in titrating dose, forgetting doses, need for multiple injections, and adherence. Physician barriers include time constraints, titration too complex for patients, lack of comfort with prescribing, and lack of support and resources.
One study1 examined patient (n=1530) and physician (n=1250) beliefs regarding insulin therapy and the degree to which patients adhere to insulin therapy. The researchers found that 33.2% of patients reported insulin omission/nonadherence at least 1 day per month, with average mean of 3.3 days. Among physicians, 72.5% reported that the typical patient does not take their insulin as prescribed, with a mean of 4.3 days a month for basal and 5.7 days a month for prandial insulin. The most common reasons for insulin omission/nonadherence for both study cohorts were too busy, traveling, skipped meals, stress or emotional problems, and embarrassing to inject in public. Furthermore, physicians were more dissatisfied with insulin therapy than patients. Both patients and physicians wanted fewer insulin injections and a flexible insulin regimen to fit patients’ lives.
“We need ongoing support and education definitely for our patients,” she said. “We need to get to the point where the patient and prescriber can say ‘we can do this.’”
Does insulin adherence decline with more injections?
“It is not definitively established in my opinion that insulin adherence declines with more frequent insulin injections, but it probably does,” said Ian Blumer, MD, medical advisor and director of the Charles H. Best Diabetes Centre. He said that more frequent injections may lead to lesser adherence due to modifiable factors, such as injection discomfort, inconvenience, and embarrassment.
“I think it is incumbent upon us [as healthcare providers] before we reflexively recommend less frequent injections to modify those factors, which are modifiable,” said Blumer. For select patients, less is more, he added, meaning that fewer injections, if based on an appropriate insulin regimen tailored to the individual’s unique needs, is better than persisting with a preferred but failing multiple daily injection approach.
Stewart B. Harris, MD, MPH, professor at the Schulich School of Medicine & Dentistry at the University of Western Ontario, shared strategies to demystify insulin therapy. “We are in a new era of insulin prescribing therapy where we have much safer insulins,” he said. “We need to move on to a more progressive and simplified patient-centered approach to insulin therapy, especially in type 2 diabetes.”
He said clinical practice guidelines encourage insulin therapy and offer algorithms for initiating, titrating, and adjusting insulin therapy.
Five steps to insulin therapy include:
1. Healthcare professionals should examine their own attitudes toward insulin, and recognize that insulin therapy can be tailored to the individual characteristics, needs, and preferences of patients during all stages of disease.
2. Healthcare professionals should convey positive attitudes toward insulin to their patients.
3. Safety and simplicity are key—start low, go slow.
4. Use a stepwise approaches to insulin intensification.
5. Empower patients with self-titration options; this is a fundamental tenet of diabetes management.
“Diabetes is complicated enough. If you can simplify anything for your patients—do it,” Harris concluded.
1.Peyrot M, Barnett AH, Meneghini LF, Schumm-Draeger PM. Insulin adherence behaviors and barriers in the multinational Global Attitudes of Patients and Physicians in Insulin Therapy study. Diabetes Med. 2012;29(5):682-689.