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02-06-2018 | Insulin | View from the clinic | Article

When you need to have a conversation with your patient about starting insulin...

Author: Clipper Young

As a clinician and diabetes educator who works with diabetes patients to manage their condition, when reviewing patient profiles, I frequently find myself in search of a better approach to starting the conversation on initiating insulin. For clinicians, insulin initiation might mean sending a few more prescriptions to the pharmacy and educating patients on proper injection techniques, the side effects of insulin, and treatment for hypoglycemia, as well as monitoring blood glucose control. However, for patients, adding insulin to their current diabetes medication regimens might lead them to think that they have failed in some way in managing their condition, that they are at fault despite being adherent to their oral antidiabetic medications, or that they have lost control over their lives.

As healthcare professionals, we have a unique role in educating patients on the nature of medical conditions

In the case of patients with newly diagnosed diabetes, we might want to share the message that diabetes is a progressive condition, so the need to ultimately start insulin is not a reflection of them personally, but an expected progression of the condition. The essence of this conversation is to help patients psychologically adjust to the idea of having insulin to help optimize glycemic control.

The psychological adjustment in patients’ minds is particularly important 

Some patients might have developed what is called psychological insulin resistance, resisting the idea of initiating insulin therapy due to misconceptions and unwarranted fears. Psychological insulin resistance can be observed in all ethnicities, genders, and age groups, making therapy intensification rather difficult. However, there are a few steps, outlined below, that healthcare professionals could consider integrating into daily practice when facing such resistance from patients.

Exhibiting empathy by identifying patients’ concerns and thoughts on insulin therapy

  • A few sample questions that can be used to assess patients’ attitudes toward insulin therapy are provided below.
    • When thinking about starting insulin, what does it mean to you?
    • What worries you the most about insulin therapy?
    • How can we help you to start insulin therapy?

Demystifying misconceptions arising from incomplete information

  • Initiating insulin does not necessarily mean insulin therapy will forever be part of their lives. With adequate lifestyle modifications leading to sufficient weight loss, patients could reduce and possibly stop insulin. Also, starting insulin can be seen as a means to prepare patients for switching to other antidiabetic agents once their glycemic levels are more controlled. Thus, insulin therapy is not seen a punishment resulting from uncontrolled glycated hemoglobin levels.

Empowering your patients with the aim to build and strengthen their self-efficacy

  • One of the many ways to achieve this goal would be teaching patients about proper injection techniques and then asking them to give themselves the first dose at the office under your supervision. In this way, you can support and provide feedback as needed. Your patients should also be encouraged to seek help from pharmacists in their communities.
  • To patients, the phrase “initiating insulin therapy” might be overwhelming and induce anxiety due to inadequate mental preparedness, possibly leading to psychological insulin resistance. We play an active role in patients’ support system, functioning not only to provide them insulin, but also to be the necessary psychological safety net in their journey to overcome that resistance and be well.
  • Davis SN, Renda SM. Overcoming barriers to starting insulin therapy. Diabetes Educ 2006; 32(Suppl 4): 146S–152S. Read full text (subscription required)
  • Polonsky WH, Jackson RA. What’s so tough about taking insulin? Addressing the problem of psychological insulin resistance in type 2 diabetes. Clin Diabetes 2004; 22: 147–150. Read full text
  • Funnell MM. Overcoming barriers to the initiation of insulin therapy. Clin Diabetes 2007; 25: 36–38. Read full text
  • Polonsky WH, Arsenault J, Fisher Lawrence et al. Initiating insulin: How to help people with type 2 diabetes start and continue insulin successfully. Int J Clin Pract 2017; 71: e12973. Read full text
  • Petznick AK. Identifying and addressing barriers to insulin acceptance and adherence in patients with type 2 diabetes mellitus. J Am Osteopath Assoc 2013; 113(Suppl 2): S6–S16. Read full text

About the contributor

Clipper Young

Clipper F Young, PharmD MPH CDE BC-ADM, is an assistant professor and a clinical pharmacist at Touro University California College of Osteopathic Medicine. Disclosures

Full biography