Why Patients are Reluctant to Start Insulin, and What to Do About it William H. Polonsky, PhD, CDE January 30, 2009 whp@behavioraldiabetes.org Good afternoon, Today, I would like to present to you some recent survey data that touches on physicians’ beliefs about their patients’ self-care actions. The title of this talk is.... my co-authors are...

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”.

Resistance to Insulin Therapy How Big is the Problem? UKPDS, 1995 Randomization to insulin (n = 496) 27% refused IT Polonsky et al, 2005 Patient survey (n= 708) 28% “not willing” to begin IT if prescribed Larkin et al, 2008 (n = 100) 33% “not willing” to begin IT if prescribed

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

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

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

Insulin Omission in Type 1 Diabetes Polonsky et al, 1995 341 women surveyed 31% omitted insulin; 9% regularly omitted Jones et al, 2000 361 female teens surveyed 11% omitted insulin regularly Major contributors are fear of weight gain and diabetes distress, not discomfort with insulin per se

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

Obstacles to IT Willingness Willing Not 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

IT Obstacles Injection-related anxiety Discomfort with injections Needle phobia

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!”

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.”

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

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

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.”

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

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

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

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

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

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

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

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

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

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

What To Do?

Overcoming IT Resistance Ask about patient’s personal obstacles

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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