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View from the clinic

Four steps I take when starting patients on insulin

Author: Jay Shubrook

I have always wanted to determine the source of my patients’ fear of insulin—Is it the needle? Is it the medication itself? Is it the fact that they will have to self-administer? Or is it, maybe, fear of accepting a long-term disease that they will have to live with and manage?

As discussed by Dr Young in his view from the clinic, psychological resistance to insulin therapy—whereby patients express concern or fear about starting insulin—is common, particularly once you’ve had the conversation about the need to start insulin.

Regardless of the reasons for fearing insulin, I knew, as a diabetologist, that insulin therapy would be central to my practice, and that my patients and I would need to find a way to overcome their anxiety about the treatment. In fact, I wanted my patients to develop a mindset that insulin could be relied upon to control their diabetes when other methods fail.

So, once I’ve determined that a patient under my care will benefit from insulin therapy, and the dust has settled on the conversation about initiating treatment, what next?

Below, I have summarized four of the approaches that I regularly use to reassure and empower patients that are starting insulin for the first time.

  • Use insulin as the first-line type 2 diabetes treatment in select patients (1 of 4)

    I typically employ this approach in individuals who are newly diagnosed with a glycated hemoglobin (HbA1c) of around 10% (86 mmol/mol; 240 mg/dL). Most people at this level of disease progression have both gluco- and lipotoxicity.

    There is no better first pharmacologic option than insulin to help patients regain control and start feeling better quickly. Moreover, in a vast majority of cases where this approach is taken, the patient can be taken off of insulin and allowed to “step down” from this therapy. In giving the news that they do not need insulin anymore, you provide a big psychological victory and allow the patient to reinforce that insulin use can be intermittent and not lifelong once it starts.

  • Ensure that the first injection is always administered under your care (2 of 4)

    The idea of sticking a sharp, steel object in one’s body is not comforting for many people. Left alone, this probably stops more than 50% from taking the first injection. However, if the patient gets their first injection in the office it will allow them to learn the correct technique and overcome common fears associated with pain and the ability to self-inject.

  • Take the first injection with the patient (3 of 4)

    In some situations, I will demonstrate the first injection (dry) on myself before the patient attempts the real thing. This approach is particularly effective with individuals who are very anxious; they will be able to see that I am able to calmly talk through the process as I inject, and see that their worst fears were not realized. They often will ask—“did that hurt?” Or “is that it?” This can go a long way toward conquering many of the fears the patient may be harboring.

  • Where necessary, forecast the need for insulin (4 of 4)

    I often give people choices in treatment. Let’s say we have a 48-year-old patient diagnosed with type 2 diabetes 2 years ago; his disease has progressed despite lifestyle interventions and metformin treatment. His HbA1c is now 11.3% (100 mmol/mol; 278 mg/dL).

    I would let the patient know that we have some options—we can either provide one medication for every 1% his HbA1c is above target, or we can start a basal insulin.

    I would let the patient know that my preference is to start insulin therapy; however, I would give them a voice in the decision-making process—if the patient is strongly in favor of taking three to four additional oral medications we can do this as an alternative. In such a case I would recommend close monitoring and short-term follow-up. If an improvement is observed with oral medications (based on fingerstick glucose monitoring results for the first month) we can continue with the plan but we will have insulin ready to rescue him if required.

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