At least Dr. Stephen A. Brunton,
executive director of the Primary Care Metabolic Group, concedes that
doctors may be the cause. Dr. Jay Shubrook, family physician and
diabetologist at Touro University in California, is the doctor
interviewing Dr. Brunton
Dr. Brunton says that doctors have always talked about insulin resistance being something that is the
result of patient resistance. However, a lot of insulin resistance
comes from practitioners. We resist using insulin for many reasons,
and that has an impact on getting our patients to target.
Dr. Shubrook asks, what is clinician
insulin resistance?
Then to quote Dr. Brunton,
“Traditionally, we have been reticent to use insulin because of the
impact it would have on slowing the flow in the office, and even in
terms of our feelings of expertise. When the basal insulins came out,
it made things so much easier—insulin could be initiated with 10
units daily. At that dose, there is a very low risk for hypoglycemia
or any other problems. With the insulin pens, it became so much
easier.
Part of it, however, is that we assume
that our patients do not want to start insulin. Perhaps, in the
past, we used insulin as a threat: "If you do not behave, you
are going to get insulin." Now we have realized that it is the
most effective regimen for getting patients under control. Part of
the problem is that the patients may still have some of those other
considerations that we may have originally laid upon them. It is our
resistance to start patients on a very therapeutic regimen.
Part of the issue of complexity is that
when patients come for the management of diabetes, many don't have
only diabetes. They may have eight to 10 different
comorbidities. We are so busy trying to manage all of that that we
tend to put off starting insulin. We may have them on three or four
oral antidiabetic drugs. So, we need to look at where our patients
are and how we can get them to target.
Many studies show how long it takes us
to make a change. It's therapeutic inertia. It has been shown that
sometimes for years, the patient is out of control, and we will give
them one more chance. We will add another oral agent, but it is not
going to have a benefit, particularly when these patients have
glucotoxicity.
We need to recognize that we have a
broad base of different therapeutic options and that today's insulin
is not your grandparents' insulin. We have better analog insulins.
We have pens. We have very small needles, so patients are much more
likely to accept insulin than we think. Insulin resistance is really
our problem. Patients are not as frightened of needles as we think.
Patients may have misconceptions about
what insulin means; for example, they might have heard, "I
started insulin and my leg dropped off." That, as you and other
clinicians know, is not why that person lost their leg, but the
patient still holds onto that, and insulin becomes a big fear. It is
up to us to help them overcome that.
Dr Shubrook says: You mentioned
many things that make it easier for us to overcome our
resistance—insulin pens, easy-to-titrate insulins, and algorithms
for treatment. How do we address the clinician resistance to using
insulin that remains?
Dr Brunton answers: The issue is to try
to develop a system in the office so that you do not have to do
everything yourself. Educate the staff to overcome some of the
barriers to implementation in the office. Introduce insulin early on
in the diagnosis. With people who have type 2 diabetes, insulin
seems to be far in the future, and the thinking is, "Oh my God,
I hope not." I say, "I have a natural therapy that
eventually you might use." We recognize that diabetes is a
progressive disease and eventually a significant proportion of
patients are going to need insulin. I view this as a positive and
say, "This natural therapy is insulin, and we will talk about
that as it gets a little closer, but let me tell you a little bit
about it." I explain the pathophysiology of diabetes and where
insulin fits in. Then, I also have staff who can go over injection
techniques and some of the algorithms, so that it is not all laying
on my shoulders.
Dr Shubrook says: Those are important
points, but I can still see some of my partners being resistant to
the use of insulin. Maybe it's based on a bad experience they have
had in the past, maybe it's just a lack of experience, or maybe it's
the math. If I wanted to talk to one of my colleagues about starting
insulin more frequently, what are some steps that they can follow?
Dr Brunton answers: First, try
to understand the concerns. Sometimes it relates to misconceptions.
Not only do we have an easier process now with basal insulin, but
show them how to titrate it. A lot of patients will start on 10
units and if they stay on that, they are not going to get the
benefits. The benefit of basal insulin comes with titration. One
does not have to go from a basal all the way to a basal bolus with
four injections a day. We can use the basal-plus approach where you
provide some short-acting insulin for the main meal. That makes
things a little easier. Now we also have GLP-1 agonists that we can
use in concert with insulin. There are many ways that we can use
insulin to help get our patients to goal.
Dr Shubrook commented: This is really
still a very important topic because we know that most of our
patients with type 2 diabetes and all of our patients with type 1 are
going to need insulin. If clinicians are not comfortable, these
patients are certainly not going to get the treatment they need.
What I have heard you say today is:
- Clinician insulin resistance is still an issue despite many advances, and sharing these advances with providers might be a first step;
- Get someone in your office who can help you so that it is not on the clinician alone to have to do this; and
- Trust some of these tools and get some positive experiences.
Dr Brunton: Yes. We have come a
long way, Jay, and that is one of the exciting things about managing
diabetes today. We have so many tools at our fingertips that can
help our patients get to goal. We have been at a plateau—about 55%
of patients are getting to goal and 45% are not. Now that clinicians
have these tools, if they feel more comfortable with them, we can
help our patients.
This discussion points out the problems
many people new to diabetes have with doctors. This reinforces
earlier blogs by David Mendosa and myself on February 24, 2017 about starting insulin at
diagnosis. Please take time to read both.
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