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Why Patients are Reluctant to Start Insulin, and What to Do About it

Why Patients are Reluctant to Start Insulin, and What to Do About it. William H. Polonsky, PhD, CDE January 30, 2009 whp@behavioraldiabetes.org. Potential Consequences of Delayed IT Initiation. May lead to long periods of chronically high blood glucose levels.

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Why Patients are Reluctant to Start Insulin, and What to Do About it

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  1. Why Patients are Reluctant to Start Insulin, and What to Do About it William H. Polonsky, PhD, CDE January 30, 2009 whp@behavioraldiabetes.org

  2. Potential Consequences of Delayed IT Initiation • May lead to long periods of chronically high blood glucose levels. • Patients may drop out of treatment to avoid IT. • Patients on insulin may come to believe that less insulin = less disease. So they may omit insulin until they begin feeling “bad”.

  3. Resistance to Insulin Therapy How Big is the Problem?

  4. Prospective IT Willingness Ethnic Differences % indicating some level of distress Polonsky et al, 2005

  5. Prospective IT Willingness Gender Differences % indicating some level of distress Polonsky et al, 2005

  6. Insulin Persistence in Type 2 Diabetes • 8484 male veterans, 2 years of observation, prescribed doses vs. pharmacy claim: • “Mean insulin complianceof 77% for chronic users indicates that most patients are makingan effort to take insulin, albeit not as prescribed by theirphysician.” • Factoring in wastage, overall use estimated as 58–65%. Cramer and Pugh, 2005

  7. Insulin Omission in Type 1 Diabetes Major contributors are fear of weight gain and diabetes distress, not discomfort with insulin per se

  8. Obstacles to IT Willingness (% of 708 Type 2, insulin-naïve patients who agree) Once started, can never stop 44.9% Will restrict my life 44.8% Starting IT means I have failed 38.4% Now a serious disease 38.1% Too painful 34.7% May cause blindness 10.1% Polonsky et al, 2005

  9. Obstacles to IT Willingness WillingNot Once started, can never stop 43% 53% Will restrict my life 42% 56% Starting IT means I have failed 37% 55% Now a serious disease 35% 47% Too painful 30% 51% May cause blindness 8% 17% Polonsky et al, in preparation

  10. IT Obstacles • Injection-related anxiety • Discomfort with injections • Needle phobia

  11. IT Obstacles • Perceived lack of control • “If I start taking insulin, I’ll never be able to stop.” • “insulin means no more spontaneity. It would restrict my life, making it too hard to to travel, eat out, or even have a life!”

  12. IT Obstacles • Low self-efficacy • “I’m just not confident I could handle the demands of insulin, like deciding how much to take and when to take it.” • “Its just too complicated; its too much for me to do.”

  13. IT Obstacles • A sense of personal failure • “If I take insulin, it means I have failed, that I haven’t done a good enough job taking care of my diabetes.” • In DAWN, US patients report more self-blame than patients from all other countries. Peyrot et al, 2005

  14. IT Obstacles • Positive gain is not expected • In DAWN, < 10% of insulin-naïve type 2 subjects believed IT would lead to better glycemic control, less fatigue or better health Skovlund et al, 2003

  15. IT Obstacles • Perceived worsening of the disease process • “Taking insulin means my diabetes will become a more serious disease.” • “Taking insulin may cause other problems, like frequent low blood sugars, weight gain, or maybe even cause more serious problems with my eyes or kidneys.”

  16. IT Obstacles • Injection-related anxiety • Perceived lack of control • Low self-efficacy • A sense of personal failure • Positive gain is not expected • Perceived worsening of the disease process

  17. Why Would Patients Feel This Way? • Personal experience (e.g. hypoglycemia) • Observation of others with diabetes • Overt and covert messages from health care providers

  18. Physician Influences • Threatening patients with insulin • “If you can’t make some positive changes in how you eat and exercise, then we’ll have no choice but to start insulin.” • Underlying messages • Insulin should be avoided at all costs • You have failed • You are to be punished

  19. Physician Resistance to IT • Time • Lack of confidence Haque et al, 2005

  20. Physician Resistance to IT • Time • Lack of confidence • Gap in knowledge, ½ of respondents • “I had no idea how to determine the dosage for the patient” Haque et al, 2005

  21. Physician Resistance to IT • Time • Lack of confidence • Wishes to avoid unpleasant confrontation • Believes that patient is not competent Haque et al, 2005

