In type 2 diabetes, blood glucose levels rise when insulin produced by the body does not work properly and there is not enough insulin to compensate for this. Many people with type 2 diabetes will require medication to manage their condition, in addition to maintaining a healthy lifestyle.In the past 12 months over 17,000 Australians with type 2 diabetes commenced insulin therapy.
Insulin is the most effective blood glucose lowering medication available. Negative thoughts or feelings people living with diabetes may have about insulin, are associated with delays and reduction or discontinuation of insulin use. Delaying insulin therapy when it is indicatedcan make achieving blood glucose targets more difficult, and prolonged periods of high blood glucose levels increase the risk of complications (RACGP, 2000).
Despite this, delays are common with both clinician’s and individual’s concerns contributing.For the person with diabetes, the greatest challenge can be overcoming psychological factors such as:
Anxiety about injections
Seeing the progression to insulinas a ‘personal failure’ which could have been avoided
Associating insulin use with negative outcomes such as the development of complications (eg: amputation) and side effects such as weight gain or hypoglycaemia.
For clinicians, limited time, appropriate skills or support from other clinicians with experience and expertise (ie: access to Credentialled Diabetes Educators) can be barriers.
It is important to start talking about insulin early, preferably soon after diagnosis, and openly discuss any concerns the person living with diabetes might have with insulin use.The Insulin Treatment Appraisal Scale (ITAS)** is a useful tool to assist in identifying an individual’s concerns about insulinand assists clinicians to understand personal barriers, provide information and dispel common myths.
In addition to setting realistic expectations regarding the possible need for insulin therapy to manage type 2 diabetes, it is important clientsunderstand when commencing insulin, that their dose will change. Frequent visits and telephone support are recommended following commencement to increase or decrease insulin dosesuntil desired blood glucose targets are achieved. Clients may be anxious about increasing their insulin doses or they may feel that insulin is not working for them. Supporting them with understanding that lower doses are used on commencement of insulin therapy, to safely introduce insulin and minimise the risk of hypoglycaemia is important. Reassuring clients that this is the recommended process, may help them to feel confident with insulin and to continue to use it.
Utilising resources such as demonstration insulin pen devices and injecting pads to familiarise clients with how insulin is delivered and allowing them to practice doing a ‘dummy’ injection can help to alleviate fears associated with injections.
A Credentialled Diabetes Educator can support clients transitioning to insulin therapy by providing education on how insulin works, timing of injections, effects of food and exercise, correct injection technique, hypoglycaemia prevention, including recognition and treatment and facilitate insulin dose adjustment.
Referral to an Accredited Practising Dietitian can support clients to avoid or minimise the potential weight gain associated with insulin therapy.
There are a wide range of National Diabetes Services Scheme (NDSS) and other resources available to assist you and your clients to prepare and successfully transition to insulin therapy.
** A copy of the ITAS is available on page 86 of the NDSS Diabetes and Emotional Health Handbook.
Furler, J. et al. (2017). Supporting Insulin Initiation in Type 2 Diabetes in Primary Care: results of the Stepping Up pragmatic cluster randomised controlled clinical trial. British Medical Journal, 256:j783.
Hendrieckx C, Halliday JA, Beeney LJ, Speight J. Diabetes and emotional health: a handbook for health professionals supporting adults with type 1 or type 2 diabetes. Canberra: National Diabetes Services Scheme, 2016.