Type 2 Diabetes and Insulin: Physician Reluctance

Hypoglycemia is the issue clinicians worry about the most before initiating insulin therapy for patients with type 2 diabetes mellitus (T2DM), according to a new study.

Insulin therapy is indicated for many patients with T2DM due to the progressive nature of the disease. Insulin therapy should be strongly considered for a patient with significant hyperglycemic symptoms and/or dramatically elevated plasma glucose concentrations, but most patients are prescribed insulin after combination therapy with metformin plus one or two oral or injectable agents, stated researchers led by Javier Escalada of the University Clinic de Navarra in Pamplona, Spain.

“When good glycemic control is not achieved despite other optimal anti-diabetic agents, insulin should be initiated. But, progression to insulin is frequently delayed, causing unnecessary prolonged periods of hyperglycemia and preventable complications downstream,” the researchers stated.

To better understand the barriers to insulin initiation in physicians, the researchers conducted a cross-sectional survey of a sample of 380 healthcare professionals, including general practitioners (GPs), endocrinologists, internists, and nurses recruited from 20 community health centers and 8 hospitals in the Spanish National Health System. A discussion group reviewed the results of the survey to propose solutions. The responders to the survey included 112 GPs, 80 endocrinologists, 81 internists, and 50 nurses.

The survey results show there are differences between professionals regarding diabetes management. In poorly controlled patients, 46% of GPs, 43.2% of internists, and 31.3% of endocrinologists waited three to six months before starting insulin, and 71.4% of GPs, 66.7% of internists, and 58.8% of endocrinologists need to confirm HbA1c levels twice.

The upper level of basal glucose more frequently considered as good control was 130 mg/dL for GPs (35.7%), and 120 mg/dL for internists (35.8%) and endocrinologists (37.5%). In patients without comorbidities, 32.5% of endocrinologists, 27.2% of internists, and 17.9% of GPs initiated insulin when HbA1c was more than 7%, while 26.3% of endocrinologists, 28.4% of internists, and 38.4% of GPs initiated insulin when HbA1c was more than 8%.

Healthcare providers agreed about some barriers to initiate insulin: to consider insulin as the last resort, the side effects, thinking insulin is “dangerous,” or the insulin interferes with patient’s social life. “However, they considered insulin as the most effective therapy and did not think that ‘basal insulin therapy is difficult,’” the researchers stated.

The American Diabetes Association- European Association for the Study of Diabetes was the guideline most used by participants as a reference guide for the treatment of T2DM, especially by endocrinologists and GPs.

Initiation of insulin therapy was frequently delayed for many sub-optimally controlled patients. The lack of experience may have made some GPs apprehensive about insulin initiation, the researchers noted. They also noted that GPs and internists feel less empowered to manage patients and think that the multiple-dose insulin regimens are difficult to manage.

The result of the discussion group was the suggestion that physicians overcome patients’ psychological insulin resistance by talking about diabetes as a progressive disease that eventually will require insulin to achieve normal blood glucose levels.

Reference: Escalada J, et al. Attitudes towards insulin initiation in type 2 diabetes patients among healthcare providers: a survey research. Diabetes Res Clin Pract. 2016 Oct 14;122:46-53.