Changing Practice

“Changing practices takes time, though. The majority of family practitioners and clinicians have some inhibitions to initiating insulin. Before the development of long-acting basal insulin, the kinetics of the drug,neutral protamine Hagedorn ( NPH, were such that onset took a couple of hours, peaked at six hours and lasted from 10 to 20 hours. With such huge variability, there was greater risk of stacking peaks and causing hypoglycemia,” Morello said.

Because of these challenges, “NPH insulin is not recommended. Use of NPH as a basal insulin has been superseded by the synthetic analogues insulin glargine and insulin determir, which provide a relatively peakless profile for approximately 24 hours and yield better reproducibility and consistency, both between patients and within patients, and a corresponding reduction in the risk of hypoglycemia,” according to the algorithm developed by the American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) Consensus Panel on type 2 Diabetes Mellitus.

Morello said she understands that initiating insulin can take more time and effort by busy physicians and their staff, but that it is worth the effort.

“Insulin does take more effort on the part of the physician and the patient,” she explained. “It’s not like giving a pill and saying ‘Take one a day.’ You have to teach people how insulin works, how to inject, when to take it, how to recognize the symptoms of low glucose and how to treat it, how to test and get values and what to do with those values.

“The education takes time, and physicians are busy, but the benefits of insulin far outweigh any other drug we have for patients who have trouble controlling their glucose levels,” Morello added. “With education, patients can amaze themselves with their ability to manage insulin.”

Guidelines recommend starting basal insulin with 10 units at dinner or bedtime, then titrating based on set guidelines.

Overcoming Resistance

Working in a specialty clinic for patients who have had a difficult time reaching their goals, Morello also has developed a few methods for overcoming patient resistance. First, she said, find out what motivates the patient. Then, determine how to improve their adherence.

“We had a woman who did not want to start insulin. She was not motivated by avoiding going blind or having kidney failure. She had a husband with Alzheimer’s, though, and being able to continue to care for him as long as he needed was the one thing that mattered enough to her to get her to start insulin and control her diabetes,” Morello recounted.

Another patient worked nights and had a totally chaotic schedule during the day, except that he watched the news at 5 p.m. every evening. When we told him to start taking all his medications then, he became completely consistent and gained control quite quickly.”

Some veterans have special issues, such as homelessness, that would make insulin appear to be less feasible. Morello argued that even those problems can be overcome.

“Food is not always secure; they may not know when or what their next meals will be — and you want to avoid causing hypoglycemia because the symptoms can be similar to being drunk, which could get them tossed out of other programs,” she said. “But they can still manage insulin.

“One of our guys lives under a bridge. He has a small insulated case he puts ice in. He keeps a buffer between the ice and insulin — even though refrigeration isn’t really necessary. Because he is so insulin-resistant, he goes through a vial in five to 10 days. What motivates him to take his insulin? It allows him to avoid getting out of his warm sleeping bags five times each night to go to the bathroom in the cold.”

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