COMMENTARY

If Insulin Is Safe, Why Are Patients Afraid of It?

Jay H. Shubrook, DO; James LaSalle, DO

Disclosures

February 23, 2017

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Jay H. Shubrook, DO: Hi. I am Jay Shubrook, professor in the Primary Care Department at Touro University in Vallejo, California. I am pleased to introduce my colleague, Dr Jim LaSalle, family physician and diabetes expert. Today we will talk about the safety of insulin.

Some of my patients understand that insulin is important and necessary for diabetes, but other patients really push back when I introduce insulin. I hear a lot about patients who report that relatives had problems with insulin: "When my aunt had to take insulin, she lost her foot," or "When my grandmother first had diabetes, she went blind." How do you approach patients with these concerns about the safety of insulin when they really need it?

James LaSalle, DO: I believe that that is a loaded question. Insulin is safe, and that should be the first thing we say to patients. But also, this is a cultural matter that involves social, religious, socioeconomic, and trust issues. It is a conundrum for many people. When we look at this, we have to dive into the issue and ask what we can do about it. How can we explain to patients that insulin truly is safe?

A group from the University of Texas Southwestern in Dallas are among the few who have researched the problem.[1] They asked 44 Mexican American patients with non-insulin-dependent diabetes whether they had any hesitancy about taking insulin. In all, 43% had concerns. Their reasons included having observed or hearing about a family member who had a major adverse effect with insulin.

Many people are fearful that insulin is addicting. Many people do not understand the consequences or benefits of taking insulin over a long period of time. People are afraid of insulin—that the injections hurt; that it could have other effects on them, such as weight gain, fatigue, or lethargy; that it would really impede their lifestyle. Of interest, 25% of the patients in the Texas study[1] were worried that insulin would cause blindness.

We need to dive into this and ask why patients have these fears. We have had the insulin molecule since Banting discovered it in 1921.[2] He was an orthopedic surgeon, which I find intriguing. In 1922, Leonard Thompson was the first person to receive insulin for type 1 diabetes, and he thought it was a miracle drug. But in 2017, we still have patients who are resistant to taking insulin.

Look at the evolution. First we had beef and pork insulin, and then the protaminated human insulins. Now we have human insulins, analog insulins, and even biosimilar insulins. Along with these developments has come an evolution in our understanding of the pharmacology and the physiology of insulin.

Perhaps more important is the delivery system of insulin. Up until the early 1960s, insulin was delivered with a reusable syringe and needle. People had to boil their needles and soak them in alcohol. The needles were not the right size; the bore was relatively large, anywhere from 18- to 25-gauge. You could understand that those injections hurt. Look at the changes that would have occurred in the pharmacokinetics of insulin if it were given into the muscle, or the potential for lipodystrophy or infection, or for giving the wrong dose because people were drawing it up from a vial.

Some people now do not recognize that those problems ever occur. When we look at the pharmacokinetics of the new insulins—the peakless insulins and the time-action curves—it is a whole different picture from that of three, two, or even one generation ago.

If we can understand those problems, we can better solve the patient's concerns in the office. We have a diabetic team that helps, but people really look to the primary care provider to answer these questions.

Dr Shubrook: It sounds as though there are many things that we providers can do to make sure we convey that today's insulin is not the insulin of the past and, quite honestly, is a much different insulin than what those relatives took. I also worry that when we use insulin when the diabetes progresses, we are using it at the end of the disease when everything else has failed. How does that play into a patient's reluctance? Do you talk about that with your patients?

Dr LaSalle: Yes. I believe that about 27% of people who have type 2 diabetes are taking some form of insulin.[3] In 2011, the Centers for Disease Control and Prevention reported a similar number, noting that about 18% of patients used insulin only and 13% use insulin in addition to other antidiabetic medications. That is a gross underutilization of this molecule to treat diabetes. A lot of primary care physicians are at fault because they do not use insulin appropriately. We have guidelines now and they should be used more than they are. We need to understand that insulin plays a role in improving endothelial function by stimulating endothelial-derived nitric oxide synthase. If patients already have endothelial damage, the insulin will not be able to provide as much of an effect. Insulin has other benefits; it is an anti-inflammatory, among other things. We need to understand that we may want to use insulin earlier. We can combine it with other hypoglycemic drugs, such as the GLP-1 agents. Used correctly, we see that people tolerate it better, have fewer side effects and better profiles, and that their diabetes is better controlled.

Dr Shubrook: It sounds as though you are advocating earlier use of insulin. Do you tell your patients earlier in the disease that they may need insulin?

Dr LaSalle: Insulin is a discussion on day 1. Patients need to understand that insulin is a good thing, not a bad thing. I do not hold it over their heads and say, "If you do bad things I will give you insulin." I tell them that we will use insulin when it is appropriate and that we will show them how to use insulin, perhaps even before they need to use it, so that they feel comfortable with it and do not see it as some kind of a punitive weapon.

Dr Shubrook: That is very important. Do you ever take people off insulin? It sounds as though people are concerned that they will be taking insulin over a long period of time.

Dr LaSalle: Yes, they are. If you catch someone early in the course of diabetes, with an A1c above 9% and glucose toxicity, you can use insulin to control their diabetes relatively easily. You get them out of the state of glucose toxicity and then take them off insulin and see how they do. Moreover, with the advent of the newer medications, sometimes we can control people's glucose very well and maybe even back off the insulin dose or even stop insulin altogether.

Dr Shubrook: So it sounds like the idea of "once on insulin, always on insulin" is no longer true.

Dr LaSalle: If you are using it relatively early along the timeline of the disease, or under certain circumstances such as surgery, stress, or illness, then that is correct. If you are using it at the very end of the disease process, the answer then is probably not.

Dr Shubrook: In conclusion, you are saying that today's insulin is different from the insulin of the past. We have more refined insulins that are safer, easier to take, and come in easier delivery methods. We know that insulin has an important effect and that everyone with type 2 diabetes will need insulin at some point. Start that conversation early. When patients understand that insulin is their friend and not their foe, it changes the conversation. Is that correct?

Dr LaSalle: Absolutely correct.

Dr Shubrook: Thank you so much for being here today. We appreciate your expertise.

Dr LaSalle: Good to see you, Jay. Thank you very much.

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