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A Productive Discussion on Insulin
| Author: Holly Schachner, MD, Pfizer Senior Medical Director |
| Article Date: 10/1/2007 |
A Productive Discussion on Insulin
Type 2 diabetes is a growing problem both in the United States and around the world with an estimated 230 million people globally suffering from diabetes.1 You may be seeing a similar growth in your own practice of people presenting with diabetes or at increased risk of diabetes and wondering how to manage the increasing number of patients.
According to the American Diabetes Association (ADA), well-controlled blood sugar is the cornerstone of effective diabetes management to help prevent the serious long-term micro- and macrovascular complications of diabetes and they recognize insulin as one of the most effective medications to control blood sugars.2,3 But despite this, studies have shown that insulin initiation may be delayed for as many as five to ten years4.
There are many reasons why the use of insulin is delayed, including peopleÕs fears of injections, fear of disease progression, social embarrassment and feelings of failure3. However, it is essential for physicians and patients to understand the pathophysiology of diabetes, the effect of diabetes on the body and why it is important to consider insulin early on as a treatment option.
In my experience as an endocrinologist, I often saw patients who were not fully aware about their type 2 diabetes and the role of insulin in the treatment of the disease. I sometimes had to have difficult conversations with patients about the need to add insulin to their treatment regimen when they were reluctant to do so. The following are some tips that I found helpful for having a more productive conversation with patients which helped them to feel more comfortable about deciding to take the next step on their treatment path to effectively manage and control their diabetes.
Educating Patients about the Progressive Nature of Diabetes
Many patients donÕt know that diabetes is a progressive disease.3 Despite their making lifestyle changes and already being on oral treatment, patientsÕ bodies will continue to produce less and less insulin3 .This is the nature of the disease and not anyoneÕs ÒfaultÓ. When a patientÕs hemoglobin A1C level begins to increase above the target level, doctors often consider introducing additional therapy, like insulin, in order to lower blood sugar levels.2
The patients you are considering for insulin therapy should be reassured that many others with type 2 diabetes also have experienced similar changes in their disease. In fact, approximately two out of three people with type 2 diabetes have uncontrolled blood sugars even if they are currently on treatment.3 Patients need to realize that type 2 diabetes is a complex disease and treatment regimens will be different based on each individualÕs needs.
There are many treatment options available to help patients with diabetes achieve lower blood sugar levels. Typically type 2 diabetes patients require multiple therapies to effectively reach and maintain optimal glucose control. Even a slight decrease in an A1C level can lead to significant reductions in risk of these complications4.
It may be helpful to discuss the pathophysiology of diabetes with patients at diagnosis and at subsequent visitsÐ and to explain that one of the main reasons their blood sugar is elevated is because their body can no longer effectively secrete enough insulin. Thus, treatment with insulin helps replace what their body is lacking. Eventually, diet and exercise and oral treatments may not be enough to control blood sugar levels and effectively manage a personÕs diabetes. For patients not controlled on oral agents, insulin allows for better A1C control.
The most common side effect of insulin that patients need to be aware of is low blood sugar (hypoglycemia), which can range from mild to severe and that they will need to check their blood levels as advised by you. Symptoms of hypoglycemia include shakiness, sweating, dizziness, hunger, and difficulty paying attention5. Hypoglycemia may be more likely to occur if insulin is taken in the face of increased exercise or decreased food intake. Patients can learn how to adjust their insulin doses to accommodate for changes in their daily food intake, level of exercise, etc, and thus minimize the risk of hypoglycemia.1
Insulin as part of a diabetes treatment regimen can lead to good A1C control when itÕs used in the appropriate type and dosed as designated by a physician. You may want to remind patients of the goals of their treatment -- to control their blood sugars, which may help reduce long-term diabetes complications.
Educating Patients about Insulin Treatment Options [
Once you have the initial conversation with your type 2 diabetes patients about introducing insulin to their treatment regimen, it is important to also provide them with some information about insulin and insulin types that might be best to treat their condition.
Types of Insulin5, 6, 7
There are different types of insulin that can be used depending on various factors such as an individualÕs A1C levels, response to insulin, age, lifestyle choices and diabetes management style. Below are the various types of insulin and how quickly and long they work, which can vary depending upon the specific brand prescribed.