  22. Physician Resistance to IT • Time • Lack of confidence • Wishes to avoid unpleasant confrontation • Believes that patient is not competent • Hypoglycemia and weight gain • “Initiating insulin in a patient who is not compliant on a diabetic diet and has morbid obesity is generally not a very good idea” Haque et al, 2005

  23. Physician Resistance to IT • Time • Lack of confidence • Wishes to avoid unpleasant confrontation • Believes that patient is not competent • Hypoglycemia and weight gain • No beneficial outcomes • DAWN: “Just over half of physicians/nurses agree • that insulin can have a positive impact on care.” Haque et al, 2005, Peyrot et al, 2005

  24. Insulin Use and Glycemic Control % reaching listed goals Harris et al, 1999

  25. IT Obstacles • Injection-related anxiety • Perceived lack of control • Low self-efficacy • A sense of personal failure • Positive gain is not expected • Perceived worsening of the disease process

  26. What To Do?

  27. Overcoming IT Resistance • Ask about patient’s personal obstacles

  28. Overcoming IT Resistance • Ask about patient’s personal obstacles • “What are some of the reasons why taking insulin seems so unpleasant to you?”

  29. Overcoming IT Resistance • Ask about patient’s personal obstacles • Encourage an immediate injection

  30. Overcoming IT Resistance • Ask about patient’s personal obstacles • Encourage an immediate injection • Provide a sense of control regarding IT

  31. Overcoming IT Resistance • Identify patient’s personal obstacles • Encourage an immediate injection • Provide a sense of control regarding IT • “I’d like you to try insulin for just a month. At the end of the month, if you don’t think its been worthwhile, or if it still seems as awful as you’re imagining it might be, I promise to help you stop.” • Design IT regimen to minimize lifestyle restriction

  32. Overcoming IT Resistance • Identify patient’s personal obstacles • Encourage an immediate injection • Provide a sense of control regarding IT • Consider insulin pens

  33. Overcoming IT Resistance • Identify patient’s personal obstacles • Encourage an immediate injection • Provide a sense of control regarding IT • Consider insulin pens • Pass along the good news

  34. For Maddy: How Insulin Affects Your Blood Sugars Hemoglobin A1c Level 3 months INSULIN 3 months 6 months 9 months 12 months

  35. For Maddy: How Insulin Affects Your Feelings of Fatigue Fatigue Level 3 months INSULIN 3 months 6 months 9 months 12 months

  36. Overcoming IT Resistance • Identify patient’s personal obstacles • Encourage an immediate injection • Provide a sense of control regarding IT • Consider insulin pens • Pass along the good news • Address patient’s concerns

  37. Addressing Psychological Insulin Resistance Obstacles Discuss It means I have failed with my treatment Insulin won’t help Will wreck my quality of life • No one manages diabetes perfectly • No matter what you do, you may need insulin, because diabetes is “progressive” • Insulin improves glucose control; Nobel Prize not given for drugs that don’t work • Long-term benefits of good control • Short-term benefits include increased energy, better sleep and mood

  38. Addressing Psychological Insulin Resistance Obstacles Discuss Injections hurt It means diabetes is getting worse I will get complications • Hurts less than SMBG • Advantages of insulin pens and thinner, smaller needles • Diabetes is “progressive”; insulin helps control BG levels and keeps the disease from getting worse • Investigate and challenge this belief • Insulin is much more likely to reduce than raise complications risk

  39. Overcoming IT Resistance • Identify patient’s personal obstacles • Encourage an immediate injection • Provide a sense of control regarding IT • Consider insulin pens • Pass along the good news • Address patient’s concerns

  40. Take-Home Messages • Reluctance to begin IT is widespread • But take hope! • IT resistance can be overcome

  41. Take-Home Messages • Common obstacles include: • Injection-related anxiety • Perceived lack of control • Low self-efficacy • A sense of personal failure • Positive gain is not expected • Perceived worsening of the disease process

  42. Overcoming IT Resistance • Identify patient’s personal obstacles • Encourage an immediate injection • Provide a sense of control regarding IT • Consider insulin pens • Pass along the good news • Address patient’s concerns

  43. Behavioral Diabetes Institute Website: www.behavioraldiabetes.org INFO: info@behavioraldiabetes.org CALL: 858-336-8693

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