Approaching Insulin Intensification in Diabetes Care

Davida F. Kruger, MSN, APN-BC, BC-ADM: Patients who have type 2 diabetes will lose their beta cell function over time. Now, when I first meet that patient, if they are very symptomatic and they have a very high A1C, they may need to start insulin right then and there. But otherwise, over time they will lose their beta cell function. They have insulin resistance. That insulin resistance beats up on the beta cells, and over time they’re going to use up their own beta cells and their ability to produce their own insulin.

We’re actually doing them a disservice by not talking to them about that from the day we meet them so that they understand it’s not something they did wrong, but it’s the nature of the diabetes. Over time, they’re going to need insulin, and we shouldn’t delay that. They should understand that they’re going to perhaps need a basal insulin to start, and as that beta cell weans more, they’re going to need a rapid-acting insulin before meals to cover their food. But it’s a progressive nature of the disease. It’s something we understand. Patients need to understand that from the get-go, and as health care providers, we need to feel more comfortable with insulin so that we don’t delay the start.

Serge Jabbour, MD: When I start patients on insulin, I teach patients how to titrate insulin every 3 days to a goal, because I’ve seen providers who may start insulin, and as patients come back in 3 months, you will not see any good outcomes. You need to titrate the insulin on a regular basis. That’s why it’s important to teach patients the goals we’re looking for. So, I tell patients, “Your fasting sugar in the morning should be 130 mg/dL. If you check your sugar 2 hours after a meal, it should be below 180 mg/dL.” If I start a basal insulin, I tell patients, “If your fasting sugar is above 130 mg/dL after 3 days, go up on the basal by 3 units,” until they reach that goal. Then they look at their postprandials and they can adjust the mealtime insulin. That’s why it’s important to educate patients when we start insulin on how to adjust the insulin. That’s how we can reach a successful outcome.

Davida F. Kruger, MSN, APN-BC, BC-ADM: I think we underestimate patients’ concerns about starting insulin. Although, with the appropriate education, I have found that patients will move on to insulin. They just need to understand the reason why. But it’s really important to talk to them when they are concerned about starting or are resistant to starting insulin. “What is your concern?” Be really open with the question.

It may have been that they watched someone start insulin, and that’s when their complications started. Well, it isn’t that their complications started because of the insulin—it’s probably because their control hadn’t been good up until that point. So, I think you need to find out from the patient what’s going on with them, why they don’t want to start insulin, or what you perceive. Sometimes, it’s because they haven’t been asked.

Ask that question: “What is your concern?” Talk it through with the patient. “I’m concerned that people look at me differently. I’m concerned that it will impede my ability to go out with my friends at night. It will limit my activities.” Usually, you can talk all of those things through with the patient. They may be concerned about how to time it. They may be concerned about the size of the needle. And most patients think that the needle is about this big, when we know that they’re very small, very sharp, and very easy to use. In my practice, I make sure they get an injection before they leave my office. Most of the time they say, “Is that all it is? I should have done this sooner.” It helps them feel better. So, talk to them about that. “Are you up at night going to the bathroom? This will help with that.”

The other concern is the cost. All medications for people with diabetes can be costly, but there are co-pays with insurance. As we increase the dose, sometimes we have to increase how many boxes or how many vials are used, and sometimes that affects the patient’s cost, as well. Being concerned about those things and working that through with the patients is really important, as well.

Transcript edited for clarity.