Barriers and Counseling Strategies for Initiating Basal Insulin31,32
| Barrier | Strategies |
|---|---|
| Complexity of insulin regimens | Introduce 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 failure | Explain 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 | |
| Hypoglycemia | Give 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 gain | Explain 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 insulin | Explain 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 concerns | Explain 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 pain | Show 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.