COMMENTARY

The Insulin Talk: What To Say When Your Patient Needs to Start Insulin

Jay H. Shubrook, DO; Eugene E. Wright, MD

Disclosures

December 29, 2016

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Starting the Insulin Conversation

Jay H. Shubrook, DO: Hi. I am Jay Shubrook, DO, professor in the Department of Primary Care at Touro University, in California. I am delighted to talk today with Eugene Wright, MD, a clinical faculty member in the Department of Community and Family Medicine at Duke University School of Medicine.

Our topic today will be, how do you start a conversation with your patients about insulin? This is a very important topic. Sometimes this is a simple conversation, but other times, it can be quite charged and there can be resistance, from both the provider and the patient. How do you start this conversation with your patients when you think they need insulin?

'When the Time Is Right, We'll Go to Insulin'

Eugene E. Wright, MD: This is a very interesting topic. The most important thing to do is disconnect the patient's behaviors from the progression of the disease. Most patients are dealing with many emotions when insulin initiation is required. Their first thought is that somehow this represents a failure of them or their behavior. I try to make the conversation about the progression of their disease and the failure of their therapies, not their personal failures.

Dr Shubrook: Those are very important points. Do patients understand that?

Dr Wright: I try to start the conversation about insulin and the progression of diabetes well in advance—months, or sometimes years, before they actually need insulin. As we start treatment for a patient's diabetes, we talk about diabetes as a changing condition that requires changing therapies over time. When the time is right, we will go to insulin.

Dr Shubrook: What if I am your patient, and you think I need insulin? What are you going to say to me?

Dr Wright: If you are at the point where your diabetes is no longer controlled on oral agents and you are not glucose-toxic from the perspective of having polyuria and polydipsia, and you are feeling bad; or if you are just a person who, over months to years, has diminishing responses to two or three oral therapies, we start to have the conversation. Remember when I said, "As this disease progresses, we want you to live long enough to require insulin"? Well, you are at that point now. We have done all we can do with the oral therapies; now it is time to take it to the next level.

'I'm Scared of the Shot'

Dr Shubrook: I am a little nervous about this shot. You want me to actually take a shot every day?

Dr Wright: I try to discern whether it is the needle that patients are afraid of, or what is in the needle. If you separate that, you are often able to address more specifically their concerns. With the size of the needles that we have today, and taking a shot once a day, that is not typically the major concern of many of my patients. I have found that the major concern is the sense that going to insulin, with all of its connotations—the sense of personal failure, the worry that this may not work—is the real issue. I try to focus on that.

In North Carolina, we talk about the size of the needles not being as large as mosquito stingers. We give it some perspective.

Dr Shubrook: That certainly makes sense to me. How often do you have patients take their first shot in the office?

Dr Wright: As often as I can, depending on their situation and level of comfort. It is a great way to introduce the needle to them, either as a "dry shot," or if they come in and are starting to be a little toxic, we give them an actual insulin shot, right there in the office. They can see the injection technique; they understand it, and they see that it is not what they thought it would be. They do not feel differently after the shot. Patients who are glucose-toxic, in a very short period (usually a matter of days), start to feel better. They are not getting up as much at night to go to the bathroom. They are not drinking water or soft drinks every 10-15 minutes.

Dr Shubrook: I like that point. People are going to see tangible benefits in that they are feeling better very quickly with insulin, probably more so than any of the other medications. That is important.

Dr Wright: Absolutely. Those are the easier patients to get started on insulin, because they see the difference almost immediately.

How Much Insulin to Start?

Dr Shubrook: You are going to start me on insulin. How much do you start?

Dr Wright: I like using weight-based insulin dosing for my patients. In North Carolina, most of our patients weigh 100 kg or more, so I start with 0.2 unit/kg of a basal insulin, given once a day, typically at night. For lighter patients, or if you are afraid to go that high, 10 units is a good starting dose.

The most important thing, wherever you start, is to titrate the dose, and patients can titrate on different schedules. I have some patients who titrate daily on the basis of their fasting blood sugars; others titrate every 3-4 days on the basis of their fasting blood sugars. It is all about the patient's level of comfort after you get over the hurdle of getting them started.

Dr Shubrook: You start with 10 units or 0.2 unit/kg per day of a basal insulin?

Dr Wright: Yes. It is usually given at night, but it can be given any time of the day, just as long as it is the same time every day.

Patient Education: What Should You Warn Patients About

Dr Shubrook: What are some problems that I might anticipate when I start insulin? What might you warn me about?

Dr Wright: We often have a conversation about hypoglycemia. Although it is relatively uncommon in people with type 2 diabetes, and certainly with the doses that we start with, we teach people how to recognize the signs and symptoms of hypoglycemia and what level they should be concerned about having their blood sugars drop below. We talk about the need for self-monitoring of blood glucose. I want to make sure that you are comfortable pricking your finger and knowing what the numbers mean.

Many times, patients have heard myths about insulin, such as that it causes blindness or heart disease, and we try to dispel those myths. I typically will engage the patients and ask them, "What do you know about insulin? Let's talk about it." I also like to have them leave the office that first day with some literature that they can take home and read, and encourage them on their return visit to come back with more questions.

Dr Shubrook: Those are fabulous points, and applying them to our busy daily practices will make this conversation easier and certainly improve the health of our patients.

Dr Wright: I find in our daily practice, that over time, this actually takes less time. If we have a meaningful conversation about insulin and titration, the myths and their concerns, and we can get those out of the way early, the other times that we meet tend to go much faster. I tend to invest the time early on to make sure that patients have a firm understanding and a basis on which to move forward with insulin therapy.

Dr Shubrook: Investment in time up front will pay off in dividends over time later, and certainly in the health of our patients. Thank you so much.

Dr Wright: Thanks, Jay.

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