The ‘other’ insulin resistance syndrome

Being diagnosed with diabetes ranks as a significant stress event. After the initial shock, most people will adjust to taking new medications and try to follow a healthier lifestyle. Doctors are usually aware that their patients are stressed out about their recent diagnosis and try to reassure them. It is possible in doing so, they downplay the serious nature of diabetes. They may be losing a window of opportunity to educate patients about diabetes, and, particularly, about the nature of diabetes as a progressive condition.

Mr IB was diagnosed with Type 2 diabetes in 2000 and treated with Glucophage for more than 10 years. When his control deteriorated, his doctor at the time added a second tablet which improved glucose levels in the first year. Then Mr IB complained of being tired and was finding it difficult to run his business.

At his first consultation with me, his HbA1c was 9,7%. To add a third tablet would, at best, lower the HbA1c to 8,0%. Mr IB needed insulin. He is now on one injection of basal insulin at night and uses his tablets during the day. He feels much better and is happy to have started the insulin injection. He repeatedly asked me why the first doctor had never started insulin. This is a case of insulin resistance in the doctor.

Type 2 diabetes develops when insulin is no longer working efficiently to take glucose, the body’s fuel, out of the blood into each working cell. This means the blood glucose levels will now rise. When some insulin is still being produced by the pancreas, diabetes can be treated with tablets. The tablets either help lower insulin resistance or stimulate more insulin secretion. However, once the pancreas cannot make enough insulin to keep glucose levels under control then the only source of extra insulin is via injection.

The Diabetes Attitudes, Wishes and Needs (DAWN) Survey, conducted in several countries, showed that doctors tended to only institute insulin therapy when absolutely necessary. It was also found that the need for insulin was used as a threat to motivate patients, however, we know that as many as 40-60% of patients will need insulin 6 to 10 years after diagnosis, regardless of previous medication. So starting insulin therapy is due to the progression of diabetes, not the failure of the patient to achieve good control. This is a concept that both patients and doctors need to appreciate more.

The current targets for good diabetic control are laid out in Table 1. An HbA1c of less than 7% would be considered good in most patients. Doctors should follow treatment guidelines from both local and international societies which emphasise the need to take action if good glucose control is not being achieved.

The HbA1c should ideally be checked every three months until it is at the desired level and if this is not reached, the treatment plan should be reviewed. The guidelines do advise a stepwise approach of first increasing tablet strength, then the number of tablets and then adding insulin. However, the guidelines support earlier use of insulin, if the doctor thinks it would be beneficial.

As we know there is considerable emphasis on living healthily – correct food choices, regular exercise and weight loss if needed. Doing this can slow down the progression of diabetes, so doctors tend to give patients a chance to institute these measures. Changing to a healthy lifestyle can be the most difficult part of managing diabetes for most people, but it is not acceptable to keep delaying intensification of medication just because both, patient and doctor, are waiting for the day the perfect healthy lifestyle arrives. Good diabetic control should not be deferred until this happens. It is much better that the patient increases their treatment, including initiating insulin if necessary. If afterwards the patient does manage a significant change in lifestyle, this will be reflected in lowering of their blood glucose levels.  At this point, it may be possible to decrease medications again.

The danger of doctors only prescribing insulin as ‘the last resort’ is that patients can remain poorly controlled for a significant amount of time – as in my patient Mr IB, who waited at least four years. What are the barriers that cause this ‘other’ insulin resistance in doctors?

Several studies have identified these areas of concern:

• • Doctors assume the patient will not want the insulin so they do not want to suggest it. Communication is vital to overcoming this barrier. Many patients are quite prepared to use whatever treatment necessary to improve their diabetes control.
• • Initiation of insulin requires time to educate the patient and many practices do not have the infrastructure to do this. This is where a diabetes nurse educator (DNE) is invaluable. He or she would be able to go through the fears and myths with the patient and support them with their new regimen.
• • Doctors worry that the patient will not manage the practicalities of injections and the increase in blood glucose monitoring that is required. Modern glucometers and insulin pens have become exceptionally patient-friendly. Lancet devices are being developed to be less painful, so patients will be happier to test regularly. Doctors frequently express concerns that their patients may not know how to adjust insulin doses appropriately. Teaching dose adjustments in a stepwise manner will allow the patient to gradually improve the glucose levels without risk.
  • Doctors are concerned about side effects, especially hypoglycaemia and weight gain. The old rule of ‘start low and go slow’ can be applied to avoid low blood glucose, especially in the elderly. It would be important to continue to emphasise lifestyle improvements to prevent weight gain, particularly in the overweight patient.
  • There has been some controversy that insulin will worsen complications. This theory has been proven incorrect and it is important that doctors are up to date with the latest data.
  • The patient is scared of needles. I think needle phobia is quite rare. I have found that non-insulin injection medication does not meet the same resistance with patients.   It would seem insulin is always the concern rather than the needles.

Starting insulin timeously can only benefit patients so it is necessary to find solutions to this doctor insulin resistance. Doctors must always remember that they, more than anyone, are likely to influence a patient’s management for the better. It is not wise to avoid improving glucose control which will only lead to poor health outcomes.

Doctors who have large diabetes practices or are specialists in this field will be less likely to have this ‘other’ insulin resistance syndrome. They’re more confident in their prescribing and usually have a better infrastructure for educating patients. All doctors looking after patients with diabetes should stay up to date with treatment guidelines. It is always possible for a doctor to discuss challenging treatment situations with more specialised colleagues. In this way, all patients with diabetes can be offered the best advice and initiated on any appropriate therapy, including insulin.