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Overcoming Barriers to the Initiation of Insulin Therapy

Martha M. Funnell, MS, RN, CDE

New recommendations for themanagement of type 2 diabetescall for more rapid initiation of

both oral medications and insulin thera-py.1 Although most providers agree thatinsulin is an efficacious approach to themanagement of type 2 diabetes, manystill consider insulin therapy as the lastresort and indicate that their patients arehesitant to take insulin.2 In addition, theinitiation of insulin therapy is difficultin the confines of a 10-minute officevisit.

Assessment of BarriersThe first step is to determine thepatient’s view of insulin therapy andcorrectly identify barriers from thepatient’s perspective. The discussionabout the need for insulin therapy affectspeople differently. Some may feel angryor betrayed, others fear that insulin willadd to the burden and stress of manag-ing diabetes, and still others may feeloverwhelmed or frightened.3

To determine a patient’s concerns,ask questions such as:• What do you need to know to consid-

er insulin therapy?• What problems do you think you will

encounter?• What do you see as the biggest nega-

tive of insulin? The greatest benefit?• What would help you overcome your

concerns?• Are you willing to try insulin? If not,

what would cause you to considerinsulin?

The first response to such questions isvery rarely a full accounting of thepatients’ true concerns. Continuing to

ask questions, such as “Why do youthink that is?” or “Can you tell me moreabout that?” will help both you and thepatient better understand the existingbarriers so that you can best supportpatients in the decision-making process.

Patient-Identified Barriers to InsulinTherapyThe decision to initiate insulin therapyultimately belongs to the patient withtype 2 diabetes. Common barriersamong patients include beliefs thatinsulin is a personal failure, that insulinis not effective, that insulin causes com-plications or even death, or that insulininjections are painful, as well as fear ofhypoglycemia, loss of independence,weight gain, and cost. There are, howev-er, strategies providers can use todecrease patient barriers to insulin thera-py and assist patients with the decision-making process.4

Insulin as a personal failure A common belief among patients is thatthe need for insulin therapy is indicativeof a personal failure to manage their dia-betes appropriately.2 Explaining type 2diabetes as a progressive disease ofinsulin resistance and b-cell failure fromthe onset will help to diminish or evenprevent this erroneous belief. Point outto patients that they have not failed butthat the other treatment options havefailed them. Although many providersuse insulin as a “threat” to promote mealplanning and exercise behaviors,2 thisstrategy ultimately backfires when thepatient does need insulin, despite havingmade recommended mealtime and phys-ical activity changes. Instead, describe

insulin as a logical step in the continu-um of treatment.

Insulin is not effectiveA surprising number of patients whoparticipated in the Diabetes Attitudes,Wishes, and Needs study indicated thatthey did not believe insulin was effectivefor treating diabetes.2 Although the rea-sons behind this lack of belief were notassessed, this barrier could stem frompersonal experiences in which friends orfamily members were prescribed insulinin doses insufficient to lower blood glu-cose levels, but still resulting in sideeffects such as weight gain or hypo-glycemia. Although most patients thinkof diabetes as a “sugar” problem, point-ing out to them that diabetes is actuallyan insulin problem and that the insulinsused in therapy today are very similar tothe insulin that the body naturally makesmay be helpful.

In addition, providers tend to basethe decision to recommend insulin onhemoglobin A1c levels, whereas patientsare often more concerned about theeffects of diabetes and its treatment ontheir current lives. Assessing patients’concerns and goals is necessary to framethe messages about insulin to match theirgoals beyond glucose control. For exam-ple, patients who want more flexibility intheir lives or more energy for activitiesthey enjoy may be more amenable toinsulin therapy if they are taught how itcan be used to achieve those goals.

