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

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?
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

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 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

7. 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

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 %
Starting IT means I have failed 38.4%
Now a serious disease %
Too painful %
May cause blindness %
Polonsky et al, 2005

9. Obstacles to IT Willingness
Willing Not
Once started, can never stop 43% 53%
Will restrict my life % %
Starting IT means I have failed 37% %
Now a serious disease % %
Too painful % 51%
May cause blindness % %
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

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

21. 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

22. Physician Resistance to IT
Time
Lack of confidence
Wishes to avoid unpleasant confrontation
Believes that patient is not competent
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
“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

24. 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

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

26. 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

27. What To Do?

28. Overcoming IT Resistance
Ask about patient’s personal obstacles

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

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

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

33. 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

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

35. 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

36. For Maddy: How Insulin Affects Your Blood Sugars
Hemoglobin A1c Level
3 months INSULIN months months months months

37. For Maddy: How Insulin Affects Your Feelings of Fatigue
Fatigue Level
3 months INSULIN months months months months

38. 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

39. 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

40. 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

41. 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

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

43. 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

44. 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

46. Behavioral Diabetes Institute
Website:
INFO:
CALL: