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Patient Compliance with Insulin Therapy

Adherence to a prescribed insulin regimen is a common problem. About 78% of diabetics have either low to medium adherence to their insulin regimens. Non-adherence can be caused by any one of the following factors:

Insulin non-adherence

  due to number of daily injections

  embarrassment

  feeling worse after injecting

  forgetting to inject

  injection site pain

  perception that it is too time-consuming

  weight gain

 

Insulin and Type 2 Diabetes
 Many patients who have type 2 diabetes may eventually fail to meet the target A1c level and maintain glycemic control, and because damage to beta-cells is progressive, insulin therapy may eventually be needed. Insulin can help the patient attain glycemic control but as with any diabetic therapy, there are benefits and risks. Insulin therapy increases the risk for hypoglycemia, and because insulin resistance and associated hyperinsulinemia are part of the pathophysiology of type 2 diabetes, exogenous insulin increases insulin levels and may cause weight gain, hypoglycemia, increase the risk of developing metabolic syndrome, and worsen the level of insulin resistance.

The barriers that prevent early and effective use of insulin and adherence to insulin therapy in patients who have type 2 diabetes are significant, but can be overcome. Key points for patient education should include:

The disease will likely progress over time:

  Without insulin some patients may fail to meet target A1C

     -Many patients fail oral medications and should be reminded that diabetes, in many cases for reasons that cannot be controlled, is a progressive disease.

 

  Insulin may eventually be needed with disease progression

     -Diabetes patients may need insulin if other therapies fail to maintain glycemic control as insulin production by the pancreas declines.

 

  Insulin has many unique benefits

     -Insulin has many benefits: Patients who have type 2 diabetes and need insulin should be told that insulin provides benefits that are not available from oral anti-hyperglycemics. The primary benefit is a more effective way of controlling blood sugar and reduces the risk of diabetic complications. Insulin is also more effective than the oral anti-hyperglycemics at lowering HbA1c.

 

  Insulin use is not always permanent

     -Insulin therapy is not always permanent: Some patients may need insulin for only brief periods of time.

 

  Injecting insulin is fairly painless

     -The needles used to inject insulin are very fine, making injections less painful than in previous years.

 

  Insulin therapy may reduce the risk for future complications

     -Insulin therapy is not complicated and a majority of patients quickly learn that using insulin and monitoring blood sugar levels is a simple process. Also,

     -Insulin therapy can free up the patient from concerns about future complications while providing more control of the disease.

 

Insulin as the First Choice for Therapy for Type 2 Diabetes

If the patient shows signs of catabolism where their A1c is >10% or the blood glucose is >300mg/dL, the immediate implementation of insulin therapy should be considered to attain normoglycemia (thereby reducing the risk for pancreatic beta-cell dysfunction). Metformin should also be considered at this time alongside the insulin, and for the patient who has ketonuria but no weight loss, a GLP-1 agonist or insulin can be used. And for the patient who may have difficulty with insulin therapy a sulfonylurea can be started now, as well.

 

And there is evidence to show that short-term insulin therapy started soon after the initial diagnosis of type 2 diabetes can reverse beta-cell dysfunction, decrease insulin resistance, and preserve beta-cell function, and it can produce long-lasting hypoglycemic control and drug-free remission. There is also considerable research and clinical experience that supports the effectiveness of this approach, but the extreme difficulty in identifying patients that will benefit from this are barriers to its use, and so it has not been widely used.

 

Patient Compliance with Oral Medications

Let's take a moment to discuss common oral medications that may be used to help achieve glycemic control in patients with type 2 diabetes. Adherence to a prescribed oral medication regimen, or combination injectable and oral treatments, is a common problem. 45% of patients with type 2 diabetes do not achieve glycemic control and medication adherence is a major factor. This is due to several factors both patient-related and those outside of their control.

Many non-patient reasons are associated with non-adherence, including:

  health care systems that are not coordinated/integrated with other health care centers in the area

 

Patient characteristics associated with non-adherence

  lower age, educational level, income level

  perceptions about treatments

  perceived burden to obtain and take medications (costs, complexity)

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