Table 3.

Barriers and Counseling Strategies for Initiating Basal Insulin31,32

Complexity of insulin regimensIntroduce easy-to-use insulin pens
Demonstrate use of pen or watch injection-pen training video with patients
Explain that for many people a single daily injection of basal insulin is sufficient to regain and maintain glycemic control for many years
Introduce simple titration algorithms and explain that education is available
Suggest the use of FDA-approved mobile applications
Self blame and feelings of failureExplain that as T2D is highly influenced by age and genetics, insulin is required by approximately 30% of patients as part of the natural course of the disease, not patient behavior
Remind patients that insulin is indicated as first- and second-line therapy for T2D and therefore is not a “last resort”
Explain that all patients experience β-cell failure but at different rates
Introduce the possibility of insulin use at diagnosis
Do not use insulin as a “threat” or “punishment” for not dieting, exercising, or taking oral agents
HypoglycemiaGive a realistic description of the potential harm and life-threatening potential
Explain that incidence of serious hypoglycemia is rare, and give patients estimates of how frequently less serious hypoglycemia occurs
Explain that long-acting, once-daily formulations cause less hypoglycemia
Give patients advice on how low is “low”, and how to prevent hypoglycemia
Express conviction that prophylaxis and treatment of hypoglycemia can be learned
Weight gainExplain that once-daily formulations are associated with less weight gain than split-dose regimens
Give patients information on how much weight gain is normally observed (<2.5 kg)
Provide information on healthy eating and low carbohydrate diets, including dietician advice
Reassert that daily exercise can minimize weight gain and improve glycemic control; suggest exercise programs
Patient misconceptions regarding insulinExplain that T2D is serious from the beginning, not because insulin is initiated
Explore any influential negative experiences the patient may have had
Explain that insulin helps to reduce the likelihood of complications and does not cause complications such as amputations or dialysis, etc.
Reassure patients who drive for a living that it possible to apply for an exemption to the rule preventing interstate commercial driving
Social concernsExplain that basal insulins allow control with a single daily injection which can be administered in private
Introduce pen technology, which allows fast convenient administration
Let the patient define their special situations
Respect the courage needed in the beginning to inject in public
Introduce ultra-long-acting insulin, which may allow flexible any-time daily dosing
Suggest group classes to discuss social concerns and solutions with peers
Injection painShow that needles are small and very fine
Explain injection technique
Introduce insulin pens and let the patient touch the device
Carry out an initial injection without insulin
Explain that pain is often ower with insulin injection than finger-stick glucose measurement
Suggest breathing techniques (deep breathing, forceful exhalation) to control anxiety
  • FDA, US Food and Drug Administration; T2D, type 2 diabetes.