Insulin Delivery Methods9
Syringes: Syringes are the most common method of insulin delivery. Insulin gets injected into the subcutaneous tissue using hypodermic needles that are small and disposable. Needles come in various thickness and lengths, and the syringes come in varying unit sizes depending on an individualÕs specific insulin requirements. To fill the syringe with the appropriate insulin dose, the patient must insert the needle into a vial of insulin and draw up the appropriate dose.
Pens: Insulin pens resemble a thick desk pen with a cartridge that contains insulin. A pen needle must be attached at each use and an individual must dial the dose of units, rather than drawing it out of a vial like use with a syringe. Pen needles also come in various sizes, just like syringes. Some pens use replaceable cartridges of insulin; other models are totally disposable after the pre-filled cartridge is empty.
Jet Injectors: Jet injectors use a mechanism which produces high-pressure air to deliver a fine spray of insulin through the skin. Jet injectors have no needles. The high pressure causes the insulin to turn into a vapor and subcutaneously penetrate the skin.
Insulin Pumps: An insulin pump is a small device worn outside your body that is connected with flexible tubing to a catheter located under the skin. The catheter site can be worn on the abdomen, leg or buttocks. The pump is worn 24 hours a day to provide continuous variable doses of insulin throughout the day The pump is able to be programmed to deliver a steady stream of insulin (basal rate) as well as give bolus doses to correct high blood sugar (hyperglycemia) or to cover meals (bolus or prandial dose). The pump allows for tighter control of blood sugar levels without multiple injections as well as allows very small increments of insulin to be delivered.
Inhaled Insulin: Currently, there is one FDA-approved inhaled insulin. It is a mealtime insulin, taken using a specially designed inhaler. A foil blister contains a pre-measured dose of insulin and an inhaler device releases the insulin for inhalation. A blister of the inhaled insulin is inserted into the special inhaler, a patient pumps the inhaler and presses a button causing the insulin to be released in a cloud into the chamber. They then breathe in normally through the mouth, sending the insulin into the lungs, where it is rapidly absorbed into the bloodstream and circulated to cells throughout the body, and it works similar to other rapid-acting insulins to help reduce blood sugar levels. All type 1 diabetes patients and some type 2 diabetes patients will have to take some longer-acting injected insulin in addition to inhaled insulin.
Additional Resources to Help Patients with Their Insulin Therapy
After your initial conversation with your patients about their diabetes and insulin, they may have additional questions or be nervous about starting their new treatment. Below are some additional resources for your patients that you can suggest.
Diabetes Educators10
As you are aware, diabetes educators can be a great resource for your patients who have additional questions or concerns about their diabetes or beginning treatment with insulin. You may have a diabetes educator in your office, or there may be one who works at a local hospital, who could be very helpful in further educating your patients about the progressive nature of diabetes and insulinÕs role in diabetes treatment.
Local Support Groups11
Patients may benefit from participating in a support group for people with diabetes to discuss their own experiences and relate to other patientsÕ experiences with the disease and treatments. You may already be aware of local support groups in your area, but if not, the ADA website HYPERLINK 'http://www.diabetes.org' www.diabetes.org has a list of local groups and events, as well as a number that your patients can call for more information: 1-800-DIABETES.
Online Resources
In addition to the ADA website, there is a wealth of information about diabetes and insulin to which you can direct your patients online. These sites include those from physician and patient organizations, such as the ADA, the National Diabetes Information Clearinghouse, and the National Diabetes Education Program, along with sites specific to the type of insulin your patients may be taking. Many of these websites not only provide additional information for patients, but also additional resources and support materials to help them effectively manage and control their diabetes through the use of insulin.
Ultimately, initiating insulin in patientsÕ diabetes treatment plans can help them gain control of their blood sugar. As a physician, it is essential for you to make sure that your patients understand the important role of insulin in diabetes treatment Blood sugars that are in control may reduce the longer-term diabetes complications3. You should emphasize to patients that insulin is not a punishment.
Educating individuals with diabetes is crucial to their partnership with you to seek optimal blood glucose control and may help them understand and accept insulin therapy. They must understand their diabetes, the role that insulin may play in their treatment and the benefits that it can have on their blood sugar levels. Insulin can be an important step towards good diabetes management.
