Preparing Patients for Insulin in Type 2 Diabetes

Peter Salgo, MD: Let’s look at the barriers here. You can put cost in, if you like, but the average practitioner is sitting out there hearing us say, “Insulin is great. Let’s use insulin.” What are the barriers that providers face in dealing with that?

Robert Henry, MD: I think the biggest barrier, for example, again, is that you’re given so little time to talk with the patient. You’re given 10 minutes. Maybe, if you’re lucky, in some systems, it’s 15 minutes to see a patient. You can hardly get half of the review of systems done before you’re out of time.

Peter Salgo, MD: You’re doing a review of systems? You’re still doing that?

Robert Henry, MD: You have to.

Carol Wysham, MD: You have to.

Peter Salgo, MD: He must be a really good doctor.

Carol Wysham, MD: He is. He’s a very good doctor.

Robert Henry, MD: If you want to get paid, you’ve got to do it.

Robert Henry, MD: The issue is that, for example, the DPP-4 (dipeptidyl peptidase-4) inhibitors did so well because you could quickly give it. The side effects were minimal, and the effects were modest, but you were able to get the patient better, quickly.

Vivian Fonseca, MD: And nobody called you back.

Robert Henry, MD: Nobody calls you back. If you get them on insulin or you put them on a GLP-1 (glucagon-like peptide-1), you’re going to get a call back almost assuredly. You’re going to have to go through a training program. So, a lot of the things that developed, and medications that are being preferred, might be because they’re simple. They’re effective, but they’re very simple and safe.

Carol Wysham, MD: I think what Julio said is very important. One of the biggest problems with getting patients on insulin is the patients fearing insulin. They fear the shot. They fear all the baggage. They think it’s the end of the line. They think that that means they’re really sick. Addressing all of those questions and having the patients see what that feels like (and I love the idea of a shot and a finger stick done in close succession to one another so that the patient then knows it doesn’t hurt) is important. I find the insulin very easy to start. I teach the patient myself, but they’ve heard about insulin, sometimes for 2 years before we actually begin doing it. We talk about, now, one of the options is insulin, and we go back and forth. By the time the insulin is needed, they know that they’ve tried everything else. They know it’s not their fault that they need insulin. And I can pull a pen out, put a tip on, dial it, give it to them, have them give it, and I actually have them do it right there in the office. It is simple.

Peter Salgo, MD: You know what I hear, I hear from patients, “My grandma was put on insulin and 6 months later she was dead. It was the insulin that killed her.” But instead, it seems to me, it’s because back in that day, insulin was the last thing you gave. It was the last.

Vivian Fonseca, MD: And badly used.

Peter Salgo, MD: And badly used.

Vivian Fonseca, MD: You know, it still takes more than 10 minutes to get over that barrier, and we don’t have that luxury, certainly not in primary care.

Carol Wysham, MD: It does not take more than 10 minutes if you prepare the patient appropriately.

Vivian Fonseca, MD: You’re a persuasive person.

Carol Wysham, MD: I must be.

Julio Rosenstock, MD: My little trick is very good, and I hope it’s a very nice little pearl to do that. Because when the patient starts with diabetes, the first thing that you are going to say is, “You’re going to fine. You’re going to be okay.” Then you’re going to check this thing and get this thing, this little shot there. We’re not going to do it now, but eventually you will and it’s not the end of the world.

Robert Henry, MD: But Carol is saying it requires that the care provider has gotten over and accepted insulin because this is no easy task for a primary care provider to do. I mean, it’s much better than it used to be, but it’s still not easy. To go through all the side effects of insulin, what happens if you start them on an insulin, they go home and drive and get hypoglycemic. You have to teach them how to prevent hypoglycemia, how to use the self—glucose monitoring. It’s a little more complicated and it’s a little daunting for the primary care provider, too.

Carol Wysham, MD: I think the message I’m trying to do is counter what you’re saying. Yes, it seems daunting, but if the patient is appropriately prepared, they’re educated, they’re already doing testing, and you’re starting it early enough, hypoglycemia becomes less of an issue, it shouldn’t be that hard.

Vivian Fonseca, MD: Carol is right, and I think your guys’ concerns are out of date. Insulin hasn’t gone away despite all these 10 or 12 new classes of oral agents. The use has been gradually increasing over time. What this means is that a lot of people in primary care are using insulin and using it quite well.

Transcript edited for clarity.