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Barriers toward insulin therapy in T2DM

Barriers toward insulin therapy in T2DM. Poor glycaemic control is a risk factor for the development of diabetes-specific complications in diabetic patients. Many T2DM require insulin therapy after several years of disease duration in order to maintain

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Barriers toward insulin therapy in T2DM

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  1. Barriers toward insulin therapy in T2DM

  2. Poor glycaemic control is a risk factor for the • development of diabetes-specific complications • in diabetic patients. • Many T2DM require insulin therapy after several • years of disease duration in order to maintain • good glycemic control and prevent complications. • But many T2DM do not receive insulin therapy in a • timely manner because of a negative appraisal of this • treatment option. Kulzer B. Diabetes. 2004: 53: A438-A439.

  3. Patients’ negative attitudes towards starting insulin • therapy are based on their beliefs that the need for • insulin therapy indicates a greater severity of the • disease and proves their failure to self-manage • the diabetes adequately. • Snoek FJ. Health Qual Life Outcomes. 2007: 5:69.

  4. This phenomenon is called psychological insulin resistance . Polonsky WH.Diabetes Care 2005, 28:2543-2545.

  5. Data from the UK have shown that patients may typically delay the initiation of insulin by around 8 years despite poor glycemic control . Calvert MJ, et.al. Br J Gen Pract 2007, 57:455-460.

  6. There were also substantial reductions in cumulative incidence and time to onset of all diabetes-related complications with immediate versus delayed insulin initiation. Gordon Goodall , et al . BMC Endocrine Disorders 2009, 9:19.

  7. DCCT: Relationship of HbA1c to risk of microvascular complications Retinopathy 15 Nephropathy 13 11 9 Neuropathy Relative Risk 7 5 Microalbuminuria 3 1 6 7 8 9 10 11 12 HbA1c (%) Skyler JS. Endocrinol Metab Clin. 1996;25:243–254.

  8. To achieve tight glycemic control in T2DM, it may • be advantageous to introduce insulin therapy much • earlier in the disease course. • Unfortunately, many patients are reluctant to begin insulin and may delay starting insulin therapy for significant periods of time. Okazaki K, et.al. Diabetes 48 (Suppl.1):A319, 1999.

  9. Delayed initiation of subcutaneous insulin therapy after failure of oral glucose-lowering agents (OGLAs) in T2DM patients in the UK • Insulin-naïve patients failing on OGLAs, which collects records from general practices throughout the UK. • Retrospective cohort study • Estimate the time to insulin initiation in patients with • T2DM inadequately controlled on oral glucose- • lowering.

  10. 25% of patients had insulin initiation delayed for at • least 1.8 years • 50% of patients delayed starting insulin for 5 years • after failure of OGLA poly therapy, even in the • presence of diabetes-related complications. Diabet Med. 2007 Dec;24(12):1412-8.

  11. prevalence of insulin refusal amongst Singaporean patients with Type 2 diabetes mellitus • Cross-sectional interviewer-administered survey , 265 patients . • Refuse to use insulin (70.6%). • A tertiary level of education was associated with • willingness to use insulin . Diabet. Med. 28, 206–211 (2011).

  12. Prevalence and reasons for insulin refusal in Bangladeshi patients with poorly controlled T2 DM 212 Bangladeshi with poor glycemic control on maximum OHA • 57.5% commenced insulin immediately, 22.1% started insulin within 6 months and 20.3% refused to commence insulin despite repeated counselling. Diabet Med. 2008 Sep;25(9):1108-11.

  13. Most subjects reported several reasons for avoiding insulin, rather than just one. • Patients may associate insulin therapy with a sense • of personal failure due to common physician • practice, where the possibility of insulin therapy • may be used to motivate better glycemic control . Polonsky WH.Clinical Diabetes 2004:22,147-150.

  14. To overcome these psychological barriers to insulin treatment, first it is necessary to identify these barriers in specific patients in order to decide which interventions are appropriate. • Thus, a well-validated diagnostic tool may be helpful • to identify specific obstacles against the initiation of • insulin treatment.