Hopefully, the information and resources addressed in this article will help you to have a productive discussion with your patients on type 2 diabetes progression, the importance of good glucose control, and the role of insulin. While these conversations can often be difficult at first, once patients understand the benefits of improved blood sugar control and how insulin can be effective at lowering their blood sugars, they are more likely to understand the importance of treatment options, such as insulin.
1. World Health Organization. ÒUnite for Diabetes.Ó Available at http://www.unitefordiabetes.org/assets/files/About_diabetes.pdf
2. Polonsky W.H. Psychological insulin resistance in patients with type 2 diabetes. Diabetes Care. 2005. 28:2543-2545.
3. Brown J, Nichols G, Perry A. The burden of treatment failure in type 2 diabetes. Diabetes Care. 2004; 27:1535-1540. .
4. Diabetes Care. ÒImplications of the UK Prospective Diabetes Study.Ó 26: S28-S32, 2003.
5. American Diabetes Association. ÒHypoglycemia.Ó Available at HYPERLINK 'http://www.diabetes.org/type-1-diabetes/hypoglycemia.jsp' http://www.diabetes.org/type-1-diabetes/hypoglycemia.jsp.
6. American Diabetes Association. ÒAbout Insulin-Other Drugs.Ó Available at HYPERLINK 'http://www.diabetes.org/type-1-diabetes/insulin.jsp' http://www.diabetes.org/type-1-diabetes/insulin.jsp
7. American Diabetes Association. ÒTypes of Insulin.Ó Available at HYPERLINK 'http://diabetes.org/type-1-diabetes/basics.jsp' http://diabetes.org/type-1-diabetes/basics.jsp
8. The Food and Drug Administration ÒTypes of Insulin.Ó Available at http://www.fda.gov/fdac/features/2002/chrt_insulin.html
9. Food and Drug Administration. ÒInsulin Delivery Methods.Ó Available at HYPERLINK 'http://www.fda.gov/diabetes/insulin.html' www.fda.gov/diabetes/insulin.html
10. American Association of Diabetes Educators. Available at HYPERLINK 'http://www.aadenet.org' www.aadenet.org
11. American Diabetes Association. ÒCommunity Programs.Ó Available at HYPERLINK 'http://www.diabetes.org/community programs-and-localevents.jsp' www.diabetes.org/community programs-and-localevents.jsp
Type 2 diabetes is a growing problem both in the United States and around the world with an estimated 230 million people globally suffering from diabetes.1 You may be seeing a similar growth in your own practice of people presenting with diabetes or at increased risk of diabetes and wondering how to manage the increasing number of patients.
According to the American Diabetes Association (ADA), well-controlled blood sugar is the cornerstone of effective diabetes management to help prevent the serious long-term micro- and macrovascular complications of diabetes and they recognize insulin as one of the most effective medications to control blood sugars.2,3 But despite this, studies have shown that insulin initiation may be delayed for as many as five to ten years4.
There are many reasons why the use of insulin is delayed, including peopleÕs fears of injections, fear of disease progression, social embarrassment and feelings of failure3. However, it is essential for physicians and patients to understand the pathophysiology of diabetes, the effect of diabetes on the body and why it is important to consider insulin early on as a treatment option.
In my experience as an endocrinologist, I often saw patients who were not fully aware about their type 2 diabetes and the role of insulin in the treatment of the disease. I sometimes had to have difficult conversations with patients about the need to add insulin to their treatment regimen when they were reluctant to do so. The following are some tips that I found helpful for having a more productive conversation with patients which helped them to feel more comfortable about deciding to take the next step on their treatment path to effectively manage and control their diabetes.
Educating Patients about the Progressive Nature of Diabetes
Many patients donÕt know that diabetes is a progressive disease.3 Despite their making lifestyle changes and already being on oral treatment, patientsÕ bodies will continue to produce less and less insulin3 .This is the nature of the disease and not anyoneÕs ÒfaultÓ. When a patientÕs hemoglobin A1C level begins to increase above the target level, doctors often consider introducing additional therapy, like insulin, in order to lower blood sugar levels.2
The patients you are considering for insulin therapy should be reassured that many others with type 2 diabetes also have experienced similar changes in their disease. In fact, approximately two out of three people with type 2 diabetes have uncontrolled blood sugars even if they are currently on treatment.3 Patients need to realize that type 2 diabetes is a complex disease and treatment regimens will be different based on each individualÕs needs.