Insulin causes complications or deathMany patients with type 2 diabetes havehad experiences with diabetes throughrelatives or friends. The belief that dia-

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long-acting insulins, hypoglycemia isless likely to occur and that very fewpatients with type 2 diabetes actuallyhave severe hypoglycemia. Reassurepatients that you can teach them strate-gies so that they can prevent, recognize,and treat hypoglycemia and thus avoidsevere events.

Change in lifestyle A concern among older adults orpatients who live alone is that once theybegin insulin therapy, it will adverselyaffect their independence, eitherbecause of hypoglycemia or becausethey fear they will not be able to drawup or administer their own injections.Providing information about insulinpens or other devices to increase accu-racy and ease of administration andabout local home-care resources mayhelp to diminish these barriers.Teaching patients to correctly identifysymptoms of hypoglycemia and strate-gies to facilitate insulin use is also oftenhelpful.

Other lifestyle concerns are relatedto timing, difficulty in traveling, and lossof spontaneity and flexibility. If patientsidentify these concerns, provide infor-mation about insulin regimens that offermaximum flexibility, strategies for trav-eling with insulin, or other identifiedlifestyle barriers.

Some of these barriers result fromconcerns about injecting insulin awayfrom home, for example in public placesor at work. Some patients worry that ifthey inject in public places they will beperceived as injecting illegal drugs.Insulin pens can be very helpful forovercoming this barrier by increasingpatients’ ability to inject discretely.Using only morning and/or bedtimeinsulin regimens can also eliminate thisbarrier for some patients.

Some patients have justifiable con-cerns about the loss of their jobs if theyneed to begin insulin therapy. Althoughthere are some occupations for whichthis is true, the Americans With Disabili-ties Act requires employers to make rea-sonable accommodations for patients

betes causes complications or deathoften stems from these experiences.Although it is more likely that insulinmight have delayed or prevented thesecomplications, their beliefs about insulinin terms of its cause of and effect onthese events continues. Although it istempting to provide information aboutinsulin to counteract these beliefs, factsalone often do very little to allaypatients’ fears. It is generally more help-ful to respond by acknowledging thepatient’s fears and then providing infor-mation about the provider’s experiences.For example, “I understand your con-cern, but would it help to know that Ihave cared for many patients with type 2diabetes, and I have never known any-one who became impotent as a result ofinsulin therapy?”

Insulin injections are painfulMany patients equate insulin injectionswith inoculations or injections ofantibiotics that they have experiencedin the past. Point out that insulin nee-dles are smaller and thinner than everbefore and that most patients find itless painful than testing their bloodglucose levels. Other strategies thateducators often use to overcome thisbarrier are to give a dry injection tothemselves in front of the patient or toask patients to give a dry injection tothemselves at the time of the initialeducation, regardless of whetherinsulin is indicated. Insulin pens canalso be helpful for patients who areconcerned about the pain of injections.Although these patients are oftendescribed as “needle phobic,” very fewpatients have true needle phobias. Forthose who do, psychological counsel-ing is often needed and effective.

Fear of hypoglycemiaThe fear of hypoglycemia often stemsfrom observing people with diabeteswho take insulin. Assessing what theyhave observed and the outcome of thehypoglycemic event is needed to addressthe patient’s specific fear. Point out thatwith the use of newer rapid-acting and

with diabetes, including those who takeinsulin. In addition, the regimen may beadjusted to allow for insulin injections tobe given while patients are at homeinstead of at work.

Insulin causes weight gainIt is true that many patients who begininsulin therapy gain weight withimproved glycemia and greater mealplan flexibility. If this is a barrier, offerto arrange a meeting with a dietitianbefore the initiation of insulin to identifystrategies to prevent weight gain.

