Our Doctor of Pharmacy Candidate from LECOM College of Pharmacy, Christina Dowd, has reviewed a new book from the ADA and found that it is a good read for you. See what she has to say.
Book Review: Practical Insulin: A Handbook for Prescribing Providers
Christina Dowd, Doctor of Pharmacy Candidate LECOM College of Pharmacy
Abe Ogden, Director, Book Publishing, Greg Guthrie, Managing Editor. Practical insulin: a handbook for prescribing providers. American Diabetes Association, Inc. ®, 4th edition. Alexandria, Virginia: 2015.
This handbook, available through the American Diabetes Association, provides a quick reference for health care professionals on a variety of topics and issues that may arise when prescribing insulin, such as identifying patients who are candidates for insulin, an overview of different insulin products, insulin regimens, and patient education.
The book is well designed as a handbook, with chapters organized and titled for quick reference. It is not a substitute for more complete knowledge of insulin products and regimens, as it only provides an overview of the differences in insulin products. For example, it provides the information that insulin detemir differs from insulin glargine in that detemir binds to albumin, while glargine forms a depot, but does not discuss how this difference impacts insulin therapy. The updated edition provides some information on the inhaled insulin Afreeza, but much like its description of insulin pumps, gives little information on how to use the device.
The guide goes into more detail in describing approaches to insulin regimens, with separate chapters on treating type 1 and type 2 patients. The chapter for type 1 insulin therapy covers a guide for initiating therapy, and calculating insulin-to-carbohydrate ratio and corrective dosing. It also provides a rundown on different approaches to therapy, such as two injections per day vs three or four, with the rationale, advantages, and disadvantages of each. This quick breakdown is useful in providing a concise source to determine the pros and cons of each approach. It happily discusses the “honeymoon” phase, a phenomenon which some prescribers may not be familiar with. One drawback is that while the “dawn phenomenon” is mentioned in other chapters, there is little description of what it is and no mention of the Samogyi effect and how to differentiate between the two. Another drawback is that while the chapter also mentions a few times that the insulin dosing provided is a guideline, and individual needs can be highly variable, a provider who is skimming the information may miss that important concept.
The chapter discussing regimens for type 2 patients is much less extensive, but the high interpatient variability with type 2 diabetes perhaps warrants this. It provides the current ADA guidelines for when to initiate insulin therapy. It also offers a starting regimen guideline and titration schedule, but touches little on the complexity of adjusting insulin for patients with differing degrees of insulin sensitivity who may be on other glucose lowering agents. It does however, try to provide advisable dosing adjustments based on whether fasting, pre-prandial or post-prandial blood glucose readings are out of range in a clear, easy to follow manner.
The best chapter of the handbook is titled “Barriers to Effective Insulin Use”. The chapter outlines strategies to prevent weight gain and hypo-and-hyperglycemia. It also describes the phenomenon of hypoglycemia unawareness, and mentions the benefit of raising glycemic goals to avoid a dangerous episode in a susceptible patient. It also recommends temporarily running higher blood glucose levels, which can in many cases return sensitivity to hypoglycemia.
The most useful portion of the chapter discusses reasons for patient resistance to starting insulin. It correctly points out that if the provider subscribes to some of the stigmas of the need for insulin, the patient will believe those stigmas too. The chapter stresses provider education as well as patient education, and then goes on to outline the wrong attitudes to project to patients.
It discusses the outdated but persistent idea that type 2 diabetics who need to transition to insulin have failed somehow in therapy and not been vigilant enough in managing their disease. Provider education, as well as patient education, here is important because many providers may still hold this view. It stresses that the provider should not use insulin as a threat to gain compliance with other treatment regimens. If patients hold the view that starting insulin is a punishment for not maintaining blood sugars at goal, they will feel as though they have failed in their attempts to manage the disease, and that they are powerless to affect any change. Patients and providers alike should be educated that in reality, type 2 diabetes is a progressive disease, and that in enough time beta cell function will be lost and insulin will be needed, regardless of how well the patient manages the factors that are under their control.
This portion of the chapter also offers strategies to overcoming patient fears about insulin, such as explaining that newer syringes are not as painful as they may imagine, and insulin pens offer convenience and simplicity. Another helpful strategy is for providers to suggest a “trial run” of insulin, offering to the patient that using insulin doesn’t have to be a permanent change. If a patient tries insulin therapy without the psychological baggage of failure and lifelong injections, they may come see after a few weeks that their fears about using insulin are unfounded, and the improved glycemic control achieved with insulin has improved their quality of life.
Overall, this handbook is a useful guide for any provider working with patients who may need to begin insulin therapy. Because of its straightforward tone, and simplified language, it may be a useful guide to patients who want to educate themselves more about insulin. Its greatest achievement, however, is in presenting a positive, nonthreatening picture of insulin and its use. It even goes so far to suggest that insulin needn’t be considered a “last resort” for type 2 diabetics, and that some patients may find opting to begin insulin therapy sooner rather than later provides them with better glycemic control and more lifestyle freedom than oral agents. The handbook provides education to providers and patients without the “scary” and “doomsday” burdens that insulin use often evokes, opening the door to positive attitudes toward insulin use, and better patient outcomes.