  15. Barriers to Insulin Treatment Questionnaire( BIT) • Scale 1 :Fear of injections and self-testing • Scale 2 :Expectations regarding negative insulin-related • outcomes • Insulin works worse than pills. • People who get pills feel better. • Insulin can cause long-term complications. • Scale 3 :Expected hardship from insulin therapy • Scale 4 :Stigmatization by insulin injections • Scale 5 : Fear of hypoglycemia and permanent • damage to my health FRANK PETRAK . Diabetes Care .2007:30:2199–2204,

  16. Scale 4 “Stigmatization by insulin injections • Injections in public are embarrassing to me. Pills • are more discreet. • Feelings of dependence. • When people inject insulin, it makes them feel like • drug addicts.

  17. The literatures showed that resistance to initiate insulin may be impacted by patients’ beliefs and knowledge about diabetes and insulin. Qual Life Res (2009) 18:23–32.

  18. Lack of knowledge about diabetes and insulin therapy or erroneous beliefs and misconceptions about the disease and treatment contribute to PIR. • Some patients believe that insulin, rather than diabetes, • causes serious health problems and severe or chronic • complications, such as amputation, heart attack, or • possibly blindness and even death . Funnell, M. M. Clinical Diabetes. 2007: 25, 36–38.

  19. Patients may also perceive that insulin is for more severe disease and/or that insulin initiation means that they are becoming ‘‘more ill,’’ their disease has dramatically progressed and become more serious, or that they are at the ‘‘end of the road’’. Polonsky, W. H, et.al. Clinical Diabetes. 2004: 22, 147–150.

  20. Negative self-perceptions and attitudinal barriers • Feelings of guilt • Unable to control the disease in the future • Insulin is a threat, resulting in anger , • because patients may feel unfairly punished for • poor self-care.

  21. Women have been found to be more unwilling • than men (P < 0.001) to initiateinsulin therapy . • It was shown that women are also more likely to perceive insulin as punishment, whereas men view insulin more as a form of treatment that may help them .

  22. Fear of injections’’ consists of multiple components • Technical concerns • Fear that injections will be painful • Fear of inflicting self-harm • Fear of self-injecting • General anxiety • Needle phobia

  23. Lifestyle adaptations and restrictions • Patients may have concerns that insulin adds to the burden and stress that they already experience from managing diabetes on a daily basis ,and do not feel confident that they can handle the day-to-day demands of insulin therapy. • It cause a loss of personal freedom that will severely • restrict their lives and be too inconvenient, time- • consuming, and complex to manage may also facilitate • PIR. It adversely affecting independence and lifestyle . Funnell, M. MClinical Diabetes . 2007: 25, 36–38.

  24. Fear of side effects/complications • Patients may experience PIR as the result of misconceptions regarding their disease, so that they attribute complications of diabetes to insulin use rather than insufficient glycemic control . • patients also worry about potential side effects and • complications, such as weight gain, hypoglycemia, • which may be due to insulin use. Polonsky, W. H. Diabetes Care1994:17, 1178–1185.

  25. Hypoglycemia and weight gain are the most common side effects leading to PIR. • For those who are already overweight the prospect of • further weight gain can, therefore, be a major barrier • to both the initiation and the intensification of insulin • for both patients and health care providers.

  26. Insulin omission was found in 1/3 women of all ages with T1DM, with approximately half of the them reporting omitting insulin for weight-management purposes . • Increased weight in T2DM is associated with • increased insulin resistance, so may compromise the • efficacy of treatment ,thus reinforcing the belief that • insulin is not good for one’s health. Polonsky, W. H. Diabetes Care1994:17, 1178–1185.

  27. Fear of hypoglycemia can also be a major barrier to • achieving optimal glycemic control. • In the attempt to avoid episodes, people with diabetes may modify their maintenance of glycemic levels especially during work or school hours . • Hypoglycemia can give rise to high insecurity; the • thought of future episodes can cause fearful and • disturbed feelings.

  28. Social stigma • It is not surprising that social stigma plays a key • role in PIR because vials and syringes carry a • strong negative connotation and are usually • identified with either IV drug addicts or severe • illness . It cause social embarrassment and social • rejection.

