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Barriers to Basal Insulin
Breaking Down Barriers to Basal Insulin Use

Released: August 14, 2023

Expiration: August 14, 2024

Richard E. Pratley
Richard E. Pratley, MD
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Key Takeaways
  • Many patients are hesitant to initiate insulin because they perceive it as a “last resort” and are intimidated by the potential adverse events and complexity of insulin dosing.
  • Access to insurance and insulin are systemic barriers to insulin initiation.
  • Weight gain after insulin initiation is a concern for both patients and healthcare professionals, although this can be mitigated by incorporating insulin with another medication, such as a GLP-1 receptor agonist.

Barriers to Insulin Initiation

Insulin is our oldest drug for the treatment of diabetes. We have learned a lot about the use of insulin over the past 100 years, and this is a very important anniversary for the treatment of patients with diabetes. Throughout those 100 years, we have developed new insulins and new ways of injecting insulin, making treatment easier. However, barriers to insulin initiation remain: There are patient centered barriers, healthcare professional (HCP)‒centered barriers, and systemic barriers.

Patient Barriers

Many patients fear insulin, potentially because of an anecdote they heard. For example, a relative had diabetes, started insulin, and then underwent an amputation, or perhaps they know someone who had a hypoglycemic reaction. Some fears are not based on the effects of insulin, and some are.

People also are reluctant to start insulin because they think of it as the drug of last resort. They think, “If only I could have done better with diet and exercise” or “If only the oral medications would have worked better.” They feel as if they are a failure or that they have such a serious case of diabetes that only insulin can work—neither of which is true.

The third barrier that many people have is related to injections. The idea of giving oneself an injection is, frankly, scary for some people. Some people do not even like to do finger sticks. I have such people in my clinic, including an individual who took care of his mother and absolutely refused to give her insulin injections. It is very difficult to talk them through this and requires a lot of patience.

The fourth barrier is the potential complexity of insulin dosing. At the moment, insulin dosing is—at a minimum—once daily, but options in the future may decrease that. However, more intensive insulin therapy could require as many as 4 doses per day. Not only do patients have to administer their medication regularly, but they also must personally adjust the dose. That can be difficult for many people.

HCP Barriers

Prescribing insulin is more complicated than prescribing a once-daily oral medication that does not have many adverse events. We as HCPs must instruct patients on how to inject the medication, where to inject the medication, when to inject the medication, and how much medication to inject. We have to give patients algorithms so they can manage their diabetes at home, because every day is different, and people need to be able to adjust their insulin. That in itself is complicated, even for me. In addition, clinics often are not set up to facilitate insulin initiation. In my clinic, if I can, I try to give the first injection in the office so people can understand that the injections themselves involve tiny needles and are not painful. This gets them over the initial barrier, and the hands-on experience goes a long way toward making insulin initiation easier. In addition, weight gain is a concern for both HCPs and patients. Patients are not excited about gaining even 5 pounds of weight, and it is not unusual to gain 5-10 pounds after initiating insulin therapy. It is up to us to help patients understand why they are gaining weight and to provide strategies to mitigate weight gain after insulin initiation.

Systemic Barriers

Access to insulin is a systemic barrier to insulin initiation. Some insulins are preferred over others, making them more difficult to obtain. For example, basal insulin has a flatter curve and is preferred because it does not cause as much hypoglycemia, is more stable over time, achieves better glycemic control, and allows more flexibility in dosing. However, these preferred insulins often are difficult to access, and patients frequently have to rely on older versions of insulin. They still work but are more complicated to use.

Overcoming Barriers to Insulin Initiation

Patient Barriers

How do we overcome these barriers? First, it is important to have an open and frank discussion with patients about the benefits of insulin. We have to make sure they understand that insulin is not a treatment of last resort, and it is possible for them to stop insulin therapy in the future. I also have found it helpful to do demonstrations with insulin pens to show how easy it is to dial in a dose and how small the needles are.

When it comes to the complexity of insulin therapy, there are easier ways to prescribe insulin regimens. We should begin with basal insulin and allow patients to self-titrate to treat to a target fasting glucose level of approximately 100 mg/dL. This helps patients achieve their glycemic goals more quickly and empowers them by allowing them to be in control of their diabetes.

HCP Barriers

In terms of improving HCP barriers, it is helpful to have handouts and checklists for insulin initiation that you can readily show people in clinic. For many years, I carried an insulin pen in my front pocket because I wanted to show my patients how easy the pens are to use. Within 30 seconds, I could demonstrate how to use the pen and help overcome some patients’ initial reservations about administration.

Regarding weight gain, patients gain weight because they are controlling their blood sugar better and experiencing less glycemia and glucosuria, so their caloric balance changes. However, there are strategies to mitigate that weight gain. The first is to avoid overbasalization of insulin. We tend to start insulin and keep increasing the dose of the basal insulin, resulting in peripheral overinsulinization. Insulin is anabolic, so it promotes lipogenesis. Thus, we should use the smallest dose that controls the blood sugar.

The second thing we should do is always use insulin in combination with medications that mitigate weight gain. A prime example is a glucagon-like peptide-1 (GLP 1) receptor agonist. The American Diabetes Association recommends a GLP 1 receptor agonist as the first injectable agent when possible. However, if patients already are receiving insulin and need improved glycemic control or prandial glucose control, the American Diabetes Association suggests adding a GLP 1 receptor agonist. This can help mitigate some of the weight gain caused by insulin therapy, improve glycemic control, and decrease risk for hypoglycemia.

The third option is a fixed ratio combination of a GLP 1 receptor agonist and an insulin. These drugs are highly effective. They are titrated slowly, so they are very well tolerated, and according to clinical trials, patients can easily achieve an A1C of less than 7.0% with minimal to almost no weight gain.

Systemic Barriers

When it comes to systemic barriers and insurance access, we can work with pharmacy benefit managers, pharmaceutical companies, and people who have limited resources. Often, we can get the medication at low or no cost. If the problem is access to a certain type of insulin, we should explore alternatives. Of note, there are long-acting alternatives that have less variability and may be on formulary at a lower tier. These are all worthwhile things to do for our patients.

Summary

In summary, insulin is a great medication. We use it because it works and is appropriate for many patients with type 2 diabetes at some point in their journey. We need to make sure we are not giving patients the message that insulin is a treatment of last resort. We need to be positive about the use of insulin, explain the benefits of insulin treatment, and facilitate their initiation with insulin as best we can, either directly in clinic or with other professionals, such as certified diabetes educators and specialists or pharmacists.

Your Thoughts?

Have you encountered any barriers to insulin initiation in your practice that were not mentioned here? What strategies worked best for you in overcoming these challenges? Answer the polling question and leave a comment to join the discussion.

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Which of these barriers to insulin initiation do you encounter most often?

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