This site is intended for healthcare professionals only

Journal of
Diabetes Nursing

Issue:

Share this article

Changing diabetes by improving control: Early insulin initiation

Brian Karet

Diabetes is serious, not just because people with poor glycaemic control feel awful but because of the range and seriousness of the complications. The risk of developing many complications, particularly those affecting eyes, nerves and kidneys is reduced by maintaining good glycaemic control. It is well recognised that by using only oral hypoglycaemic agents and lifestyle modification many people do not achieve or maintain good glycaemic control (Turner et al, 1999).

Realising this, in 2006 the main European and US (European Association for the Study of Diabetes/American Diabetes Association) diabetes organisations got together and proposed a treatment algorithm which suggested using metformin at diagnosis and using insulin as one of the options for intensification if HbA1c remained above 7% (Nathan et al, 2006). But insulin is still not used as early as it should be and it seems that sometimes patients and healthcare professionals collude to avoid using it. This situation is termed psychological insulin resistance (PIR) and applies to patients and healthcare professionals in equal amounts. Among patients there is a common perception that starting insulin is an indication of failure (Peyrot et al, 2005).

So how do we overcome these barriers? Firstly, by knowing insulin works; and that, from the UKPDS, it has known vascular benefits (UK Prospective Diabetes Study Group, 1998). Secondly, modern insulins are very flexible and remarkably safe. For many people it is easy to start with one injection a day of either a premix or a basal insulin. Several studies have shown that patients, given a simple blood-glucose based titration regimen, can achieve good glycaemic control with minimal risk of hypoglycaemic episodes and do as well as patients who are directed by healthcare professionals to change their insulin doses (Davies et al, 2005; Garber et al, 2006). Initiating insulin is like learning to swim. Skill brings confidence and you wonder what all the fuss was about!

Diabetes is serious, not just because people with poor glycaemic control feel awful but because of the range and seriousness of the complications. The risk of developing many complications, particularly those affecting eyes, nerves and kidneys is reduced by maintaining good glycaemic control. It is well recognised that by using only oral hypoglycaemic agents and lifestyle modification many people do not achieve or maintain good glycaemic control (Turner et al, 1999).

Realising this, in 2006 the main European and US (European Association for the Study of Diabetes/American Diabetes Association) diabetes organisations got together and proposed a treatment algorithm which suggested using metformin at diagnosis and using insulin as one of the options for intensification if HbA1c remained above 7% (Nathan et al, 2006). But insulin is still not used as early as it should be and it seems that sometimes patients and healthcare professionals collude to avoid using it. This situation is termed psychological insulin resistance (PIR) and applies to patients and healthcare professionals in equal amounts. Among patients there is a common perception that starting insulin is an indication of failure (Peyrot et al, 2005).

So how do we overcome these barriers? Firstly, by knowing insulin works; and that, from the UKPDS, it has known vascular benefits (UK Prospective Diabetes Study Group, 1998). Secondly, modern insulins are very flexible and remarkably safe. For many people it is easy to start with one injection a day of either a premix or a basal insulin. Several studies have shown that patients, given a simple blood-glucose based titration regimen, can achieve good glycaemic control with minimal risk of hypoglycaemic episodes and do as well as patients who are directed by healthcare professionals to change their insulin doses (Davies et al, 2005; Garber et al, 2006). Initiating insulin is like learning to swim. Skill brings confidence and you wonder what all the fuss was about!

REFERENCES:

Davies M, Storms F, Shutler S et al (2005) Improvement of glycemic control in subjects with poorly controlled type 2 diabetes: comparison of two treatment algorithms using insulin glargine. ATLANTUS study group. Diabetes Care 28: 1282–8
Garber AJ, Wahlen J, Wahl T et al (2006) Attainment of glycaemic goals in type 2 diabetes with once-, twice-, or thrice-daily dosing with biphasic insulin aspart 70/30 (The 1-2-3 study). Diabetes, Obesity and Metabolism 8: 58–66
Nathan DM, Buse JB, Davidson MB et al (2006) Management of hyperglycemia in type 2 diabetes: A consensus algorithm for the initiation and adjustment of therapy: a consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 29: 1963–72
Peyrot M, Rubin RR, Lauritzen T et al (2005) Resistance to insulin therapy among patients and providers: results of the cross-national Diabetes Attitudes, Wishes, and Needs (DAWN) study. Diabetes Care 28: 2673–9
Turner RC, Cull CA, Frighi V (1999) Glycemic control with diet, sulfonylurea, metformin, or insulin in patients with type 2 diabetes mellitus: progressive requirement for multiple therapies (UKPDS 49). UK Prospective Diabetes Study (UKPDS) Group. JAMA 281: 2005–12
UK Prospective Diabetes Study (UKPDS) Group (1998) Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 352: 837–53

Related content
;
Free for all UK & Ireland healthcare professionals

Sign up to all DiabetesontheNet journals

 

By clicking ‘Subscribe’, you are agreeing that DiabetesontheNet.com are able to email you periodic newsletters. You may unsubscribe from these at any time. Your info is safe with us and we will never sell or trade your details. For information please review our Privacy Policy.

Are you a healthcare professional? This website is for healthcare professionals only. To continue, please confirm that you are a healthcare professional below.

We use cookies responsibly to ensure that we give you the best experience on our website. If you continue without changing your browser settings, we’ll assume that you are happy to receive all cookies on this website. Read about how we use cookies.