Dave Joffe, BSPharm, CDE, FACA
According to a study published in the February 2010 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, et.al.” included several noteworthy statements.
Their study suggests that insulin omission is affected by the perceived burden of insulin therapy (i.e., having to plan 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). They offer one caveat regarding the findings; they do not believe that the behavior of planning a patient’s day around insulin injections actually increases the level of insulin injection omission, but they do believe that feeling that you have to plan around injections is associated with higher frequency of skipping insulin injections. That is, when there is a conflict between scheduling of treatment and life activities, a patient can either plan 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 ffrom healthcare providers. As the authors suggested elsewhere, providers must find out what the specific issues are for each patient and work with that patient to develop solutions that work for the patient.
Their study further 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 they have found that patients do not feel that their healthcare providers are giving them adequate assistance in managing these problems, even when they raise the issue.
The authors conclude,”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 (and 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 medical researchers have 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 could 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?