Insulin is too expensiveThere is no question that diabetes isexpensive, particularly for patients whohave limited drug coverage or no insur-ance at all. Generally, however, insulinis less expensive than using multipleoral medications to produce the sameglycemic outcomes. The regimen mayalso be adjusted to decrease this barrierby using premixed insulins if co-paysare a concern or less expensive insulinsfor patients with no or limited drugcoverage. Other strategies to reducethis barrier include teaching patients toreuse insulin syringes, adjusting themonitoring schedule to reduce the costof strips and other supplies, providinginformation about the least expensivesources for insulin and other suppliesin your area, prescribing less expensiveinsulins, and referring patients to phar-maceutical company assistance pro-grams. Because prices can vary a greatdeal at different pharmacies, provide alist of prices for pharmacies in yourarea or suggest to patients that theyshop around for the best prices. This isalso a good opportunity to review allmedications to determine if any couldbe eliminated, decreased, or providedin combination form to lower out-of-pocket expenditures.

Provider-Identified Barriers to InsulinTherapyAlthough patient-identified barriersare the most common reasons citedfor delay in initiating insulin therapy,

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particularly in the early phases, whendoses are being titrated frequently.

Adopt successful strategiesConsider implementing strategies usedby other successful practices, such ascreating collaborative relationships withpatients and designing systems to facili-tate chronic disease care. Create proac-tive methods to evaluate outcomes andmonitor results so that the time spentwith patients can be used most efficient-ly and effectively. Establishing a planwith patients for follow up of blood glu-cose results by telephone or in personwill also facilitate the appropriate titra-tion of insulin and its effectiveness.

Address emotional issuesAlthough it is important to address con-cerns about diabetes in general, whendiscussing the initiation of insulin thera-py, it is essential to ask patients abouttheir thoughts or feelings about insulin.This is the most efficient way to ensurethat the messages about insulin are sup-portive, tailored for each individualpatient, and effective.

REFERENCES

1Nathan DM, Buse JB, Davidson MB, HeineRJ, Holman RR, Sherwin R, Zinman B: Manage-

many providers also are hesitant toinitiate insulin. Because provider atti-tudes are crucial for patient accept-ance of insulin, it is important todetermine whether “clinician inertia”is affecting your practice. Along withovercoming patient barriers, there arealso strategies providers can use toovercome their own barriers to insulintherapy.

Refer patients for diabetes self-manage-ment education and medical nutritiontherapyDiabetes educators can be powerfulallies in helping patients make the deci-sion to initiate insulin therapy and assist-ing with insulin dose titration. Recentchanges in Medicare, Medicaid, andother insurance packages have greatlyincreased the likelihood of reimburse-ment for these essential services.

Provide ongoing self-managementsupportPatients need not only initial educationabout insulin but also continued follow-up and support to sustain gains in dia-betes self-care behaviors. Office staffcan be extremely helpful in supportingand reinforcing patients’ self-manage-ment efforts related to insulin therapy,

ment of hyperglycemia in type 2 diabetes: a con-sensus algorithm for the initiation and adjustmentof therapy. Diabetes Care 29:1963–1972, 2006

2Peyrot M, Rubin RR, Lauritzen T, SkovlundSE, Snoek FJ, Matthews DR, Landgraf R, Kleine-breil L, the International DAWN Advisory Panel:Resistance to insulin therapy among patients andprovides: results of the cross-national DiabetesAttitudes, Wishes and Needs study. DiabetesCare 28:2673–2679, 2005

3Funnell MM, Kruger DF: Type 2 diabetes:treat to target. Nurse Pract 29:11–23, 2004

4Funnell MM, Kruger DF: Self-managementsupport for insulin therapy in type 2 diabetes.Diabetes Educ 30:274–280, 2004

Martha M. Funnell, MS, RN, CDE, isco-director of the Behavioral, Clinical,and Health Systems InterventionResearch Core at the DiabetesResearch and Training Center of theUniversity of Michigan in Ann Arbor.She is an associate editor of ClinicalDiabetes.

Note of disclosure: Ms. Funnell hasserved on advisory panels and receivedhonoraria or consulting fees from NovoNordisk, Eli Lilly and Co., and Sanofi-Aventis. These companies manufactureinsulin products for the treatment ofdiabetes.

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