There are many treatment options available to help patients with diabetes achieve lower blood sugar levels. Typically type 2 diabetes patients require multiple therapies to effectively reach and maintain optimal glucose control. Even a slight decrease in an A1C level can lead to significant reductions in risk of these complications4.
It may be helpful to discuss the pathophysiology of diabetes with patients at diagnosis and at subsequent visitsÐ and to explain that one of the main reasons their blood sugar is elevated is because their body can no longer effectively secrete enough insulin. Thus, treatment with insulin helps replace what their body is lacking. Eventually, diet and exercise and oral treatments may not be enough to control blood sugar levels and effectively manage a personÕs diabetes. For patients not controlled on oral agents, insulin allows for better A1C control.
The most common side effect of insulin that patients need to be aware of is low blood sugar (hypoglycemia), which can range from mild to severe and that they will need to check their blood levels as advised by you. Symptoms of hypoglycemia include shakiness, sweating, dizziness, hunger, and difficulty paying attention5. Hypoglycemia may be more likely to occur if insulin is taken in the face of increased exercise or decreased food intake. Patients can learn how to adjust their insulin doses to accommodate for changes in their daily food intake, level of exercise, etc, and thus minimize the risk of hypoglycemia.1
Insulin as part of a diabetes treatment regimen can lead to good A1C control when itÕs used in the appropriate type and dosed as designated by a physician. You may want to remind patients of the goals of their treatment -- to control their blood sugars, which may help reduce long-term diabetes complications.
Educating Patients about Insulin Treatment Options [
Once you have the initial conversation with your type 2 diabetes patients about introducing insulin to their treatment regimen, it is important to also provide them with some information about insulin and insulin types that might be best to treat their condition.
Types of Insulin5, 6, 7
There are different types of insulin that can be used depending on various factors such as an individualÕs A1C levels, response to insulin, age, lifestyle choices and diabetes management style. Below are the various types of insulin and how quickly and long they work, which can vary depending upon the specific brand prescribed.
Insulin Delivery Methods9
Syringes: Syringes are the most common method of insulin delivery. Insulin gets injected into the subcutaneous tissue using hypodermic needles that are small and disposable. Needles come in various thickness and lengths, and the syringes come in varying unit sizes depending on an individualÕs specific insulin requirements. To fill the syringe with the appropriate insulin dose, the patient must insert the needle into a vial of insulin and draw up the appropriate dose.
Pens: Insulin pens resemble a thick desk pen with a cartridge that contains insulin. A pen needle must be attached at each use and an individual must dial the dose of units, rather than drawing it out of a vial like use with a syringe. Pen needles also come in various sizes, just like syringes. Some pens use replaceable cartridges of insulin; other models are totally disposable after the pre-filled cartridge is empty.
Jet Injectors: Jet injectors use a mechanism which produces high-pressure air to deliver a fine spray of insulin through the skin. Jet injectors have no needles. The high pressure causes the insulin to turn into a vapor and subcutaneously penetrate the skin.
Insulin Pumps: An insulin pump is a small device worn outside your body that is connected with flexible tubing to a catheter located under the skin. The catheter site can be worn on the abdomen, leg or buttocks. The pump is worn 24 hours a day to provide continuous variable doses of insulin throughout the day The pump is able to be programmed to deliver a steady stream of insulin (basal rate) as well as give bolus doses to correct high blood sugar (hyperglycemia) or to cover meals (bolus or prandial dose). The pump allows for tighter control of blood sugar levels without multiple injections as well as allows very small increments of insulin to be delivered.
Inhaled Insulin: Currently, there is one FDA-approved inhaled insulin. It is a mealtime insulin, taken using a specially designed inhaler. A foil blister contains a pre-measured dose of insulin and an inhaler device releases the insulin for inhalation. A blister of the inhaled insulin is inserted into the special inhaler, a patient pumps the inhaler and presses a button causing the insulin to be released in a cloud into the chamber. They then breathe in normally through the mouth, sending the insulin into the lungs, where it is rapidly absorbed into the bloodstream and circulated to cells throughout the body, and it works similar to other rapid-acting insulins to help reduce blood sugar levels. All type 1 diabetes patients and some type 2 diabetes patients will have to take some longer-acting injected insulin in addition to inhaled insulin.