  29. Persons with DM often hide their injections to • avoid disturbing other people. • Thus, the fear of social stigma when injecting in public may impact adherence to treatment, as the absence of a private area in which to inject may result in either injecting too early or, in some cases, the omission of an injection. • Fears that use of syringes would damage their • relationships with others or that taking insulin • will result in family members and friends treating • them differently .

  30. This may lead to a lack of motivation due to the inconvenience and embarrassment related to injections, patients selecting suboptimal locations to inject themselves while away from home, such as in public toilets, and may also cause some patients to delay injections and avoid social activities .

  31. PIR and diabetes management • For any treatment to be optimally efficacious, it must be initiated, be properly dose-adjusted over time, and treatment compliance must be achieved. PIR may be one of the major etiologies explaining both the reluctance of patients to initiate and to intensify treatment .

  32. All components of PIR can interfere not only with the initiation of insulin treatment, but also with attempts to intensify and increase compliance with insulin therapy in individuals who are already using insulin .

  33. Physicians have also been shown to experience PIR for their patients. • Doubts about a patient’s compliance with treatment, • Fears of hypoglycemia • Weight status, • Impressions based on previous physician experience • with insulin, • Concerns about the patient’s age, • Perception that the disease is so severe that even • insulin would not help the patient Nakar, S., et.al. Journal of Diabetes and its Complications.2007: 21(4), 220–226.

  34. Overcoming Barriers to the Initiation of Insulin Therapy

  35. Patient concerned with pain from injection • Use of insulin pens • Minimal with thinner, smaller needles

  36. Patient worried that starting insulin signifies worsening diabetes • Taking insulin will control blood glucose and help prevent complications • Diabetes is a progressive disease • Taking insulin may slow down the rate of beta • cell failure

  37. Patient believes that need for insulin signifies patient failure to follow treatment regimen • beta cell activity declines over time Not related to patient compliance • Diabetes is a progressive disease

  38. Patient fears low blood sugar reactions • Use of insulin pens • Explain that severe hypoglycemia is rare in type 2 • diabetes • Self-monitoring glucose levels • Explain how to avoid and how to treat hypoglycemia

  39. Patient concerned that taking insulin will upset daily routine • Address specific concerns • Taking insulin may be less intrusive than complicated • drug regimens

  40. Patient believes that insulin will decrease his/her quality of life • Benefits from glucose control: more energy, better sleep, overall well-being

  41. Patient thinks insulin will lead to diabetic complications • Discuss role of insulin in reducing risk of diabetic complications

  42. Patient concerned that he/she will be treated differently by friends and family • Educate friends and family

  43. Patient has heard insulin causes weight gain • Role of diet and exercise

  44. Patient wants a more natural alternative therapy • Insulin is the most natural therapy for diabetes. It is replacing the hormone that the patient does not make enough of. Brunton, S.J Fam Pract 2005; 54:445.

  45. Implications of new insulin TX for PIR • There are new modern insulin analogs and more • discreet delivery systems (pen, inhaled, pump) available • which have the potential to decrease PIR and improve • treatment outcomes. • The use of a new pen system may help patients to overcome the embarrassment issues that are commonly associated with using a vial and syringe in public. • These treatment advances may help to eliminate or • reduce many of the key factors that contribute to • PIR, namely, social stigma, and fear of side effects. Korytkowski, M.2005:p27(Suppl B), S89–S100.

  46. Overcome problems with insulin dosing errors and • low adherence. This was recently demonstrated in • a study of patients with type 2 diabetes treated in a • managed care setting who switched from the • administration of insulin by vial/syringe to a prefilled • insulin pen device . • These pen overcome issues of needle anxiety and the social embarrassment associated with self-injection . • Following the switch, the patients demonstrated • improved medication adherence, fewer hypoglycemic • events, reduced emergency department and physician • visits, and lower annual treatment costs . Lee, W. C., et.al.Clinical Therapeutics, 2006, 28(10), 1712–1725. 1710–1711.

  47. Incidence of hypoglycemia is reduced using modern long-acting insulin analogs (detemir and insulin glargine) compared with human intermediate-acting insulin (NPH insulin). Hermansen, K., et.al. Diabetes Care. 2006 :29(6).1269-1274.

  48. Modern insulin analogs and pen systems offer the promise of novel insulin treatment with improved technological features.

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