Insulin Omission – An Opportunity?

Insulin Omission – An Opportunity?

According to a study published in the most recent issue of Diabetes Care, 57% of the study participants reported omitting insulin injections, with 20% doing so on a regular basis. The study, “Correlates of Insulin Injection Omission by Peyrot,” included several noteworthy statements;

Our study suggests that insulin omission is affected by the perceived burden of insulin therapy (i.e., having to plan one’s life around insulin injections and feeling that the insulin regimen interferes with activities of daily living such as social activities, work-related activities, and family care-giving responsibilities). We offer one caveat regarding our findings; we do not believe that the behavior of planning one’s day around insulin injections actually increases the level of insulin injection omission, but we do believe that feeling that one has to plan around one’s injections is associated with higher frequency of skipping insulin injections one should take. That is, when there is a conflict between scheduling of treatment and life activities, one can either plan one’s activities in a way that reduces this conflict or deal with the conflict by ignoring treatment needs. Reducing the perceived burden of insulin injections may require more effort from health care providers. As we have suggested elsewhere, providers must find out what the specific issues are for each patient and work with that patient to develop solutions that will work for him or her (24).”

“Our study suggests that insulin omission may be affected by the immediate experience of injecting insulin as painful and embarrassing (but not dissatisfaction with time needed, ease of use, or skin inflammation/ bruising). There are numerous device-related strategies for reducing pain and  embarrassment, including insulin pens, finer gauge needles, injection ports, needleless injectors, and other injection assistance devices. However, we have found that patients do not feel that their health care providers are giving them adequate assistance in managing these problems, even when they raise the issue with their providers (18).”

Note Diabetic Investor added the highlighting and for good reason we might add.

The authors conclude by stating; “For patients who report injection-related problems (interference with daily activities, injection pain, and embarrassment), providers should consider recommending strategies and tools for addressing these problems to prevent insulin omission. This may contribute to improved treatment adherence and consequent clinical outcomes.”  Or put in plain English what the authors are trying to say in a polite way, it helps if healthcare professionals would actually listen to patients and provide them with some education on insulin therapy.

For years Diabetic Investor has been telling everyone the reason more patients don’t use insulin has little to do with the so-called “pain factor.” As the authors of this study correctly point out there are several delivery system options which reduce this so-called pain factor. The real issue here is that patients are not properly educated before they initiate insulin therapy and lack of education leads to non-compliance. The fact is insulin therapy is not a simple therapy option.

Should anyone believe that this study supports the need for an alternate insulin delivery system, such as inhaled insulin we suggest you re-read the two passages above. While the “pain factor” would be taken away, with inhaled insulin the patient would still face several daunting issues with insulin therapy. Inhaled insulin does not take away the need to regularly monitor glucose levels or reduce the possibility of hypoglycemia. The fact is whether the insulin is injected, pumped or inhaled into the body several of the issues noted by the study would still be present.

While the study did not address other injectable therapy options, i.e. GLP-1 therapy the issues noted in the study favor greater GLP-1 adoption. Simply put GLP-1 therapy is very patient friendly, there is no need for regular glucose monitoring, fixed dosing, weight loss vs. weight gain and little risk of hypoglycemia. The patient simply dials out their dose and injects, that’s it. With Byetta LAR getting set to be approved by the FDA, this injection will be limited to just once a week.  What could be simpler than a patient injecting LAR every Sunday morning, in the privacy of their own home, and being done for the remainder of the week. 

Besides being extremely patient friendly, therapy options like LAR are also very physician friendly. One of the most overlooked benefits of LAR is that patient education requirements are limited. All the patient needs to know is how to mix LAR, a problem that will eventually go way when the new LAR pen delivery system is available, and where to inject. With GLP-1 therapy it doesn’t matter when or what the patient eats or what the patient’s glucose levels are- this is a fixed dosed product. Since GLP-1’s only work in the presence of glucose there is little risk of hypoglycemia. Finally, while patients on insulin therapy typically experience weight gain, patients on GLP-1 therapy typically lose weight. The weight loss should not be overlooked as it helps motivate patients to continue being compliant with their therapy.

Since GLP-1’s are not for patients with Type 1 diabetes, this study should send a strong message to insulin pump companies. Numerous studies have proven the benefits of insulin pump therapy, overlooked in these studies is a simple fact; once properly trained patients on a pump don’t miss insulin injections as insulin is being continually pumped into the body. The problem with insulin pumps has always been solving the calibration issue. While pumps have become more patient friendly over the years learning how to operate the pump is only part insulin pump therapy.

Patients new to pump therapy need to understand items such as duration of insulin action, carb counting, insulin to glucose ratios, etc. In reality the pump is like a mini-computer that only does what the patient tells it to do. Just as bad programming leads to computer problems, a poorly programmed pump leads to poor outcomes.  Simply put the hurdle faced by insulin pumps are the same issues noted in the study, patient education is critical.

Given the effectiveness of insulin pump therapy many have wondered why just 30% of type 1’s are using pumps. The reason is quite simple; the majority of physicians lack the time and infrastructure to properly train patients on pump therapy. The challenge for insulin pump companies is not building even “smarter” pumps, the challenge is helping physicians train patients on pump therapy in a cost effective manner. Physicians understand the many benefits of pump therapy they just don’t want to deal with the hassle of training patients new to pump therapy.

Ultimately the message from this study is really nothing different than what Diabetic Investor has been stating year after year, the poor quality of patient education is a leading factor contributing to poor patient outcomes. The bottom line is patient education is the most cost effective tool to improving patient outcomes, until everyone realizes this fact we will continue to see dismal patient outcomes.