Additional Resources to Help Patients with Their Insulin Therapy
After your initial conversation with your patients about their diabetes and insulin, they may have additional questions or be nervous about starting their new treatment. Below are some additional resources for your patients that you can suggest.
Diabetes Educators10
As you are aware, diabetes educators can be a great resource for your patients who have additional questions or concerns about their diabetes or beginning treatment with insulin. You may have a diabetes educator in your office, or there may be one who works at a local hospital, who could be very helpful in further educating your patients about the progressive nature of diabetes and insulinÕs role in diabetes treatment.
Local Support Groups11
Patients may benefit from participating in a support group for people with diabetes to discuss their own experiences and relate to other patientsÕ experiences with the disease and treatments. You may already be aware of local support groups in your area, but if not, the ADA website HYPERLINK 'http://www.diabetes.org' www.diabetes.org has a list of local groups and events, as well as a number that your patients can call for more information: 1-800-DIABETES.
Online Resources
In addition to the ADA website, there is a wealth of information about diabetes and insulin to which you can direct your patients online. These sites include those from physician and patient organizations, such as the ADA, the National Diabetes Information Clearinghouse, and the National Diabetes Education Program, along with sites specific to the type of insulin your patients may be taking. Many of these websites not only provide additional information for patients, but also additional resources and support materials to help them effectively manage and control their diabetes through the use of insulin.
Ultimately, initiating insulin in patientsÕ diabetes treatment plans can help them gain control of their blood sugar. As a physician, it is essential for you to make sure that your patients understand the important role of insulin in diabetes treatment Blood sugars that are in control may reduce the longer-term diabetes complications3. You should emphasize to patients that insulin is not a punishment.
Educating individuals with diabetes is crucial to their partnership with you to seek optimal blood glucose control and may help them understand and accept insulin therapy. They must understand their diabetes, the role that insulin may play in their treatment and the benefits that it can have on their blood sugar levels. Insulin can be an important step towards good diabetes management.
Hopefully, the information and resources addressed in this article will help you to have a productive discussion with your patients on type 2 diabetes progression, the importance of good glucose control, and the role of insulin. While these conversations can often be difficult at first, once patients understand the benefits of improved blood sugar control and how insulin can be effective at lowering their blood sugars, they are more likely to understand the importance of treatment options, such as insulin.
1. World Health Organization. ÒUnite for Diabetes.Ó Available at http://www.unitefordiabetes.org/assets/files/About_diabetes.pdf
2. Polonsky W.H. Psychological insulin resistance in patients with type 2 diabetes. Diabetes Care. 2005. 28:2543-2545.
3. Brown J, Nichols G, Perry A. The burden of treatment failure in type 2 diabetes. Diabetes Care. 2004; 27:1535-1540. .
4. Diabetes Care. ÒImplications of the UK Prospective Diabetes Study.Ó 26: S28-S32, 2003.
5. American Diabetes Association. ÒHypoglycemia.Ó Available at HYPERLINK 'http://www.diabetes.org/type-1-diabetes/hypoglycemia.jsp' http://www.diabetes.org/type-1-diabetes/hypoglycemia.jsp.
6. American Diabetes Association. ÒAbout Insulin-Other Drugs.Ó Available at HYPERLINK 'http://www.diabetes.org/type-1-diabetes/insulin.jsp' http://www.diabetes.org/type-1-diabetes/insulin.jsp
7. American Diabetes Association. ÒTypes of Insulin.Ó Available at HYPERLINK 'http://diabetes.org/type-1-diabetes/basics.jsp' http://diabetes.org/type-1-diabetes/basics.jsp
8. The Food and Drug Administration ÒTypes of Insulin.Ó Available at http://www.fda.gov/fdac/features/2002/chrt_insulin.html
9. Food and Drug Administration. ÒInsulin Delivery Methods.Ó Available at HYPERLINK 'http://www.fda.gov/diabetes/insulin.html' www.fda.gov/diabetes/insulin.html
10. American Association of Diabetes Educators. Available at HYPERLINK 'http://www.aadenet.org' www.aadenet.org
11. American Diabetes Association. ÒCommunity Programs.Ó Available at HYPERLINK 'http://www.diabetes.org/community programs-and-localevents.jsp' www.diabetes.org/community programs-and-localevents.jsp